The nineteenth century can rightly be called the century of medicine and biology. The ideas and practitioners of clinical medicine and biological research provided bourgeois society with ideas and institutional practices whose influences were felt in everything from politics to the arts. In this development, Germany proved to be a pioneer. With the support of national and provincial governments, clinical medicine and the human sciences flourished in Germany. By century's end, scholars in fields such as pathology, neurology, epidemiology, and experimental psychology could lay claim to being the best in the world.

In no other field was the influence of German medicine and science more palpable than in psychiatry. While English, Scottish, and French alienists and scholars proved to be the leaders in psychiatric reform during the Enlightenment, it was German clinicians, researchers, and institutions in the nineteenth century who took "mad-doctoring" and transformed it into an academic enterprise. The very form and substance of psychiatry today continues to bear the stamp of this renaissance in psychiatric work associated with the names of Wilhelm Griesinger, Otto Binswanger, Eduard Hitzig, Carl Wernicke, Carl Westphal, and, of course, Emil Kraepelin.

Eric Engstrom's study represents the first English-language monograph, grounded primarily in archival research, to explore this important moment in the intellectual and social history of Germany. With Engstrom, this rather daunting venture is in able hands. To those scholars working in the field of the history of German psychiatry, Engstrom is well-known as a thoughtful and insightful historian, particularly well-informed about the scope of archival materials available to scholars.

In large measure, Engstrom tells the story of nineteenth-century German psychiatry as a history of the professionalization and "Verwissenschaftlichung" of mad-doctoring. Inspired by Andrew Abbott's influential sociology of professions 1 and his concept of the "cultural machinery of jurisdiction," Engstrom understands German psychiatry at this time to be a contest between two groups vying for jurisdiction over the understanding and treatment of the insane. One the one hand were alienists, directors of asylums with traditionally few connections to academia. On the other hand were new generations of psychiatric clinicians interested in wedding psychiatric care with university-based research. Rather than seeing the struggle between these two communities rooted simply in bourgeois ambitions for prestige, influence, and wealth, Engstrom quite rightly interprets their disagreements as deriving from different "disciplinary economies" (p. 122). By this he means that alienists and clinical psychiatrists disagreed not solely out of competing self-interests; rather, they could not see eye to eye on most matters since they were operating under different assumptions and standards for observing, understanding, and arguing about mental illness.

What Engstrom, in effect, demonstrates is that care for the mentally ill in nineteenth-century Germany was a flashpoint for many of the most prominent social conflicts of the time. The struggle and debates between rural-based directors, on the one hand, who ran their asylums like "idealized organic, patriarchal, and economically autarkic model families," (p. 20) and urban-centred university clinicians, on the other, who took their inspiration from the natural sciences and Enlightened pedagogy, was more than a matter of professional disagreement. The rift between the two groups pitted against one another interests and values cutting across the whole of nineteenth-century German society: Christian charity versus secular reform; metaphysics versus materialism; individualism versus standardization; guilds versus free markets; countryside versus metropolis; Ständestaat versus Rechtsstaat.

It is clear from Engstrom's telling that, by century's end, it was the proponents of linking psychiatry to university clinics, cities, and scientific research who won the day. By and large, they proved successful over the course of the last third of the nineteenth century in achieving their central aims: building professional associations and journals modelled on the rest of the medical and scientific community; establishing strong ties between psychiatry and pathological anatomy and experimental psychology; and reforming and standardizing the clinical training of practitioners. Equally important, they helped make the "psychiatric polyclinic" a prominent part of the social welfare landscape of German towns and cities. Catering to large numbers of short-term patients (in 1909, for instance, the Berlin polyclinic treated 6000 patients), many on an outpatient basis, polyclinics served as a nascent form of community mental as well as a training ground for budding clinicians.

Still, Engstrom shows, this success story was not without its disappointments and shortcomings. Clinical psychiatrists proved to be as unable as their alienist colleagues in arriving at a consensus over the classification of mental disorders. In addition, widely publicized scandals over the treatment of patients in some psychiatric facilities, particularly at the end of the century, meant that the public image of psychiatry was often not very flattering. And perhaps most important of all (at least to patients) was the fact that the emphasis now placed on research and high turnover rates in psychiatric clinics meant that long-term treatment suffered. Clinics, in effect, became hubs for channelling patients to other types of facilities.

Even with these problems, however, clinical psychiatry continued to grow in the last quarter of the nineteenth century. Engstrom sees this growth as a function of practitioners' willingness to speak to a range of timely social issues. As others have observed, following unification and valorised by the popularity of Darwinism, German political culture was preoccupied with finding ways to prevent what were seen as looming social pathologies: crime, delinquency, poverty, population decline, cultural decay, and revolution.2 These concerns provided an inroad for clinical psychiatrists to involve themselves as informed experts ever more into everything from the state regulation of licensing physicians to criminal law reform to social insurance. As Engstrom puts it, "with that, they were staking a professional claim to diagnose and take therapeutic action on - ever less - marginal forms of mental deviancy across - ever wider - expanses of Imperial German society. In other words, the new didactic economy entailed a simultaneous lowering and broadening of the threshold of sensitivity toward mental deviance" (p. 173).

It is here that one might expect Engstrom to conclude his study with a discussion of the continuities in nineteenth- and twentieth-century German psychiatry. He does not take his monograph in this direction, however. And this is too bad, since it would be interesting to know how he relates the relatively optimistic, scientifically rationalistic, and socially progressive clinical psychiatry of Wilhelmian Germany - something in and of itself that may surprise many - not only to the eugenic psychiatry of the first half of the twentieth century, but also to social psychiatry and anti-psychiatry in the second half.

Engstrom seems more interested, however, in not treating the nineteenth century as a simple precursor to the twentieth century. Thus, in his conclusion, he discusses the theme of institutionalization in the 1800s and argues that the evidence shows that the impulse for this came not only from the state, but also from psychiatric professionals themselves. Though he reads this as something challenging top-down arguments that invoke the "social control" and "medicalization" of patients, it could be argued that his, too, is a top-down argument, since it places agency in the hands of a small group of elite, largely bourgeois experts.3 Indeed, the voices and contributions of any number of individual and groups - above all, patients, but also their families, local neighbourhoods, nurses, and mental health workers - are conspicuously absent here. To be sure, one can only do so much in such an ambitious book. Nonetheless, one is left with the impression that only practitioners, policymakers, interest groups, and the media - along with mental disorders themselves - shaped nineteenth-century German psychiatry. Yet, laypersons and consumers also played a formative role in the very making of medical ideas and practices at this time.4 Future studies will need to flesh out, along the lines of what Ann Goldberg has done for the first half of the nineteenth century 5, the nature and effects of everyday life in the late-nineteenth century psychiatric clinic. In the meantime, Engstrom has written an informative and well-researched book that will likely serve as a textbook in the field for quite some time.

Notes:
1 Abbott, Andrew, The System of Professions. An Essay on the Division of Expert Labor, Chicago 1988.
2 Weindling, Paul, Health, Race, and German Politics between National Unification and Nazism, Cambridge 1989; Radkau, Joachim, Das Zeitalter der Nervosität, Deutschland zwischen Bismarck und Hitler, München 1998.
3 One way of seeing all this in a more reciprocal fashion would be to understand this particular form of institutionalization as a part of a co-produced discourse of "Fürsorge," with no particular center in any one jurisdiction. On the idea of the "co-production" of knowledge, politics, and the social order, see Jasanoff, Sheila Beyond Epistemology, Relativism and Engagement in the Politics of Science, Social Studies of Science 26 (1996), p. 393-418.
4 Eghigian, Greg, Making Security Social. Disability, Insurance, and the Birth of the Social Entitlement State in Germany, Ann Arbor 2000.
5 Goldberg, Ann, Sex, Religion, and the Making of Modern Madness. The Ebersbach Asylum and German Society, 1815-1849, New York 1999.