Psychiatry as a profession

  Medical superintendents were responsible for running the asylums – ensuring there was enough food, sacking drunken staff, preventing abuse, and proposing discharge to the board if patients recovered. Some of the more able (such as John Connelly) became highly skilled in man-management and also took a leading role in the design of new asylums. The early asylum movement produced some remarkable architectural achievements but relatively few therapeutic ones. There was no specific training to be an asylum doctor – you went there and worked alongside the superintendent and if you were lucky you eventually replaced him. These were, however, generally thoughtful men (they were all men) and interested in science. In the 1840s they founded their own professional bodies – the Association of Medical Superintendents in the UK in 1841 (later to become, 1865, the Royal Medical Psychological Society and in 1971 the Royal College of Psychiatrists). The formation of this professional association in 1841 coincided with the naming of the dinosaur – a coincidence not lost on the profession’s detractors.

‘Germany’ – psychiatry’s birthplace

  In the second half of the 19th century there was a remarkable intellectual flourishing in German-speaking Europe. The collection of states that came to make up modern Germany were rivals of each other and characterized by local centres of government with prestigious universities and institutions. Unlike France at the time (where everything happened in Paris) there were several culturally and linguistically linked, but independent, centres of innovation – Munich, Berlin, Vienna, Zurich. From these came the great founding fathers of modern psychiatry: Griesinger, Morel, Alzheimer, Kraepelin, Bleuler, Freud, Jung. The first professor of psychiatry was established in Berlin (Griesinger 1864) and there were six by 1882. Compare this to England where the first professor of psychiatry was appointed in 1948.

  These academic posts were not, on the whole, placed in mental hospitals nor were they dedicated to the treatment of the legions of psychotic and demented patients who inhabited them. Most research was conducted in university clinics and most was focused on detailed examinations of the nervous system in an attempt to elucidate the mechanisms of the ‘degeneration’ that was thought to underlie mental illnesses. Three of the most influential figures found their way into the area for more personal reasons. Falling in love was the reason for both Kraepelin and Freud and family concern for Bleuler. Freud and Kraepelin had successful research posts in university departments (Freud was dissecting the nervous system of eels). A research career at that time was incompatible (in terms of both income and time) with marriage and a family. However, both had met the women they wanted to marry so there was no alternative but to relinquish their promising research posts and look for a ‘real’ job. Luckily we know that both had long and happy marriages. Bleuler was born and brought up in the Zurich cantonment and didn’t want to move. His sister suffered from schizophrenia and he was close to her and it seemed logical to return to a job at the Burghölzi hospital where she was cared for. These three men moulded modern psychiatry.

 

  3. Emil Kraepelin (1856–1926): distinguished dementia praecox (later called schizophrenia) from manic depressive disorder and laid the foundation for a rational classification of psychiatric disorders

Kraepelin (1856–1926)

  Kraepelin moved with his new wife in 1886 to become an asylum doctor in Dorpat in what is now Estonia. The professional classes spoke German but his patients didn’t – consequently he didn’t understand a word they said and could not usefully interview them. What he did do was study their case notes and observe the fluctuations in their illnesses. From this he made the distinction between schizophrenia (which he called ‘dementia praecox’ meaning early dementia) and manic depressive disorder. Although in their acute phases it was difficult to distinguish the two disorders, important differences emerged over time. The dementia praecox patients never (he believed) fully recovered and with each bout of acute illness became more disabled. Based on the course of the illnesses he established the classification into the two major functional psychoses that persists to this day.

  ‘Kraeplinian’ implies a pessimistic view of schizophrenia (if defined by its poor outcome it can only be diagnosed if there is a poor outcome) and of exaggerating its difference from manic depressive disorder. However demonstrating that you could successfully classify the psychoses at all brought enormous benefits. Once you can distinguish different groups you can begin to make sensible predictions about outcome (‘prognosis’) and develop a clearer picture of each illness. Having distinguished these two it allowed psychiatrists to start distinguishing the others (dementia, cerebral syphilis, intoxications). At the simplest level it gave psychiatry a reason to pay more attention to patients’ illnesses and provided a basis for some rudimentary predictions and development of treatments.

  Kraepelin became a celebrated and influential figure who travelled widely in his own lifetime. He was a passionate advocate for the temperance movement and on a lecture tour of Italy it was not so much his radical diagnostic ideas that amazed his Italian colleagues as the fact that he refused to drink wine. Indeed, he considered his campaign against alcohol his main contribution to humanity.