Edward M. Brown

What shall we do with the inebriate? Asylum treatment and the disease concept of alcoholism in the late nineteenth century

During the late nineteenth century a number of physicians, sometimes called inebriety specialists, combined a narrowly physicalistic disease concept of alcoholism with a high regard for the curative power of asylum treatment to advocate the development of specialized asylums for the treatment of alcoholism. Central to the idea of such an inebriate asylum was the belief that the power to detain the alcoholic was necessary to cure his disease. This article considers why inebriety specialists held this belief as well as why others opposed it. It also describes alternative approaches to alcoholism and the fate of efforts, during this period, to treat the alcoholic by confining him.

Neurology’s Influence on American Psychiatry: 1865–1915

Prior to the middle of the nineteenth century psychiatry was clearly identified with the asylum and with the humane care of the most disturbed members of society. Between 1865 and 1915, however, this began to change, and psychiatry began to assume its twentieth century form. During this period the profession became more scientific, and simple concern with humane care became suspect. Psychiatrists also began to show more interest in less severely disturbed patients who might be treated outside of the confines of an asylum. Furthermore, the treatment of these patients in particular came increasingly to be understood in psychological terms as the ground was laid for the explosive development of twentieth century psychotherapies. In the United States it is clear that these changes did not simply evolve out of the older asylum psychiatry but resulted from the catalytic action of a new medical specialty—neurology—on the practice of caring for the mentally ill. In Europe, largely through the influence of Wilhelm Griesinger, psychiatry and neurology were more or less united after 1860. In the United States, by contrast, asylum superintendents were both well organized and isolated from the mainstream of medicine. This meant that newer perspectives were assimilated in the course of conflict and competition between two professional groups. Neurologists stimulated the assimilation of these newer perspectives by advocating a more scientific approach to patients, criticizing the quality of asylum care, treating patients previously unnoticed by psychiatrists, and importing a new psychological point of view from Europe. While asylum superintendents at first bitterly resisted the intrusion of these new specialists into their territory, in time they came to adopt a point of view quite similar to that of the neurologists. By the first World War this process was largely complete, and psychiatry was well on its way toward assuming its twentieth century form. This chapter will trace, in greater detail, the events just outlined. It will focus on developments in the United States because they serve both as a demonstration of how the intellectual and social shape of professions change and as an example of how such changes are brought about through conflict between social groups.1

Between Cowardice and Insanity: Shell Shock and the Legitimation of the Neuroses in Great Britain

Traumatic war neuroses emerged as a new phenomenon during the First World War. While soldiers in earlier wars had been diagnosed as insane or suffering from nostalgia, or homesickness, these diagnoses were not thought to have been caused by the trauma of warfare (1). In contrast, the prevalence of war neuroses during World War I has been linked specifically to the circumstances of the fighting. As late as 1977, for example, a noted historian of military psychiatry commented that, in World War I, warfare had reached new heights of destruction and terror. In the early phases, optimum conditions were presented for the emergence of psychiatric casualties in that new troops were locked in intense prolonged combat with heavy concentrations of artillery fire and a high incidence of battle losses (2).

François Leuret: the last moral therapist

By the 1840s French psychiatrists had abandoned Moral Treatment as an individual psychological therapy, as opposed to an institutional practice. One advocate of Moral Treatment, however, would not go along with this movement. In three books and several papers published between 1834 and 1846, François Leuret (1797–1851) advocated aggressive psychological treatment. Recent commentators have understandably concentrated on the controversies surrounding Leuret’s practices. What such an approach has failed to make clear, however, is that Leuret had a complex, systematic psychological theory supporting his clinical judgements. In addition to reviewing the controversies that surrounded Leuret, this paper spells out Leuret’s psychological theory and shows how he used this theory to think about the individual psychotherapy he provided for his patients.