Thursday, January 1, 2009

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 were the result of 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 Greisinger, 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. What this meant was 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 outlined above. 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
Before the Civil War the practice of psychiatry occurred almost exclusively within the walls of asylums. The wave of reforming optimism which swept over the United States in the early nineteenth century resulted in the construction of a number of these institutions. By 1844 the superintendents of thirteen asylums were ready to form the Association of Medical Superintendents of American Institutions for the Insane (AMSAII) and establish the American Journal of Insanity. While this association was the first organization of medical specialists in the United States, it was quite different from those which followed it. As the name of the association suggests its members were not primarily interested in a class of patients, as was true of pediatrics, or with diseases of a particular organ system, as with opthalmology, but with the administration of a particular institution. This administrative slant was so pronounced, in fact, that even assistant asylum physicians were excluded from membership in AMSAII. As early issues of the American Journal of Insanity demonstrate, concerns with asylum management rather than scientific studies of insanity dominated the early meetings of the association. Some superintendents wrote about the consequences of religious revivals, mental hygiene and medico-legal subjects but these issues always remained marginal to the day to day problems of caring for severely disturbed patients. Concerns with the quality of asylum care during the first half of the nineteenth century resulted both from the humanitarian impulses of the early superintendents and a need to legitimize asylum care in a society where hospitals were seen chiefly as places to die. The narrowness of these concerns, however, made members of AMSAII vulnerable to criticism that they had isolated themselves from important scientific developments in medicine.2
By the end of the Civil War some of the early optimism which had led to the founding of the insane asylum was beginning to fade. Foreign born patients appeared more difficult to treat, chronic patients were accumulating and asylums were beginning to become overcrowded. Nonetheless asylum superintendents were still confident about their approach to patients and, indeed, some physicians were beginning to apply the principles of asylum care to the treatment of alcoholics by creating specialized inebriate asylums.3 At the same time, however, a new group of professionals was organizing itself and preparing both to claim expertise in the treatment of the insane and to advocate a radically expanded vision of the idea of mental illness and health. The new professionals called themselves neurologists and with their claims to a truly scientific understanding of the nervous system in health and disease they both challenged the hegemony of the medical superintendents and opened the way to a transformation of the field of psychiatry.
The American Neurological Association was established by eighteen physicians at a meeting in New York City in 1875 and the Journal of Nervous and Mental Diseases was designated as their official organ in the following year. In contrast to AMSAII which was founded out of the real need of asylum superintendents to discuss common problems, the ANA was founded in the faith that recent scientific studies of the nervous system would soon change the treatment of nervous diseases sufficiently to justify their new specialty. These early neurologists drew their confidence in their scientific understanding of the nervous system from several sources. In Europe advances were being made in the development of a localizing neuropathology. The older theories of phrenology had not only been put to rest but discoveries such as Broca's delineation in 1860 of a speech area in the brain opened the prospect that the true functions of the brain would soon be outlined. The concept of the reflex arc developed in the first half of the nineteenth century by Bell, Magendie and Hall had also created the possibility that the basic physiological processes of the nervous system would soon be understood. Indeed some such as Carpenter and Laycock in England attempted to use the concept of reflex action to explain "higher" mental functions and such pathological phenomena as somnambulism and trance. While these developments were occurring in Europe, some Americans were also contributing to the scientific foundations of the new specialty of neurology. During the Civil War, S. Weir Mitchell, who was later to be one of the leaders of American neurology, and his colleagues William W. Keen and George Read Morehouse had an opportunity to observe a vast number of peripheral nerve injuries. These observations were carefully recorded and formed the basis for subsequent publications including Mitchell's internationally renowned Injuries of the Nerves and their Consequences.4
While neurologists could use these specific scientific developments to give substance to their claims of scientific expertise, they were also eager to wrap themselves in the broad banners of positivism and scientism, which were so popular at the time, and to draw on models that had been successful in other areas of science. Some such as Edward Spitzka studied in Germany and brought back the conviction that new scientific methods would soon lead to great breakthroughs in neurology. Others were eager to present themselves to the public as scientific critics of such popular "delusions" as spiritualism.5 Virtually all of them drew heavily on contemporary theories of evolution, particularly those of Spencer, and popular ideas about the conservation of energy. This strong identification with the values of science contrasted sharply with the moral and religious tone of many asylum superintendents. It was also in terms of these differences in style, rather than specific scientific differences, that the conflicts between the neurologists and the asylum superintendents expressed themselves.
In practice many of the bold scientific claims of the neurologists were, however, no more than programatic. While some neurologists were among the first to introduce lectures on nervous and mental diseases into medical school curricula, late nineteenth century American medical schools offered very little support for research careers. What research neurologists did was usually privately funded, on a small scale and largely clinical. To make a living these new specialists generally found themselves in office practice in American urban centers such as Boston, New York and Philadelphia. Unlike the opthalmologist, whose clearly superior skills and narrowly focused specialty allowed comfortable referral relations with the general practitioner, the neurologist, like the pediatrician and the gynecologist, defined his speciality quite broadly. This put the specialist in neurology in direct competition with the generalist. Freud, whose practice in the 1880s resembled that of his American counterparts, also reflected their experience when he wrote that:
On the one hand the prospects in the treatment of... (organic nervous) disorders... were never promising, while on the other hand, in the practice of a physician working in a large town, the quantity of such patients was nothing to the crowds of neurotics whose number seemed further multiplied, by the manner in which they hurried, with their troubles unsolved, from one physician to another.
Because many of the neurotics to whom Freud refers were likely to agree with their family physicians that their complaints were "only nervousness," neurologists faced the difficult task of convincing the public to take these complaints seriously and to insist on neurologic treatment.6
In order to win serious consideration for the nervous patient, neurologists had to present nervousness in medically acceptable terms. Because the suffering of these patients could not be explained in terms of anatomically discrete neuropathological lesions they turned to physiological ideas, particularly that of the functional disorder. While such physiological thinking had less prestige, at the time, than anatomical explanations, it still had greater medical legitimacy than what would now be called psychological explanations. The latter were seen as "spiritual" and more appropriate for the theologian or novelist than the doctor. The awkwardness of such physiological thinking about patients' complaints is, perhaps, suggested by the title of W.B. Carpenter's popular book Mental Physiology; while the lengths to which this style of thinking could be pushed can be seen in Freud's Project for a Scientific Psychology. When, in the 1880s, the great neurologist Charcot turned his attention to hysteria and treated it as a functional disorder, however, the physiological approach succeeded in establishing the nervous patient as medically ill.7
Perhaps the first successful proponent of the notion of functional nervous disorder was the American neurologist George Miller Beard. In 1869 Beard announced his discovery of what was to become--even more so than hysteria-- the typical functional disorder of the age: neurasthenia. Without special training in neurology, Beard made his discovery while using a form of "general electrization" he had learned from a lay practitioner. Placing the electrodes on his own hands, Beard gave a mild electrical massage to all the muscles of the patient's body and he repeated this process daily for weeks or months as necessary. What he found was that two-thirds of his patients recovered from a wide variety of complaints such as fatigue, dyspepsia, headaches and nervousness. Viewing electricity as a kind of tonic, traditionally associated with vital nervous energy, he reasoned that all of these patients suffered from a lack of nerve force which his treatment restored. "Nervousness," he proclaimed, " is really nervelessness." He argued that this lack of nerve force was the result of a specific functional nervous disorder that he called neurasthenia and in the years following his initial publication he became a tireless advocate of the importance of this condition. 8 Beard's physiological explanation of neurasthenia in terms of nerve force as well as his apparent ability to cure this illness had great appeal. Not only were some relieved to learn that they suffered from something real, but others were reassured to learn that their "symptoms, which for a long time had kept them in a state of alarm, if not despair, lest they might be precursors of incurable disease of the brain or spinal cord" could be treated. Beard's theory also had special appeal for affluent patients, who were of particular interest to neurologists in private practice. By drawing on contemporary notions of evolution, this theory suggested that the victims of neurasthenia were most likely to be highly successful as well as highly refined people. The highly developed "nervous organization" of such "brain workers" it was argued, made them especially sensitive to the stresses of advanced civilization. Because Beard explained the protean manifestations of neurasthenia by calling on three central ideas of the period-- the reflex theory, the electrical nature of the nerve impulse and the law of conservation of energy, heLink also left little doubt about the scientific status of those who treated it.9
While the diagnosis of neurasthenia and Beard's explanation of it achieved international standing, which they maintained into the twentieth century, Beard's treatment was soon eclipsed by the more comprehensive rest cure. This treatment was developed by S. Weir Mitchell who, like Beard, had established an office practice after the Civil War. Drawing on his observation that "complete rest and plentiful food" allowed exhausted soldiers to return to the front, he tried the same approach in 1874 with Mrs. G. a "lady of ample means, with no special troubles or annoyances, but completely exhausted by having had children in rapid succession and from having undertaken to do charitable and other work to an extent for beyond her strength." When he discovered that she could not tolerate complete bed rest he added passive massage to the regimen and was delighted by her recovery. Soon he added electrotherapy, over-feeding and seclusion of the patient from her family to the treatment. This treatment, particularly his insistence on secluding the patient from her family, showed considerable insight into the family dynamics surrounding invalids. Mitchell nonetheless was consistent in emphasizing the somatic aspects of the rest cure-- even calling his book describing the cure Fat and Blood. This treatment, like the concept of neurasthenia, achieved international popularity-- even Freud spoke highly of it. It also provoked one of Mitchell's patients, the noted feminist Charlotte Perkins Gilman, to write 'The Yellow Wallpaper' a stinging satire in which she suggests that the rest cure nearly drove her crazy.10
With diagnoses like neurasthenia and treatments like the rest cure achieving significant popularity, a new type of medical practitioner, the nerve doctor, was emerging. In Europe a sharp split betweem this new specialty and the older form of practice, which centered around the asylum, was largely avoided. In Germany, for example, the influential Wilhelm Greisinger assumed the chair of Psychiatry and Neurology at Berlin in 1865. By uniting psychiatry and neurology with the prestige of a university chair as well as his slogan "psychological diseases are diseases of the brain," Greisinger established a tradition that left little room for the kind of interprofessional conflict that marked the American scene. In France the great neurologist Charcot worked at that country's largest asylum, the Salpetriere; and In Austria, while Freud pursued his office practice with nervous patients, his mentor, Meynert, held a chair at the University and conducted a program of research on localizing neuropathology.11
In the United States the absence of a strong university medical school tradition and the presence of a well organized association of asylum superintendents left those neurologists who wanted to emulate their research oriented European counterparts isolated from the most interesting patients. During the late 1870s and early 1880s this situation contributed to one of the most bitter conflicts in the history of American psychiatry. Having established a national association of their own in the early 1870s, American neurologists were soon ready to launch an organized critique of the dominant branch of the psychiatric profession. The New York Neurological Society, which represented the core of the national association, fired the first volley in 1878 by submitting a formal petition to the New York State legislature demanding an investigation of the asylum system of that state. When the legislature's committee on public affairs absolved the state's hospitals the following year, the neurologists claimed there had been a whitewash. After this initial clash, however, momentum built and soon led to an alliance between the neurologists and members of the National Conference of Charities and Corrections which was a group of charity reformers concerned with placing public welfare on a more "scientific" footing.
By 1880 this coalition of neurologists, charity reformers and a few reform minded asylum superintendents were ready to form the National Association for the Protection of the Insane and the Prevention of Insanity (N.A.P.I.P.I.). Dedicated ( in George Miller Beard's words) to "obtaining universal recognition of the fact that it is no disgrace to be crazy," this organization provided a forum for neurologists to continue their attack on the management of American asylums. They pointed to the growing isolation of asylum superintendents from new developments in medicine, the seemingly excessive preoccupation of the superintendents with the physical plants of their asylums, the superintendents' lack of scientific training and the paucity of scientific research done in asylums. They also joined with English psychiatrists in complaining about the use of mechanical restraints on insane patients in the United States. Because asylum care in the 1870s had deteriorated from what it had been thirty years earlier, some of the neurologists' criticisms were well taken. The thrust of these criticisms, however, was aimed not so much at the specific abuses as at establishing the ideal of "science" as the norm of good psychiatric care. Because asylum superintendents did not take this criticism passively, what evolved was an intense war of words between a group of self-proclaimed advocates of the ideals of science and a group that considered itself uniquely qualified to provide humane care for the insane. In this context asylum superintendents were assailed as "despots," "autocrats," "reactionaries," and "businessmen who had lost interest in medicine and science," while the superintendents expressed their contempt for "outside meddlers," "soft headed humanitarians," and "neuropaths."12
The conflict between the neurologists and the asylum superintendents was not, however, limited to the question of asylum reform. The assassination of President Garfield by Charles Guiteau in 1882 provided another arena in which both groups could attempt to demonstrate the superiority of their professional perspectives. By providing an opportunity for the most outspoken members of the two groups to line up on opposite sides of the question of guilt versus insanity, Guiteau's trial probably gave the public more insight into the conflicts within the profession than into the accused's mental state. John Gray, who was superintendent of the Utica Asylum in New York and editor of the American Journal of Insanity (which he owned), took the position that Guiteau was sane because he "had been motivated neither by uncontrollable rage nor by the torrents of insane compulsion...(but instead)... thought, reasoned and controlled his actions." Guiteau's claim that he killed the president out of inspiration was dismissed by Gray as after-the-fact rationalization and his long history of strange behavior as egotism. The star defense witness, the neurologist Edward Spitzka, argued that Guiteau was insane because his crime was "the result of a morbid project rather than a delusion strictly speaking." This broad definition of what counted as insane behavior was supported by Spitzka's view that Guiteau's long history of strange behavior was due to a "congenital malformation of the brain." With testimony like this Spitzka no doubt demonstrated his familiarity with the latest European scientific theories, especially the popular theory of hereditary degeneration. Nonetheless Gray's narrow interpretation of criminal responsibility prevailed. Guiteau was convicted and hung-- perhaps inevitably considering public sentiment about the assassination. Within a few years the neurologists' position seemed increasingly plausible and few doubted Guiteau's insanity.13
Not long after the Guiteau trial the sharp controversies between the neurologists and the asylum superintendents died down almost as abruptly as they had begun. By the mid 1880s the NAPIPI was dead and with it the chief instrument of the neurologists attack. In part this was due to the death of some of the most active leaders of the organization. In part it was due to a split between the neurologists and the lay members of NAPIPI, some of whom were hostile to all medical experts. It was also, no doubt due to the fact that the asylum superintendents slowly began to reform their organization. By 1892 AMSAII had broadened its membership to include assistant asylum physicians and at the same time, in a significant symbolic gesture, they changed the name of the organization to the American Medico-psychological Association. Of particular interest is the fact that in 1894 the distinguished neurologist S. Weir Mitchell was invited to address the newly renamed association. Mitchell initially refused the invitation, perhaps not wanting to rekindle the controversies of the 1880s. The invitation was renewed; and when he spoke,Mitchell did not pull his punches. He repeated many of the same criticism that had been made in the early 1880s and told his audience:
You were the first specialists and you have never come back into line... You soon began to live apart and you still do so. Your hospitals are not our hospitals; your ways are not our ways... I am strongly of the opinion that... the belief that no one could, or should, treat the insane except the special practitioner has done us and you and many of our patients a lasting wrong.
While some of Mitchell's criticisms were unjust because he seemed to be unaware of changes that had occurred in the care of the insane, the American Journal of Insanity published a remarkably mild response. Clearly the members of the American Medico-psychological Association were confident enough in their own progressive reforms that they were willing to listen to their critics.14
Another reason that the neurologists may have moderated their criticism of their asylum based colleagues was that they had achieved a degree of success in establishing themselves as experts in the care of the mentally ill. What this meant, in part, was establishing the value of the non-asylum treatment of the insane. Because of the great popularity of asylum care in the early nineteenth century and the wide acceptance of the view that isolating the insane from the harmful influences of their environment was an important ingredient in successful treatment, non-asylum care had no formal place in American medical theory or practice. In an influential paper on "The Non-asylum Treatment of the Insane" published in 1879, the neurologist William A. Hammond argued "that the medical profession is, as a body, fully capable of treating cases of insanity as cases of any other disease, and that in many instances sequestration is not only unnecessary but positively injurious." According to Hammond, neurologists, and even some general practitioners, were better able than asylum superintendents to recognize cases of insanity during their early and treatable phase. With the exception of "those who refuse food, who have homicidal or suicidal tendencies, or delusional or morbid impulses, which prompt them to the destruction of property or other acts of violence," he argued, they were also quite able to treat them at home. Because twentieth century definitions of mental illness are so different than those of the 1870s it is difficult to understand Hammond's point without considering a specific case. For example:
M.g., a lady thirty years of age, and a widow for three years, consulted me on February 20th, 1877, for what was considered to be incipient insanity, and an affection in all probability, requiring, it was feared, incarceration in a lunatic asylum. The patient was quiet and orderly in her demeanor, and so far as her friend's accounts went, entirely sane, except on one point of fear of contamination, which was exhibited by mental distress, and the practice of washing her hands without there being obvious cause for doing so...
Treating her with a mixture of a mild cathartic, a bromide and opium, he reported that within three to four months her mental strength was improved and she was better able "to contend with the ridiculous notions which govern her." By advocating the non-asylum treatment of a case of "incipient insanity" such as this Hammond was redefining the place of asylum care in psychiatry and enlarging the field of "out-patient" treatment that Beard had begun to stake out with his concept of neurasthenia. By the beginning of the twentieth century many asylums (which were often called hospitals by then) had established out-patient departments.15
By the 1880s the field of non-asylum treatment was well established and a significant number of neurologists could make a living treating neurasthenics as well as patients such as the one described by Hammond. Perhaps the most important condition that neurologists treated, however, was hysteria. Both because hysteria mocked neurologists' efforts to explain it in terms of their localizing neuropathology and because it responded to such distinctly "unmedical" treatments as hypnosis, suggestion, and psychoanalysis, it opened the way for some neurologists to broaden the field of psychiatry by developing a psychological point of view. Traditionally viewed as a disorder of women, hysteria had long been the bane of physicians' lives. As Reynolds put it in a standard medical text, " The employment of the word 'hysterical' may sometimes be found indicative of the state of mind of the practitioner rather than that of the patient's health." Viewed in terms of twentieth century categories, the hysterical woman's symptoms have recently been described as a covert rebellion against her limited oportunities in life. For nineteenth century neurologists, however, hysteria was interesting because so many of its symptoms resembled those produced by genuine neurologic lesions. Paralysis, ataxia, abnormal movements, dysasthesias, and seizures could all be found. If the power of neurologic diagnosis was to be established, hysterical imitations had to be distinguished from the real thing. Even the great English neurologist Hughlings Jackson was interested in the difference between hysterical seizures and epilepsy. For Jackson as well as many of his counterparts in Europe and America, however, hysteria itself was of little interest after the process of differential diagnosis was complete. According to Jackson's influential doctrine of concomitance "mental symptoms...are, strictly speaking, only signs to physicians of what is going on or what is going on wrongly in a part of a patient's material organization." From this point of view the protean and perplexing symptoms of hysteria offered little promise of neurologic insight.16
Not all neurologists, however, followed Jackson's lead. Particularly in France, under the influence of Jean Martin Charcot, neurologists began turning their attention toward hysteria as a condition worthy of study in itself. Beginning his career as Medicin de l'Hospice de la Salpetriere in 1862, Charcot had used his "museum of living pathology" to delineate numerous neurologic syndromes. When he turned his attention to the study of hysteria in the late 1870s he was generally recognized as one of the world's leading neurologists. With Charcot studying hysteria, others could not easily ignore it. Charcot was important not only because of his prestige but also because he presented his views in terms that were readily acceptable to late nineteenth century neurologists while at the same time opening the way for others to go beyond his findings to develop a psychological point of view toward hysteria and other nervous disorders. For Charcot the fact that hysteria 'left no material trace that can be discovered' and therefore resisted efforts to explain it in terms of localizing neuropathology was of less importance than the fact that it was "governed, in the same way as other morbid conditions, by rules and laws." In his hands, for example, hysterical seizures appeared to proceed through distinct and readily observable stages. While observations like this later came under severe criticism, they were important at the time because they allowed neurologists to see hysteria as a genuine disease. Charcot's understanding of hysteria was also readily accepted by neurologists because it was consistent with their belief that only materialistic explanations could be regarded as truely scientific. For Charcot the dominant idea in the etiology of hysteria was hereditary predisposition. Drawing on the popular theory of hereditary degeneration, he generally established the presence of such a predisposition by giving the patient's family history, where psychic disturbances, organic nervous diseases and more or less diffuse diseases of other kinds in relatives were mentioned.17
In spite of his strong somatic bias, Charcot's studies on hysteria opened the way for the development of a psychological point of view in at least two ways. The first of these was his legitimation of hypnosis as a tool of neurological research. Since the late eighteenth century regular physicians had largely avoided using hypnosis. Efforts to explain its effects in material terms, that is in terms of a magnetic fluid, had been consistently unsuccessful and medical discourse had no place for "spiritual' explanations. Consequently during the nineteenth century, with exceptions like James Braid in England, hypnosis was largely the property of irregulars such as spiritualists and magnetic healers. Even in the 1870s neurologists who attempted to employ hypnosis ran the risk of being regarded as charlatans. When Charcot started to use hypnosis to study hysteria in 1878 this began to change. Only after 1882, when Charcot's findings with hypnosis were accepted by the Academie des Sciences, which had rejected similar findings three times in the previous century, could other neurologists begin to investigate hypnotic phenomena in earnest.18
One reason that Charcot's understanding of hypnosis was readily accepted was that, like his understanding of hysteria, it was quite consistent with the dominant scientific mores of the time.Viewing hypnosis as only "an artificially produced morbid condition--a neurosis" which "disclose(d) itself almost always on soil predisposed by hysteria," he regarded its potential as a treatment as quite limited. Nonetheless, others, notably Charcot's rival Bernheim, extended the territory established by Charcot by arguing that hypnotic phenomena could be found in normal people as well as in hysterics and by demonstrating the therapeutic potential of hypnotic suggestion.Still others such as Janet, Breuer and Freud built on Charcot's work, using hypnosis to establish their remarkable hypotheses about the presence of an unconscious mental life. With this work psychological theory and psychological treatment were well on their way to being established as part of the field of psychiatry.19
Charcot also created an opportunity for neurology and psychiatry to incorporate the psychological in to their domain through his consideration of the role of trauma in the etiology of hysteria. While regarding hereditary predisposition as central to his understanding of this disorder, he did grant that "a thorough acquaintance not only with the disease, but also with the conditions under which it is produced will... (be seen)... as useful from the fact that nervous disorders often ensue without any traumatic lesions and simply as a result of ...psychical nervous shock." It is of interest that Charcot's consideration of traumatic, that is to say, emotional factors resulted from his study of male hysterics-- particularly those men who were the victims of a puzzling nervous disorder often referred to as "railway spine." Because women were expected to be emotional it was easy to see their hysteria as simply due to an inherited nervous weakness. The possibility, Charcot noted, that "a firemen of a locomotive, for instance, never before emotional, at least in appearance, may as the result of a railroad accident... become hysterical just like a woman-- this (had) never entered into the imagination of some people." While Charcot regarded the terror that such a fireman might have experienced as only an "agent provocateur" that released the disposition to disease, the fact that he acknowledged that emotions might result in hysteria in such apparently robust individuals clearly weakened the explanatory importance of heredity. In the hands of other neurologists, most notably Charcot's student Freud, the importance of traumatic factors could be expanded to the point of virtually replacing heredity as the dominant idea in the etiology of hysteria-- for women as well as men. The fact that such traumatic factors also appeared to be treatable through new psychological means also contributed to an important wave of therapeutic optimism among neurologists.20
With this significant work occurring on the continent of Europe, Americans could not completely ignore hysteria, hypnosis and the developing psychological point of view. Among those claiming expertise in caring for the mentally ill, neurologists were among the first to import these new ideas and approaches. While some neurologists were interested in European developments in the 1880s and 1890s, widespread interest did not develop until after 1906. In that year Pierre Janet, who was viewed as a representative of the "school established by Charcot," delivered an important series of lectures on "The Major Symptoms of Hysteria" at Harvard University and another series of lectures on psychotherapeutics at the Lowell Institute. The year before, the Swiss neurologist Paul Dubois' book, The Psychic Treatment of Nervous Disorders, (for a time regarded as the bible of psychotherapeutics), had been translated. By July 1907 seventy-nine papers and ten books were listed in the Index Medicus under the heading "psychotherapy" -- a heading that had first appeared only in may 1906. The psychological ideas of Bernheim, Dubois, Janet and especially Freud, were, however, not imported without controversy. At the opening of the twentieth century controversies among neurologists about the legitimacy of psychological ideas and treatments had, in fact, clearly upstaged lingering disagreements between neurologists and those working in psychiatric hospitals. While most hospital-based psychiatrists had little use for the new ideas, reformers saw the new psychological approach as a way to revitalize their work. Indeed, the combination of increasing conflict among neurologists and a progressive rapproachment between psychologically oriented neurologists and reform minded hospital psychiatrists contributed greatly to establishing the boundaries of the field of psychiatry that have prevailed through most to the twentieth century.21
Disagreements among neurologists over hypnosis, suggestive therapeutics and especially psychoanalysis took on a somewhat regional character. While Boston neurologists were relatively eager to import the new approaches, neurologists in other cities such as Philadelphia imposed a virtual quarantine to prevent their spread. Perhaps a lingering sympathy for transcendentalist philosophy made Bostonians particularly receptive to the results of hypnotic experiments and even psychical researches. In any event between 1890 and 1909 a loosely knit group of psychologists, philosophers, neurologists and even men associated with psychiatric hospitals--the so-called Boston school-- cooperated to develop a sophisticated psychological approach to mental disorders. The two neurologists in this group, Morton Prince and James Jackson Putnam, deserve special mention. Prince began his medical career treating diseases of the nose and throat but switched to the study of nervous diseases in the early 1880s. A visit to Charcot (with his ailing mother) and another trip to study with Bernheim firmly established his interest in hysteria and hypnosis. By 1890 his own research allowed him to publish a paper on "Some of the Revelations of Hypnosis: Post-Hypnotic Suggestion, Automatic Writing and Double Personality." Accepting Bernheim's view of hypnosis as a normal phenomena, Prince used this technique less as a therapy than as a tool to conduct a series of original researches, particularly on the subject of multiple personality.Prince's importance, however, was perhaps less as an original researcher than as a publicist for the importance of psychological issues. In 1906 he founded the Journal of Abnormal Psychology, which was highly influential in introducing professionals to this area. In the same year he also published The Dissociation of a Personality, which was, perhaps more than any other single early twentieth century work, responsible for exposing the American public to the mysteries of the subconscious.22
To understand the role of the profession of neurology in introducing the psychological point of view into psychiatry, however, it is perhaps more useful to consider less original thinkers than Prince, Janet, or Freud. From this point of view those neurologists who gave up a firm commitment to somaticism to accept the psychological ideas of others are of particular interest. Here the best known American example is James Jackson Putnam. Educated in Germany like such ardent materialists as Spitzka, Putnam was a highly influential proponent of the somatic point of view in the years after the Civil War. At a meeting of the American Neurological Association in 1876 when George Miller Beard presented a series of experiments which tested " how much could be done in the way of effecting cures in cases of rheumatism, neuralgic sleeplessness and various forms of chronic diseases by exciting in patients a definite expectation," Putnam replied that he "had never seen any evidence that cure had been effected by mental influences in cases where actual disease existed..." By 1909, however, Putnam was ready to enthusiastically welcome Freud, when the latter gave a series of lectures at Clark University, and by the time of his death in 1918 Putnam had become the leading American advocate of psychoanalysis. Freud's charisma notwithstanding, Putnam's own career clearly must have been critical in producing such a radical transformation. Certainly his friendship with members of the Boston "school" such as William James and Morton Prince played a role as did Putnam's own philosophic interests.23
Two features of Putnam's neurological career, however, should also be mentioned. First, Putnam studied not only in Germany but also in England with Hughlings Jackson. While Jackson's principle of concomitance kept him from directly pursuing psychological investigations, his dynamic and evolutionary approach to nervous function bears some striking similarities to Freud's dynamic psychology. Indeed Putnam remembered Jackson teaching that "when the hierarchy of (cerebral) functions... suffers derangement at any part... the attempt at a reestablishment of some sort of equilibrium is always such that the new arrangement tends to safeguard itself..." One wonders whether Putnam's exposure to this style of thinking prepared him to find Freud's dynamic explanations in terms of energy, regression and defense more congenial. In any event, the fact that Freud's style of theorizing in terms of dynamic and evolutionary concepts was generally familiar to neurologists must have allowed them to take his ideas seriously even when they did not agree with him.24 To understand Putnam's willingness to accept a specifically psychological etiology for hysteria it is important to note that Putnam, like Charcot, had considerable experience with traumatic neuroses like "railway spine." Because such patients often suffered from apparently trivial injuries and because they often developed symptoms only some time after the accident their compensation by railway companies was the subject of considerable controversy. In examining these patients Putnam had to distinguish between hysteria, as a genuine disorder, and deliberate simulation. Perhaps his success in doing so allowed him to take hysteria seriously and prepared him to accept Freud's emphasis on traumatic factors in the etiology of hysteria. The experiences of other neurologists with traumatic neuroses may also have prepared them for Freud's theory of the traumatic etiology of hysteria. In any event neurologists did find that theory a comfortable way to understand Freud and continued to ascribe it to Freud long after he had changed his views.25
Perhaps the greatest effect of the new European ideas on American neurology was not as a source of hypnotic experiments or explanations for traumatic neuroses but as a source of effective treatments. As practitioners, neurologists were always aware of the importance of such treatments in attracting patients. While electrotherapy and the rest cure continued to suffice for some neurologists, their limitations were well known by the turn of the century. Indeed even in the 1890s there was some willingness to understand these treatments in psychological terms. At the same time Europeans were developing several kinds of psychotherapy and claiming dramatic results. Hypnosis itself could be used therapeutically. Bernheim, who saw hypnosis as only an extreme form of the normal suggestive influence of one person on another, advocated using suggestions to directly correct symptoms. Those who found such suggestive therapeutics deceptive and perhaps unethical could turn to Dejerine or Dubois who advocated using moral appeals and reasoning to persuade patients to get better. And, of course, there was Freud and his "psycho-analysis." After Janet's visit in 1906 and Freud's in 1909, competition between the advocates of these various approaches intensified.26
There were, however, other sources of competition as well. Particularly in Boston at the turn of the century Christian Science, the New Thought Movement and the Emmanual Movement were all successful in attracting patients to religious healers. Such competition with religious movements was not altogether new to neurologists. In the 1870s, for example, Beard and Hammond devoted considerable energy to demonstrating that materialist explanations of trance phenomena were superior to the supernatural explanations offered by the quasi-religious movement known as "modern" spiritualism. What was new at the turn of the century, however, was that the new psychotherapies were not so easily distinguished from their religious counterparts. Janet, for example pointed out the similarities between Dubois' "medical moralization" and Christian Science; the Emmanual Movement actually used friendly neurologists to develop their approach.27 The New York neurologist C.L. Dana summed up the situation: "After all, the question is not whether we should use psychotherapeutics, hypnotism or suggestion; we as neurologists are confronted with the fact than an enormous number of mentally sick people are running around and get their psychotherapeutics from the wrong well."28
While some neurologists were actively developing and promoting the new forms of psychotherapy, others saw these new treatments as a threat to neurology . For them the psychological point of view undermined the identity of the profession. While one neurologist saw Freud and Dubois as contradicting one of neurology's fundamental beliefs because he got the impression "that neither one of them believes that there is ever a physical foundation for nervous disorders," another neurologist worried that enthusiasm for psychoanalysis and psychotherapy would deprive neurologists of those basic diagnostic skills that gave the profession its claims to expertise.29 Still a third said that he was "in favor of psychotherapy but such as he can practice without labeling it or calling the attention of his patients to it and saying to them "Here I am a practitioner of psychotherapeutics." "I am a neurologist, he added, "I am not going to call myself a psychotherapeuticist any more than I would call myself an electrician."30 What this meant was that somatically oriented neurologists might adopt such techniques as suggestion, that could be incorporated into their familiar mode of practice, while rejecting more elaborately systematized methods such as psychoanalysis. Even such a staunch somaticist as the Philadelphia neurologist Francis X. Dercum could claim that "suggestion as an adjuvant may, in skillful hands, aid in the most unmistakable manner in bringing about a recovery." On the other hand he added, "psychanalysis (sic)... is a cult, a creed, the disciples of which constitute a sect. To be admitted to its brotherhood it is merely necessary that he should be converted to the faith, not that he should be convinced by scientific proof, for none such is possible."31
The split among neurologists over psychotherapeutics in general and over psychoanalysis in particular widened during the second decade of the twentieth century. Some neurologists were not only troubled by the sectarian character of the psychoanalytic movement but by what they saw as Freud's exclusive concern with sexual factors in the etiology of nervous disorders or as one of them put it,"this eternal harping on sex as if it were the only thing in life."32 One focus of these differences was the Journal of Nervous and Mental Diseases. Because this journal published the proceedings of the American Neurological Association it was virtually the official journal of that organization even though it was privately owned by its editor Smith Ely Jelliffe. After Jelliffe's "conversion" to psychoanalysis in the early years of the century an increasing proportion of the journal's articles were devoted to psychoanalytic subjects. By 1913 a number of neurologists, feeling that there was literally not enough room in that journal for their organic approach and that of the psychoanalysts, rebuffed Jelliffe and founded a new journal--The Archives of Psychiatry and Neurology. After this dramatic event organically and psychologically oriented neurologists continued to grow further apart. For neurologists interested in psychotherapy and psychoanalysis this did not result in professional isolation, however, because while some neurologists were rejecting the psychological point of view, hospital based psychiatrists were increasingly coming to accept it.33
The rapproachment between hospital based psychiatrists and neurologists had been going on since the 1890s. The fact that psychiatrists emphasized their scientific credentials and their interest in disease processes made the differences between the two professions less apparent. Not only were some neurologists running psychiatric hospitals and hospital psychiatrists caring for "extra-mural" patients but they were even participating in the same professional organizations. The Boston Medico-Psychological Society, which was founded in 1880 by asylum psychiatrists, for example, admitted neurologists to membership in the 1890s and in 1901. changed its name to the Boston Society for Psychiatry and Neurology.34 While the new psychological approaches had little to offer most institutionalized patients, they did offer the possibility of some cures and this appealed to reformers hoping to cast off psychiatry's custodial image. Some efforts to introduce psychotherapy and psychoanalysis into psychiatric hospitals were made. As William Alanson White noted, however, the effect of such treatments was more easily measured in improved staff morale than in increased patient well being. Of greater importance to the relationship between psychiatry and neurology was the fact that after the turn of the century psychiatrists were increasingly anxious to reach beyond institutional walls and no longer limit their activities and responsibilities to the institutionalized mentally ill. After 1910 the mental hygiene movement, with its emphasis on preventing mental disorders, gave this change in psychiatry its rationale. Adolf Meyer's ecclectic "psychobiology," which stressed understanding individual patients through a complete account of their biographies, gave these changes a theoretical foundation. Neurologists interested in psychotherapy could now find a more comfortable home in the newly expanded field of psychiatry.35
By the time of the First World War, then, the boundaries of the field of psychiatry had been radically altered. The nineteenth century distinction between asylum superintendent and nerve specialist had been obliterated. Neurologists were no longer concerned with the nervous patient but rather with the diagnosis and treatment of organic disorders of the nervous system. Psychiatry, while not completely abandoning its commitment to the institutionalized mentally ill, had expanded its claims of expertise to cover a broad domain beyond the walls of the hospital. Late nineteenth century neurologists had catalyzed this change in psychiatry in several ways. By insisting that psychiatrists adopt a more scientific posture toward their work they had stimulated reforms that allowed the profession to achieve a degree of credibility in the twentieth century. By legitimizing the care of the nervous patient they had opened up a new field into which twentieth century psychiatrists were able to move. By introducing psychological theories and psychological treatments they had given psychiatry the tools it needed to broaden its claims of expertise. In stimulating this broad expansion of psychiatry late nineteenth century neurologists may not have succeeded in demonstrating that it "is no disgrace to be crazy" but they did contribute to the astonishing willingness of twentieth century Americans to see themselves has having psychiatric problems.

1 . Jacques M. Quen, "Asylum Psychiatry, Neurology, Social Work and Mental Hygiene:An Exploratory Study in Interprofessional History," J. Hist Beh.Sci. 13 (1977):3-11 presents a similar argument to that presented in this paper.He adopts a broadly interprofessional focus, while this paper focuses more narrowly on the dynamic influence of the new profession of neurology. 2 .Gerald Grob, Mental Institutions in America: Social Policy to 1875 (New York: The Free Press, 1973). Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the art of asylum keeping, 1840-1883, (Cambridge U.K.: Cambridge University Press, 1984). For a discussion of types of medical specialty see; Bonnie Blustein, "New York Neurologists and the Specialization of American Medicine," Bull. Hist. Med. 53, no.2 (Summer 1979): 170-183. Among those early superintendents who wrote on non-asylum related issues were: Isaac Ray, Mental Hygiene (Boston:Ticnor and Fields, 1863); Isaac Ray, A Treatise on Medical Jurisprudence of Insanity (Boston: Charles C. Little and James Brown, 1838); Amariah Brigham, Remarks on the Influence of Mental Cultivation and Mental Excitement Upon Health (Boston : March Capen and Lyon, 1832) 3 . Edward M. Brown,"What Shall We do with the Inebriate: Asylum Treatment and the Disease Concept of Alcoholism in the Late Nineteenth Century," Journal of the History of the Behavioral Sciences,21(1985):48-59. 4 . Russell N. DeJong, A History of American Neurology (New York: Raven Press, 1982), pp.37-41. A. Earl Walker, "The Development of Cerebral Localization in the Nineteenth Century," Bull. Hist. Med. 31, no.2 (March-April 1957): 99-121. Franklin Fearing, Reflex Action: A Study in the History of Physiological Psychology (Cambridge, Mass.: MIT Press, 1970), p.237.S. Weir Mitchell, Injuries of Nerves and Their Consequences (Philadelphia: Lippincott, 1872) 5 .Edward M. Brown, "Neurology and Spiritualism in the 1870s," Bull.Hist.Med. 57,(1983):563-578. 6 .T.H. Weisenberg, "Neurologic Teaching in America," Trans.Sect.Nerv.and Ment. Dis. AMA(1908):11-15.For a discussion of research done by neurologists see: Bonnie Ellen Blustein, Preserve your love for science: life of William A. Hammond (Cambridge U.K.:Cambridge University Press, 1991) . Stephen Young Wilkerson, "Mind Over Body:James Jackson Putnam and the Impact of Neurology on Psychiatry in Late Nineteenth Century America," Unpublished Ph.D.dissertation (1978), Duke University.Sigmund Freud, An Autobiographical Study (New York :W.W.Norton, 1963),p.29. 7 .Kenneth Levin, Freud's Early Psychology of the Neuroses (Pittsburgh: Univeristy of Pittsburgh Press, 1978),pp.16-63.
William B. Carpenter, Principles of Mental Pathology (London:C. Kegan Paul & Co., 1879).Sigmund Freud, The Origins of Psychoanalysis (New York:Basic Books, 1954), pp. 347-446. 8 .Charles Rosenberg, "The Place of George Miller Beard in American Psychiatry," Bull.Hist.Med.36 (1962):245-259. Edward M. Brown, "An American Treatment for the 'American Nervousness': Beard and Rockwell's General Electrization," Presented to the American Association for the History of Medicine, May 1980. 9 .Young amd middle aged men worried especially about developing general paresis or tabes dorsalis both of which were, at the time, fatal and of unknown etiology. George Miller Beard, A Practical Treatise on Nervous Exhaustion (New York: Wm. Wood & Co.,1880)pp.87,115.Barbara Sicherman,"The Uses of a Diagnosis: Doctors,Patients, and Neurasthenia," J.Hist.Med.and All.Sci.32(1977):33-54. 10 .S. Weir Mitchell, "The Evolution of the Rest Treatment," J.Nerv.Ment. Dis. 31(1904):369.Sigmund Freud, The Standard Edition of the Complete Psychological Works,Vol.1 (London: The Hogarth Press, 1966),pp.36,55.Sigmund Freud, The Standard Edition of the Complete Psychological Works, Vol.2 (The Hogarth Press, 1966),p.267.
Charlotte Perkins Gilman, "The Yellow Wallpaper," in The Charlotte Perkins Gilman Reader, ed. Ann J. Lane (New York: Pantheon books, 1980), pp.3-20. 11 .Erwin H. Ackerknecht, A Short History of Psychiatry (New York and London: Hafner Publishing Co., 1968), pp.64-73. 12 .Bonnie Ellen Blustein, "'A Hollow Square of Psychological Science':American Neurologists and Psychiatrists in Conflict," in Madhouses, Mad-Doctors and Madmen, ed. Andrew Scull( Philadelphia: University of Pennsylvania Press, 1981),pp.241-270.Albert Deutsch, "The History of Mental Hygiene," in One Hundred Years of American Psychiatry, ed. J.K. Hall (New York: Columbia University Press, 1944),pp. 325-366. Barbara Sicherman, The Quest for Mental Health in America:1880-1917 (New York:Arno Press,1979) Gerald N.Grob, ed., National Association for the Protection of the Insane and the Prevention of Insanity (New York:Arno Press, 1980),p13. Gerald N.Grob, Mental Illness and American Society, 1875-1940 (Princeton:Princeton University Press,1983) 13 .Charles E. Rosenberg, The Treal of the Assassin Guiteau (Chicago and London: University of Chicago Press,1968), pp.95-97,161-162. 14 .Sicherman, The Quest for Mental Health, pp. 249-256. 15 .William A. Hammond, "The Non-Asylum Treatment of the Insane," Neurologic Contributions 1, no.1 (1879): 1-22. William A. Hammond, "Mysophobia," Neurologic Contributions 1, no.2 (1879): 40-54. 16 .Currently the best introduction the historical study of Hysteria is Mark S. Micale, Approaching Hysteria, Disease and its Interpretations, (Princeton: Princetion University Press, 1995).J.Russell Reynolds, "Hysteria," in A System of Medicine, ed. J. Russell Reynolds (London: MacMillan and Co., 1872)c p. 82. Carroll Smith-Rosenberg, "The Hysterical Woman: Sex Roles and Role Conflict in the Nineteenth Century," Social Research 39 (1972): 652-78. Owsei Temkin, The Falling Sickness (Baltimore and London: The Johns Hopking University Press, 1971), p.352. 17 .Edward Shorter, From Paralysis to Fatigue: A History of Psychosomtic Illness in the Modern Era (New York: The Free Press,1992) pp.166-200.Michael R. Trimble, Post-Tratumatic Neurosis; From Railway Spine to Whiplash (New York: John Wiley and Sons,1981) p.42. Jan Goldstein," The Hysteria Diagnosis and the Politics of Anticlericalism in Late Nineteenth-Century France," Journal of Modern History 54(1982)209-239.Levin, Freud's Early Psychology, p.43. Ilza Veith, Hysteria: The History of a Disease (Chicago and London: University of Chicago Press,1965) pp.228-247.J.M. Charcot and Pierre Marie, "Hysteria Mainly Hystero-Epilepsy," in A Dictionary of Psychological Medicine, Vol. 1, ed. D. Hack Tuke (Philadelphia: P. Blakiston, Son & Co.,1892), p.628l Ola Andersson, Studies in the Prehistory of Psychoanalysis (Stockholm: P.A. Novstedt and Soner,1962) p.38. 18 .Brown, "Neurology and Spiritualism". Henri F. Ellenberger, The Discovery of the Unconscious (New York: Basic Books, 1970), pp.83-101. 19 . J.M. Charcot and Gilles de la Tourette, "Hypnotism in the Hysterical," in A Dictionary of Psychological Medicine, ed. D. Hack Tuke (Philadelphia: P. Blakiston, son & Co., 1892) p.606. 20 .Mark Micale, "Hysteria Male/Hysteria Female: Reflections on Comparative Gender Construction in Nineteenth-Century France and Britain," in Marina Benjamin (ed.) Science and Sensibility: Essays on Gender and Scientific Enquiry, 1780-1945, (London: Basil Blackwell, 1991) Edward M Brown, "Between Cowardice and Insanity:Shell Shock and the Legitimation of the Neuroses in Britain during World War I," in ed. Everett Mendelsohn et al. Science, Technology and the Military, Volume xii/2,(Dortrecht: Kluwer Academic Publishers, 1988),323-345. Andersson, Prehistory, p.39. Sigmund Freud, "Heredity and the Aetiology of the Neuroses (1896)," in Early Psychoanalytic Writings, ed Philip Rief (New York: Collier Books, 1963), pp. 137-50. Jean Martin Charcot, Clinical Lectures on Certain Diseases of the Nervous Stysem, Trans. E.P. Hurd (Detroit: Davis, 1888), pp.100-101. 21 .John Chynoweth Burnham, Psychoanalysis and American Medicine, 1894-1918: Medicine, Science and Culture (New York: International Universities Press, 1967), pp.47-83. Anonymous editorial, "Professor Janet's Visit to Boston and Psychotherapeutics," Bost. Med. Surg. J. 155 (1906):622. E.W.Taylor, "The Attitude of the Medical Profession toward the Psychotherapeutic Movement," Bost. Med. Surg. J. 157 (1907) 845.
22 .Nathan G. Hale, Jr., Freud and the Americans: The Beginnings of Psychoanalysis in the United States (New York: Oxford University Press, 1971) pp.116-150. Morton Prince, Psychotherapy and Multiple Personality: Selected Essays, ed. Nathan G. Hale, Jr.(Cambridge: Harvard University Press, 1975).Otto Marx, "Morton Prince and the Dissociationof a Personality," J. Hist.Beh. Sci. 6 (1970): 120-130. Michael G. Kenny, The Passion of Ansel Bourne: Multiple Personality in American Culture (Washington D.C.:Smithsonian Institution Press,1986), pp.129-160. 23 .Nathan G. Hale, "Introductory essay," in James Jackson Putnam and Psychoanalysis, ed. Nathan G. Hale (Cambridge: Harvard University Press, 1971), pp.1-67.George M. Beard, "The Influence of the Mind in the Causationa and Cure of Disease and the Potency of Expectation," J.Nerv.Ment. Dis. 3(1867):430-1.Russell G. Vasile, James Jackson Putnam:From Neurology to Psychoanalysis (Oceanside, N.Y.: Dabor Science Publications,1977). 24 .Kenneth Dewhurst, Hughlings Jackson on Psychiatry (Oxford: Sanford Publications,1982), p.122.E.Stengel, "Hughlings Jackson's Influence on Psychiatry," Brit.J.Psychiat. 109(1963):348-55. 25 .Wilkerson, "Mind Over Body," pp.233-276. James J. Putnam, "Recent Investigations into the Pathology of So-called Concussion of the Spine," Bost.Med.Surg.J.109 ((1883):217-220. Anonymous Editorial,"Railway Spine," Bost.Med.Surg.J. 109 (1883):400. Burnham, Psychoanalysis and American Medicine, pp.180-3.Edward M. Brown,"Regulating Damage Claims for Emotional Injuries Before the First World War,"Behavioral Sciences and The Law,8(1990):421-434. 26 .Burnham,Psychoanalysis and American Medicine, pp.67-83.Hale, Freud in America, pp.225-50. 27 .Brown, "Neurology and Spiritualism". Pierre Janet, Psychological Healing, Vol.1 (London:George Allen and Unwin, Ltd., 1925), pp 99-109. Elwood Worcester, Samuel McComb and Isador H. Coriat, Religion and Medicine: The Moral Control of Nervous Disorders (New York:Moffat,Yard & Co., 1908). 28 .American Neurological Association, reported in J.Nerv.Ment. Dis. 35(1908): 783. 29 .Burnham, Psychoanalysis and American Medicine, p.79. 30 .American Neurological Association, reported in J.Nerv.Ment. Dis. 35(1908):784. 31 .Francis X. Dercum, Rest suggestion and other Therapeutic Measures in Nervous and Mental Diseases (Philadelphia: P. Blakiston,Son & Co.,1917), pp. 276,353. 32 .Burnham,Psychoanalysis and American Medicine, p.122. 33 .James B. Mackie, "The Journal of Nervous and Mental Diseases: The first 100 Years; III. 1902-1944. The 42 year Editorship of Smith Ely Jelliffe, A Practical Mystic," J.Nerv.Ment. Dis. 159(1974):307.John C.Burnham, "The Founding of the Archives of Neurology and Psychiatry or What was Wrong with the Journal of Nervous and Mental Diseases," J.Hist. Med. 36(1981):310-24. 34 .Sicherman, "The Quest for Mental Health," p.263. 35 .Grob, Mental Illness, pp. 112-18,121,144-178.

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