Transnational history of medicine after 1950: framing and interrogation from psychiatric journals.

Communication amongst medical specialists helps display the tensions between localism and transnationalisation. Some quantitative sampling of psychiatric journals provides one framework for understanding the history of psychiatry and, to some extent, the history of medicine in general in the twentieth century. After World War II, extreme national isolation of psychiatric communities gave way to substantial transnationalisation, especially in the 1980s, when a remarkable switch to English-language communication became obvious. Various psychiatric communities used the new universal language, not so much as victims of Americanisation, as to gain general professional recognition and to participate in and adapt to modernisation.

Introduction

Scholars writing the recent history of medicine and medical specialties have an abundance of evidence on which to work. What is not easy to identify for the decades in the immediate past, however, is a general framework within which they can gain perspective on their specific sources and subjects. This article, based on patterns evident in professional journals in one specialty, is designed to suggest some general framing for the second half of the twentieth century and, in the process, possibly to identify areas for further investigation.

Evidence from psychiatric medical journals shows, particularly, how patterns of transnational communication of medical ideas changed over the decades after World War II. During the whole twentieth century, specialists in psychiatry practised and carried out research in different national communities that commonly were conceptualised as either political or virtual ‘nations’, such as the German ‘Deutsche Sprachraum’ 1 or Scandinavia.2 Members of those national communities discussed with each other their ideas about the science and practice of psychiatry. Often, too, members of a psychiatric community would receive or send ideas across a national boundary by communicating with some members of another community.

Beginning with World War I, the amount of communication between national psychiatric communities diminished dramatically. After about 1950, however, the amount of transnational diffusion of ideas increased very greatly in psychiatry, as in all medicine and science. In this article, journal contents and patterns of citation in journal articles are used to profile how and why transnational communication contributed to some general historical changes in psychiatry.

The main evidence this article presents on patterns of psychiatric communication comes from the leading US journal in the field, the leading British journal, and two leading German journals. From each of these journals, a number of particular years were chosen randomly, spread as evenly as possible over the last half of the twentieth century. For each particular sample year, several attributes of each original article, and the references that the author or authors cited, are recorded uniformly. In addition, in part for control, I conducted some parallel sampling in the main Scandinavian and the main Belgian journal.3

The limitations of sampling and of quantitative historical research are well understood. Nevertheless, such research as is reported below can identify long-term trends and in this way provide a framework within which to understand other kinds of evidence.

Historians of the twentieth century now often write in terms of tensions that arose between local and provincial groups, on the one hand, and forces of transnationalisation, on the other.4 Then and now, physicians communicating internationally often believed that they were acting as agents of modernisation, or what many professionals at the time viewed as ‘progress’. Within science and medicine, professional journals were the major formal means for diffusing innovation and for transferring from one community to another the thinking, technology and technological systems that embodied innovation.5

Particularly in the last decades of the century, many professionals described international exchanges as ‘globalisation’. An examination of psychiatric journals does confirm one strategy for historians: it is necessary to separate globalisation from transnationalisation. Globalisation became tied to technology and free-market capitalism as well as travel and cultural openness.6 It is true that in globalisation, political and economic uniformity incidentally gave an additional, if implicit, impetus toward fulfilling the goal of making medical knowledge universal, as in any ideal science. Yet, communication in the service of globalisation was just part of the more general transnational communication that medical specialty journals carried out.7 It is my findings from those journals that provide some framing for historical change, at least in the one special field of psychiatry.

Already some scholars using other major historical configurations have examined the history of psychiatry after World War II. Some of the very best of them contributed to Psychiatric Cultures Compared (Amsterdam: Amsterdam University Press, 2005). They focused on various national psychiatric systems of the whole twentieth century, with special attention to the politics, economics and socio-cultural contexts of care for the mentally ill. A special concern of the authors was modernisation in psychiatry. ‘The idea of progress in psychiatry has been inextricably bound up in the idea of modernity,’ wrote Ido de Haan and James Kennedy in the conclusion to the book. At the same time, all of the essays in that book, in comparing the cultures of modernising psychiatric communities, implicitly raise the question of how ideas and practices in the general specialty of psychiatry came to be so similar in different localities, implying that progress and modernity were goals that psychiatrists used to shape the specialty even across community or national lines.8

My investigation of psychiatric journals illuminates the way in which this worldwide homogenisation occurred. Yet, as de Haan and Kennedy indicate, the question of progress and modernising haunts the understanding of at least this one special branch of medicine.9 Therefore I have tried to use evidence of the transfer of possibly innovative thinking and technique to explore the changing profile of psychiatry after World War II.

The presentation of these findings is divided into the following parts. First, to set the stage, communication in medicine is discussed, followed by a brief summary of this author’s earlier findings that cover the first half of the twentieth century. Then new evidence is presented concerning journals in the post-World War II decades. In a final section, I review some of the considerations and questions that may grow out of this material.

Communicating in Psychiatry after World War II

Communicating within the specialty was the major means by which psychiatrists pursued their common quest for modernity. They learned, taught and advocated means to keep up with the international technology, products and standards common in industrialising and mass societies.10 Of course, in their advocacy, they also defended local customs and tried to shape mental health care at all levels. Sometimes, rightly or wrongly, they, like many others, confused modernisation with Americanisation, a subject that will be discussed below.

In the past two centuries, psychiatry has existed in a world in which technology greatly facilitated communication. Much of the communication between psychiatrists took place within the national and regional communities or localities that have sometimes been conceptualised as isolated cultural islands. By the late nineteenth century, national islands, and more local communities within national and linguistic groupings, found their isolation constantly breached so that new ideas and viewpoints flowed in and sometimes flowed out; or, as Peter Galison has described it for the sciences in general, thinkers, like merchants, were active agents trading across boundaries.11

The professional journals provide fundamental evidence about many kinds of past events.12 To a substantial extent, it is evidence about intellectual and professional leaders, it is true. The research reported below therefore primarily addresses journals as major institutions through which leaders of the specialty communicated with each other and with practitioners working with patients. Implicit in this inquiry is the entire system by which ideas and opinions spread and through which, also, the audience could often express reactions that, in turn, influenced colleagues working at all levels in medicine, including leadership figures.

Historians of science and medicine have generally started out by examining the writings and other accomplishments of leaders of any field. In recent decades a number of scholars have tried to view events ‘from the bottom up’—how, in the case of medicine, people experienced healthcare in a variety of settings, including hospitals. Another current interest has been to combine the two perspectives and ask about interactions between producers of biomedical knowledge and their audiences. This author has therefore approached journals as indicators of élites interacting with other tiers of the audience for ideas about the theory, practice and problems of practising psychiatry.

There were, of course, means of both local and transnational communication other than publication. The most important is obviously the actual travel of persons—well known for centuries to be especially important amongst, for example, surgeons.13 Moreover, personal travel was notoriously accelerated by the increase in rapidity of transportation. Indeed, so much travel has taken place that it would be impossible to construct for the last few decades a research parallel to the classic of Thomas Bonner, who showed that between 1870 and 1914, 15,000 American physicians travelled to study at German universities.14

Throughout the twentieth century, international scientific meetings in particular provided a formal venue for transnational interactions. But other international institutions also appeared. Nicolas Henckes has found that by the last decades of the century, the World Health Organization (WHO) played a substantial role in shaping mental health policy in France. When hospital and private practice-based élites in psychiatry in France could not agree on policy, they mobilised the élites in the WHO to formulate international standards, standards that the locals could then use to manipulate their own governmental and institutional authorities to formulate particular mental health policies.15

A second type of communication during the twentieth century was by letter, telephone, and, ultimately, email—holding together what Stephen Casper, writing about the closely related specialty of neurology, has labelled a whole ‘epistolary economy’. Already with the telephone, however, the amount of written evidence of communication diminished, and with the ultimate rise of email, the whole nature of communication changed, as many scholars are currently documenting in many ways.16

Yet, throughout the twentieth century, even in the midst of all of the means of transferring ideas, the published record of psychiatry in journals, as in all medicine and science, still constituted the central evidence of communication in the specialty.17 That evidence shows not least that transnationalisation in psychiatry proceeded on several levels simultaneously.

Always, however, for the period after World War II there obtrudes one particular major question: how did the transformation of English into the universal language of science and medicine affect psychiatry? That inquiry raises a further, if only implicit, question: is it also possible to use journal evidence to chart the intellectual domination of the most wealthy and powerful country of the late twentieth century? Peter van Strien has characterised this process as American ‘colonisation’, as he applied it to European social psychology. Others simply refer to American intellectual imperialism.18

Everyone knows that cultural nationalism can generate strong feelings, even amongst the most intellectual human beings. There is, in fact, a substantial historical literature suggesting that local cultures outside of the United States remained much more intact late in the twentieth century than critics of the McDonaldisation of the world might maintain.19 So this controversial question posing the importance of the local, as opposed to the transnational, sharpens the basic inquiry of the journal evidence: how permeable were the boundaries of psychiatric communities?20

Background: The Breakdown of International Communication after World War I

In my earlier research, using simple citation counting, I found that with World War I, medical writers in general, on both sides of the Atlantic, cited publications outside of their own national and linguistic communities dramatically less often than they had before.21 To my knowledge, historians have still not recognised this remarkable shift. Clearly, there was no steady line of progress toward internationalism that scholars and observers seemed to detect at the end of the twentieth century. So what was the actual pattern? When and how did the remarkable post-World War I nationalism in psychiatry give way? Or did it?

In my earlier work, my evidence for provincialism in the Deutsche Sprachraum was limited and somewhat, but not entirely, impressionistic. My evidence for the United States, however, was more extensively empirical, namely, actual counts of citations or abstracts in leading journals.22 Graphic material embodying my findings shows rough, secular trends in both general medicine and, in close parallel, psychiatry. From this material, patterns emerge that show particularly how US medicine became remarkably provincial very suddenly during and after World War I.

The first chart (Graph 1) shows how this nationalism appeared in the New England Journal of Medicine. Similar results come from surveys of other American journals such as the Journal of the American Medical Association.

Graph 1

In articles in sample years of the New England Journal of Medicine, 1871–1981, the percentages of citations of publications that were in French or German.

The next two graphs (Graphs 2 and 3) show how a parallel development took place in the area of psychiatry, using the main American journal in that field. Graph 2 documents the remarkable and dramatic decline of German and French citations. Graph 3 explicitly pictures the rise of English-language material.

Graph 2

In articles in sample years of the American Journal of Insanity/American Journal of Psychiatry, 1883–1983, the percentage of citations of publications that were in German or French.

Graph 3

Percentages of citations of publications in different languages in sample years of the American Journal of Insanity/American Journal of Psychiatry to show the increase in the proportion of English-language references between 1902–3 and 1937–8.

Graph 4, the record of abstracted literature in the Journal of Nervous and Mental Disease, makes the same points. This sample is of special interest, because the abstracts were chosen largely by the same editor over several decades, thus, in part, controlling for changes in editorial policy. Moreover, this editor was more international than perhaps anyone else anywhere in the field, and so that chart, with only an extremely modest American bias, gives as well balanced a picture of the transnational reading of the world’s literature of nervous and mental diseases as would any one journal.

Graph 4

Percentages of original languages of articles abstracted in the Journal of Nervous and Mental Disease in sample years between 1902 and 1937, suggesting the long-term decline of French and German and the rise of English in the world psychiatric-neurological literature.

In the German journals for that same post-World War I period, the citations were so consistently and overwhelmingly from German-language journals that I did not even bother to chart them; for example, in the Allgemeine Zeitschrift für Psychiatrie for the whole large volume of 1924–5, the citations were exclusively to German-language journals and books, except for one article in which the author described a recent visit to America.

Altogether, then, a picture of the state of professional communication in psychiatry in the inter-war period becomes clear: there was extreme nationalism and provincialism, compared to the rather extensive transnational awareness of psychiatrists and closely allied professionals in the pre-World War I period. I am assuming, of course, that German and American specialists reflected general trends in the outlook of psychiatrists in most developed countries.

Did some types of content travel better between national psychiatric communities than other types? Here I can offer only my impression of the inter-war literature. Institutional concerns, such as hospital administration, forensics and the like, tended to be particularly locally centred, as one might expect. Technical and instrumental developments, by contrast, such as the various new shock therapies of the 1930s, tended to travel rapidly from one psychiatric community to another.23 Clinical matters, such as diagnosis and non-technological treatment, varied but, on the whole, they did not move easily from the journals of one country to those of another. Nor should that be a surprise. A variety of studies has underlined the local nature of clinical knowledge.

Post-World War II Journals

Evidence from the second half of the twentieth century is complicated by a major factor already mentioned: the emergence of the English language as the lingua franca—as wits put it—of science and medicine. I have therefore for this time period moved somewhat beyond citation counting by language. Moreover, I have tried to take advantage of a second development in medical research—the emergence of multi-authored papers.24 So I have begun an inquiry into how far, by the opening of the twenty-first century, the transnationalisation touted in the last part of the twentieth century had actually proceeded amongst different psychiatric communities.

In the post-World War II decades, the Science Citation Index and other publications of the Institute for Scientific Information (ISI) greatly stimulated citation studies. This ISI material provides important information that assists us in understanding what happened. Most particularly, it became clear that, across the globe in science in general, investigators were publishing in the English language by the 1980s. If scientists expected to be cited—even to be cited in publications in their own local languages (including those in French!)—they had to publish in English. The percentage of science publication appearing in English was about ninety per cent, and the ‘journal impact factor’ of English-language publications was comparable or greater.25

Psychiatrists everywhere who wanted to read or write in the field in the 1980s and after had to be aware that three journals dominated world psychiatry: the American Journal of Psychiatry, the British Journal of Psychiatry, and the Archives of General Psychiatry (another US journal). Authors in those three journals not only wrote in English, but they most frequently cited work from the other two of the three journals.26 This self-reinforcing dominance did much to facilitate, if not force, the universalising of the English language in psychiatry.27

In part, then, my findings simply chart the course by which English became a universal language for psychiatry after World War II. Everyone knows it happened, but evidence of the extent, and perhaps the timing, of Anglicisation may still generate horrified fascination, if not surprise. It is still necessary to ask, what was the significance of that change?

Method

My empirical data for the period since 1950 come from several types of inquiries concerning articles in the several journals sampled.

The language used by the author.

Language of the article.

Language or languages of the items in the article references.

The international component in the references of each article.

An article is counted as having a substantial international component if ten to fifteen per cent or more of the references come from publications outside of the national or linguistic boundaries of the journal.

The national identity of the author.

An author signing from a base outside of the national or linguistic group of the journal is considered transnational.

Authors—single or multiple for any particular article?

Subject matter patterns.

The general type of subject matter of the article.

In reporting data from the sampled American, British, and German journals, it is possible, rhetorically, to make different arguments.28 That is, if one starts with the US journal to set up the basic narrative, then one sets up a standard and model against which the others become mere marginalised comparisons. If, however, one starts with a German journal, then the American journal, along with the other US journals that it represented, appears as a problem or even a challenge. In what follows below, I shall try to display both types of narrative and argument.

A US Journal: The American Journal of Psychiatry

The record of the American Journal of Psychiatry suggests that the isolationist American parochialism and self-sufficiency that appeared after World War I flourished even more after World War II. Charts picturing the profile of this and other journals are already provided above. It was clear that psychiatrists in the United States, for whatever reason, did not read non-English language sources. Only very near the end of the century did evidence of non-American writings begin to appear in a very small way.

In 1949, the references in twenty-five per cent of the articles in the American Journal of Psychiatry carried an international component, that is, as noted above, at least ten to fifteen per cent from non-US journals and books. That is not very much international awareness, because that twenty-five per cent contrasts markedly with the seventy-five per cent of the articles that reflected no input, or virtually no input, from non-US publications. This profile of references confirms the extent to which the national provincialism, indeed, isolation, of American psychiatrists persisted after World War II.

My sampling shows that this basic profile continued through to 1964: seventy-five per cent or more of the articles did not have a significant international component. Then, beginning with my sample year of 1969, a slight, but permanent, shift became evident that continued for the next twenty years: the proportion of at least slightly non-US awareness shifted from twenty-five per cent to between thirty-one and thirty-eight per cent. Yet, at the end of the century, the authors in more than sixty per cent of the articles in the American Journal of Psychiatry were still effectively depending exclusively on US references. That did not represent much of a change toward international awareness over half a century.

Moreover, the minority of authors who did cite non-US works more and more often cited only those written in English. The evidence suggests the extent to which most American psychiatrists lived in an exclusively Anglophone world.

The provincial orientation of the authors went even further. Only at the end of the 1970s did non-US authors begin to appear in the journal (ten per cent in 1979, five per cent in 1984, fifteen per cent in 1989). That international participation may have reflected, not transnationalisation, but changes in European and other psychiatric communities—not least accommodating to the visibility of the three dominating Anglophone journals.

A UK Journal: The British Journal of Psychiatry

The leading UK journal, the Journal of Mental Science, renamed the British Journal of Psychiatry in 1963, shows that the mid-century British community operated, in part, as a mediator between Anglo-American psychiatrists and those who were not part of that transatlantic community. In 1951, sixty-three per cent of the authors included significant (>ten to fifteen per cent) non-British representation in their references. For twenty years, that level continued. Then in the 1981 sample, it increased to eighty-one per cent. This citing of some foreign sources was deceiving, however. Most of the ‘foreign’ citations were from the US and, of course, in English. They therefore did not represent Continental or other input. In thirty years, 1951–81, the percentage of British Journal of Psychiatry articles with virtually or completely all-English-language foreign items went, in my sample, from thirty-seven to, eventually, sixty-seven per cent (this last was the count in 1981—Graph 5).

Graph 5

Percentage of articles published in sample years in the Journal of Mental Science/British Journal of Psychiatry from 1951 to 1981 in which the references in the articles were all, or virtually all, in the English Language.

What made the British Journal of Psychiatry of particular interest in a field that was becoming transnationalised was the fact that in the last decades of the twentieth century significant numbers of the authors came from outside Britain—and not just Canada, Australia or New Zealand. In 1971, twenty-six per cent of the articles had foreign authors, and by 1981, forty-three per cent—including a substantial number of Americans in the latter figure (about one-fifth of the 1981 articles had authors from the US). From one point of view, the British Journal was losing its British character and becoming just a pillar of the dominating Anglophone core—but one through which non-British authors could achieve world visibility.29

Two German Journals

A narrative from the German point of view appears clearly in the figures for the Archiv für Psychiatrie und Nervenkrankheiten, which, in 1984, changed its title to the European Archives of Psychiatry and Neurological Sciences. Even before the name change, the editors had started publishing articles in English—sixteen per cent in 1979. By the first year of the English-language name, 1984, sixty-one per cent of the articles were in English, as opposed to only thirty-nine per cent in German. The editors, in their advice to contributors, stated clearly in 1984 that ‘papers should preferably be written in English’.30 Indeed, by 1994, one hundred per cent of the articles were in the English language. (Graph 6)

Graph 6

Percentage of articles in English and percentage of articles with a substantial component (>10–15 %) of international (non-German) citations in the same sample years, 1949–1994, in the Archiv für Psychiatrie und Nervenkrankheilen, which changed title to the European Archives of Psychiatry and Neurological Sciences in 1984.

This journal, reflecting professional organisation and outlook in Germany, included neurology and neuroanatomy/neurophysiology to a substantial extent—sixty per cent in 1949 and around seventy per cent in 1959 and 1969. By 1979, however, explicitly psychiatric content had reached over half, and the English-language 1984 volume included sixty-three per cent psychiatric articles. Thus, two things were going on at the same time. Firstly, the content reflected the astonishing rise of a new discipline, neuroscience. The explosive expansion of neuroscience literature soon brought many new journals, and those journals were overwhelmingly published in English.31 As neuroscience materials began to migrate to new journals, psychiatry became more prominent in the European Archives. Even in the neuroscience material in the journal, however, the growing dominance of English in that field, as well as in psychiatry, was obvious. Thus, the not-primarily psychiatric material provides an adventitious control case to suggest that the ingress of English was general and not distinctive for psychiatry.

The general dilemma of the German-language psychiatric community shows up clearly in the references in the articles in the Archiv/European Archives. In 1949, only thirty-three per cent of the articles had references that included a substantial (again > ten to fifteen per cent) international component. This was, of course, more than in the contemporary US sample (the extreme of scientific isolation outside of France) but much less than the British: that is, immediately after 1945, German-language medicine continued to be Germano-centric.

Then this profile changed. Already by 1959, the figure for articles with an international component in the references had risen to sixty-two per cent. By 1969, it was eighty-five per cent; in 1979, ninety-six per cent; and in 1984, one hundred per cent. (See Graph 6.)

Moreover, by the 1990s, authors in the Archiv/European Archives could be demonstrably international even by citing references that were not German, but, moreover, were all in the English language. In 1984, in nineteen per cent of the articles, all or almost all of the references were in English. By 1994, thirty-five per cent of the articles had no significant component in any language other than English—not even German. This transformation to English over a third of a century confirms strongly that in psychiatry, as in science in general, whether or not one liked it, there was indeed a new lingua franca.

The record of another German journal, Fortschritte der Neurologie, Psychiatrie und ihrer Grenzgebiete, confirms this pattern. As late as 1959, articles on neurology and related neurosciences constituted sixty-two per cent of the content, and the figure was still 38 per cent in 1996. Whilst references in sixty per cent of the 1959 articles had a significant international component, the proportion rose to eighty-seven and ninety-one per cent in 1986 and 1996 (Graph 7).

Graph 7

Percentage of articles with a significant proportion (>10–15%) of references international, that is, non-German, in the Fortschritte der Neurologie, Psychiatrie und ihrer Grenzgebiete between 1959 and 1996.

Moreover, by 1996, forty-four per cent of the Fortschritte articles included references that were all, or virtually all, in English, although the journal continued to be published in German.

Members of the German psychiatric community understood that the editors of the other German journal, the Archiv/European Archives, hoped that by switching to English, their publication might join more prominently in the international world of psychiatry.32 It is true that the English version did gain more substantial citation in other—now largely English-language—journals.33 Yet what is most striking is a contrast. In the continuing German-language publication, the Fortschritte, the number of articles written by one or more foreign authors was consistently, in the small sample, seven per cent or less. Similarly, for at least twenty years, the percentage of non-German-language authors in the Archiv/European Archives ranged from six per cent to eighteen per cent in the German-language issues. After the Archiv/European Archives converted fully to English, however, the proportion of non-Sprachraum authors increased to forty-two per cent (1994). This transnational participation represents a facet of the success of the journal in using the English language to increase access to the international psychiatric community.

Journals from Smaller Countries

The processes apparent in the switch to English to achieve international visibility can be displayed in what happened in another journal, Acta psychiatrica scandinavica. Like a number of others, this journal had started in 1926 so that the specialists in Scandinavian countries could gain international visibility.34 At first, the Acta, like the German journals, combined neurology, neurosciences and psychiatry. Already in 1961, however, before counterparts in other countries, the Acta split the psychiatric material off into a separate journal. This newly constituted journal in 1961, according to the editors, welcomed ‘original papers in psychiatry and related fields. Papers are published in English, German, or French according to the wishes of the authors.’35

In 1961, however, there was only one non-English article (in French—but by a Scandinavian author), and still only one in 1970 (in German). Since virtually all of their articles continued to appear in English, in 1973 the editors took the final, logical step and suddenly in midyear announced that the journal published ‘original papers in English on psychiatry and adjacent fields,’ with the additional note in the instructions for authors, ‘Either American or English spelling is acceptable as long as it is consistent.’

Nor was this just a superficial change in language. Where, in 1961, references in Acta articles were largely divided between Scandinavian, British and American publications, already, by 1970, the references were disproportionately British and American. In 1979, forty-nine per cent of the articles (no matter what the country of the author) had references that were all, or virtually all, in the English language. The proportion was still running about the same in 1988. It would be difficult to document better how completely psychiatrists, no matter where, were communicating in English.

Switching to English, however, had one effect the editors of the Acta may not have anticipated, and it was the same effect noted in the Archiv/International Journal from Germany: the Acta became a largely international journal, providing an outlet for psychiatrists from every area of the world. In 1961 and 1970, the proportion was still about half from Scandinavian psychiatrists. In 1988, only about twenty-two per cent of the articles came from Scandinavian authors. Indeed, in just the first three issues that year, there were contributions from the USA (19 per cent), the UK and Germany, but also from many other countries, including Taiwan, Belgium, Ireland, China, Korea, Hungary, Japan, Spain, Saudi Arabia, Nigeria, Israel, Australia, The Netherlands and Jordan.

There is another case that illustrates the dilemma faced by a small national medical community. This was Austria, part of the German-language medical community. For a long time after World War II, the outlet of choice for psychiatrists in that national community was a general medical journal, the Wiener Medizinische Wochenschrift. Most specialists thought of themselves as clinicians who covered both neurology and psychiatry, and in 1948, one journal, on ‘Nervenheilkunde’, nervous disorders, began publication. A succession of journals with remarkable continuity of editors culminated in 1985–1986 in Neuropsychiatrie, which continued to publish in German with a strong emphasis on practical, clinical articles.36

The editors of that regional specialty journal faced great financial problems. Publishers were watching not only circulation numbers but the ‘journal impact factor’ with which they could compete with Anglophone publications. Neuropsychiatrie was at a great disadvantage in that market, even though amongst German-language journals in general, the Austrian publication had a high impact factor. To the editors, ‘the fetish’ of journal ratings was ‘Amerikanisch’. The editors feared ‘falling victim to globalisation’, when what they wanted to do was to serve a defined psychiatric community.37

Another small country in a larger linguistic community was represented by a Belgian journal, the Acta neurologica et psychiatrica belgica. Parallel to the Austrian editors, the Belgian editors after World War II were publishing French-language articles on mostly neurological topics.38 Then, in 1970, the journal split, and a purely psychiatric journal appeared, based mostly on local organisation presentations and with a profile that was much like that seen in Austria. What was most striking about the Belgian journal, however, was the fact that in the first issue of the essentially new psychiatric journal the editors wrote candidly that the journal would be published in French to meet both local and transnational aspirations. Of the three Belgian languages, French, they wrote, would have the largest international audience. The editors then went on to add, ‘For the same reason, original articles may also be published in the English language.’39 Indeed, afterwards they regularly announced that articles would be published in either French or English. Yet as late as 1975, only one English-language article appeared during that year. In 1983, the percentage of articles in English had increased to twenty-one per cent. But by that time, following, with some delay, the pattern of the Acta psychiatrica scandinavica and the German European Archives, more than forty per cent of the authors came from outside Belgium as the journal served an increasingly international clientèle. Moreover, sixty-three per cent of the 1983 articles had references that were virtually all in English.

Psychiatry, Journals and Transnationalisation

This sampling from a group of journals raises many questions even as it suggests some general conclusions. Much of what these data show would be familiar, on some level, to most people in the field of psychiatry who lived through the late twentieth century. Yet, showing these trends in a concrete form may be helpful to those of us trying to discern patterns of change in psychiatry in those decades.

There were contingent factors. The founding of local journals—in Canada and Israel, for example—diverted some authors from international journals. New subspecialty journals, especially in psychopharmacology and related areas, as well as the neurosciences, also diverted papers, but apparently the transnational component did not diminish. Moreover, physicians at the time in all fields continually complained that with the multiplication of journals they were unable to keep up with the literature, and so their reading had to be selective.

Nevertheless, some secular trends did appear in the psychiatric journals. Most overwhelming, of course, was the shift to English. Psychiatry, as I have noted, in this way paralleled what was happening in science and medicine in general.40 The timing of the shift to English in Continental journals may not have been merely incremental, however. Many observers tied that shift to the events of 1968 in Europe, which brought a general opening (and some people believed a modernising) of academic institutions. In Germany around 1972, there was a general movement to publish academic books in English, just at the time that psychiatric journal articles appearing in English increased everywhere.41 In France, according to Jean-François Picard and William H. Schneider, the term ‘modernisation’ was used to cover over the real truth, which was Americanisation of the medical schools, in substantial part through the influence of the Rockefeller Foundation.42

One piece of evidence that I uncovered, however, suggests that modernisation did not necessarily mean transnationalisation. A striking change toward modernisation that took place in both American and European psychiatry was the growth of collaborative and team research. In the American Journal of Psychiatry, the number of single-author papers shrank steadily:

1949: 62% single author

1989: 11% single author

In the Archiv/European Archives, likewise the percentage declined from eighty-four to eight (with the most rapid change in the 1960s).

Yet this opening for truly transnational collaboration was not effective. Virtually none of the collaborative teams publishing in any journal included members working outside of the national community. Occasionally, an article would show up comparing an illness or practice in two quite different countries, but such comparative items were rare in any of the journals. Moreover, the pattern in psychiatry contrasted with that in the physical and biological sciences. A team of sociologists reported in 1993 that ‘there has been a tremendous growth in transnational collaboration…. The medium [i.e., median] co-authorship rate amongst the thirty most productive countries in the period 1981–1986 was an impressive nineteen percent.’43 This figure for natural scientists contrasts strongly with my very much lower figure for psychiatrists, who even late in the century seldom collaborated or teamed with colleagues in other national communities. Whether this comparative lack of transnational collaboration was characteristic of all of medicine or just specialists in psychiatry is a question that needs to be investigated directly.

Of course, as already indicated, transnationalisation in psychiatry took forms other than published research collaboration. As Andrew Lakoff has shown in his examination of the psychiatric community of Argentina, there were constant, explicit pressures on practitioners to keep up-to-date, to use new techniques and medications, in short, to modernise. Most of those pressures directly or indirectly came from overseas. Against those pressures were the set ways and styles of different communities of practitioners.44

The traditional sensitivity of psychiatrists to their local cultural environments raises the question of whether or not, in the late twentieth century, the specialty was more responsive or less responsive to cultural pressures than were other medical specialties—and therefore possibly more or less transnational. From studies of journals there is one piece of evidence. Not only science journals but also journals for other medical specialists converted to English at least as fast as did the psychiatric journals. By 1985, for example, twenty-four of the twenty-seven leading surgery journals in the world were publishing exclusively in English.45

Psychiatry, of course, embraced a number of approaches and aspects, and, following my earlier findings, I looked for evidence of differences in rates of international citations in articles on different types of subjects—clinical studies, reports and tests of technical and pharmaceutical therapies, institutions connected with the specialty such as schools and hospitals, and social studies of mental illness. In the German journals, all subjects had significant international elements in all years. In the American Journal of Psychiatry, with the exception of social and institutional articles that were largely local in focus, there were no clear patterns suggesting that any type of subject might be more transnationalised than any other, chiefly because there were so few international citations. This same pattern of no significant trends also applies to estimates of local cultural content in the journals. My negative results indicate that the question of exactly what content travelled best in the late twentieth century therefore will have to be investigated using other evidence.46

The psychoanalytic stream in psychiatry presents a special case but one that suggests both questions and comparisons. The process of transnationalisation was relatively rapid, in spite of open, often institutional opposition in psychiatric communities. What made it so easy for at least some psychiatrists to ‘appropriate’ psychoanalytic and dynamic treatments, is suggested, in part, by the rapid spread of other defined treatments, such as those using shock techniques or psychoactive chemicals.47 That is, psychoanalysis was a highly technical, well-defined procedure.

Americanisation or Transnationalisation?

Obviously, the question of resistance to transnationalisation will also need further investigation using still different approaches: for example, in 1979, Jerome Kroll pointed out the profound philosophical assumptions that kept French and American psychiatrists apart. Volker Roelcke has worked extensively on the history of not only cultural differences but also fundamental variations in approach between German and other psychiatrists.48

Certainly, the mixture of negative emotions generated by anti-Americanism contributed to resistance to any transnationalisation that involved the use of English and certain styles of medical practice. One such style was the American emphasis on laboratory tests, with a relative de-emphasis on clinical sense. Christopher Lawrence, particularly, has described laboratory-based medicine as an issue amongst non-American medical practitioners in general.49

It is easy to understand that the wealth and numbers connected to American medicine could become intimidating. A British writer in 1981, for example, had to admit concerning his subject, psychiatric aspects of diabetes, that ‘most of the work which is cited below refers to and originates from North America.’50 Yet as Michael Hunt has recently reminded us in another context, Americanisation makes sense only in a context of general globalisation, that is, the economic and social aspects of transnationalisation. Andrew Lakoff quotes an Argentine psychiatrist: ‘We always copy European models here, for better or for worse—and now, American. We are strongly colonised.’51 Psychiatrists from even large countries like Germany and France could find themselves searching for niches in which they could excel and become part of a world special interest group—following the successful model long pursued in Norway, The Netherlands and other small countries and communities.52

The continuing, conspicuous provincialism of many American psychiatrists, of course, generated deep resentment. The French resentment is quite public, but Germans have also reacted as the hopelessly Anglophone Americans put German-language and even just German contributions on the same level as those of some small, possibly backward country.53

The course of English-language dominance seemed unstoppable at the end of the twentieth century. Some Germans expected that with the fall of the Berlin Wall and the reunification of Germany, German would rebound as a language of science and medicine. Their beliefs and hopes were not fulfilled. English continued to predominate.54

It may well be, however, that to understand transnationalisation in psychiatry, it is necessary to see language as a mere technology of communication; that is, modernisers implicitly used English as a tool for bringing into psychiatry up-to-date and new techniques and ideas. The more important question, then, would be, what did it mean to modernise psychiatry? This question brings us back to the finding that modernising, too, had local and national aspects as well as transnational.55

Still, it would be wise to consider that transnationalisation in medicine may also have symbolised a continuing goal that need not be tied to globalisation. That goal, already noted above, was the universalism of science.56 Despite cynicism, and despite the power of localism, idealism as it existed in the late twentieth century could still create a vision of a universal science of psychiatry. At the same time, many members of a variety of psychiatric communities still believed that, in practising their specialty with a given set of patients, there were elements that were local, not universal.

Conclusion

An historical profile of psychiatry therefore arises from the professional journals. Between the wars, there was an unprecedented national or linguistic-group provincialism, which I have used as a point of departure for post-World War II events. By the 1980s, publishing psychiatrists everywhere, and possibly practising psychiatrists as well, had inadvertently furthered transnationalisation by switching to English-language communication, as demonstrated in the German Archives and the Scandinavian Acta. The speed of the transformation was about the same as in other medical specialties.

Even though this switch may have favoured the largely linguistically handicapped Americans, other psychiatrists deliberately used English as a means of achieving transnational awareness and visibility. Because psychiatrists used English as a tool to announce innovations and to keep up-to-date in their field, historians may wish to attend to the contention that, even in local psychiatric communities, those who were communicating in the English language were thereby facilitating and shaping modernisation and transnationalisation, rather than imagined ‘Americanisation’.57 Indeed, it may be most useful to follow Jan Nederveen Pieterse and conceive of transnationalisation or globalisation ‘as a process of hybridisation which gives rise to a global mélange’.58

My findings emphasise that medical specialists, especially after the 1970s, used the common language as a technology to communicate between national communities. That communication, however, favoured the technologies of psychiatry—pharmaceuticals, physiological treatments and programmed psychotherapies. Aspects of psychiatric practice that had strong local bases—clinical, institutional, legal—did not travel as well in journals, as shown not only by my counting but also by the struggles of the editors of the Austrian Neuropsychiatrie.

It is easy to see in the journals how psychiatrists of the late twentieth century strove to be modern, to keep up-to-date with what appeared to be new in the science and practice of psychiatry. Indicators of broad secular trends can call attention to many of the factors that were operating simultaneously to produce changes in psychiatry over the late twentieth century. Patterns revealed by journal contents and references thus provide at least one suggestive framework within which to focus on fundamental questions of content and practice, even as historians of psychiatry, and of medicine in general, continue to examine the critical intersection of the transnational and the local.