Richard Noll. American Madness: The Rise and Fall of Dementia Praecox. Cambridge Harvard University Press, 2011. 395 pp. $45.00 (cloth), ISBN 978-0-674-04739-6.
Richard Noll.
American Madness: The Rise and Fall of Dementia Praecox. Cambridge
Harvard University Press, 2011.
395 pp. $45.00 (cloth), ISBN
978-0-674-04739-6.
Reviewed by Janet Miron (Trent University) Published on
H-Disability (January, 2013) Commissioned by Iain C. Hutchison
Miron on Noll, _American Madness_
"As the precursor to schizophrenia, _dementia
praecox_ has left an indelible mark on modern psychiatry," wrote Roy
Porter a decade ago.[1] Nevertheless, in spite of its significance, the history
of dementia praecox has been neglected in the American context. Richard Noll
helps to fill this void with _American Madness: The Rise and Fall of Dementia
Praecox_. In rich detail, he examines the reaction to, and metamorphosis of,
Emil Kraepelin's theories in the United States, unraveling the factors that
contributed to both the dramatic ascendancy of dementia praecox in the early
1900s and its demise and succession by schizophrenia shortly thereafter. A
complex story of psychiatry's pursuit of knowledge, legitimacy, and relevance,
the history of dementia praecox as told by Noll illustrates the professional
aspirations, egos, frustrations, desperation, divisions, and politics that
imbued attempts to understand and alleviate what was perceived as one of the
most prevalent mental afflictions plaguing society at the time. Published in
advance of the new DSM-5 scheduled for release in 2013, _American Madness_
offers timely insight into what was and remains the murky waters of mental
illness and disease classification.[2] Indeed, Noll reveals not only the history
of dementia praecox, the impact of Kraepelinian biological psychiatry, and the
path American psychiatry took from the 1890s to the 1930s, but, more
fundamentally, the power, perils, and paradoxes of medical nomenclature.
Noll's study is not concerned with the experiences of
individuals and their families who struggled with mental illness or were
diagnosed with dementia praecox, nor does it profess to. Rather, Noll
concentrates on elite members of the psychiatric profession. It is medical
theories, debates, and practices, not lay society, popular discourse, or
cultural context, that preoccupy Noll in his endeavor to explicate American
psychiatrists' embrace of dementia praecox as a "real" disease in the
early twentieth century. To understand the responses of American psychiatrists,
Noll situates the disease within its broader context, discussing in depth Emil
Kraepelin (1856-1926) and his work on dementia praecox. Kraepelin presented
dementia praecox as biologically based, chronic, and incurable, a form of insanity
that afflicted mostly adolescents and young adults, especially males, and was
marked by an inevitable deteriorating process. For Kraepelin, the trajectory of
dementia praecox distinguished it from the periodically occurring manic
depression, and with this he established a now "familiar juxtaposition
between ... the two great categories of the insanities" (p. 69). As Noll
discusses, Kraepelin's theories represented a paradigm shift, a move away from
idea of "unitary psychosis," which posited that only one form of
madness existed.
Through the prism of Kraepelin's work in Germany, Noll
deftly portrays the intricate web of discussions and debates on disease
classification and the increasing emphasis on scientific methods in psychiatry
at the beginning of the twentieth century. Kraepelin's classification system
was based on what was purportedly "systemic
science": quantifiable data collected longitudinally
over a period of years (p. 63). Age of onset, course, and outcome of mental
illness became paramount and served to define mental diseases, rather than
patient symptoms (such as mania, melancholia, or dementia). Prognosis became
the "organizing principle behind Kraepelin's system" (p. 66).
As Noll discusses, some critics questioned the
subjectivity behind observations of patients, yet advocates deemed Kraepelin's
methods a "clinical way" of looking at disease (p. 67). In any case,
Kraepelin "dethroned etiology," according to Noll, by arguing that
the cause of disease was subordinate to understanding course and outcome (p.
116).
While painting a portrait of the broader context of
psychiatric theory, Noll's main objective is to delineate the permeation,
reception, transformation, and also distortion of Kraepelin's concepts and
methods in the United States. On the west side of the Atlantic, Kraepelin's
concept of dementia praecox and the ideas expressed in the 1896 and following
editions of his textbook, _Psychiatrie_, were promoted initially by German
Swiss ??migr?? Adolf Meyer (1866-1950), who would profoundly shape American
psychiatry in the early twentieth century. Along with August Hoch (1868-1919),
Meyer served as the main conduit through which Kraepelin reached the largely
English-speaking audience in the United States, and thus Noll spends
considerable time addressing his life and works. Examining the reasons behind
the appeal of dementia praecox to American psychiatrists, Noll argues that
Kraepelin seemed to offer a solution to a profession that was undergoing a
crisis of legitimacy and seeking to align itself with modern science. While
faith in the asylum and the promise of moral therapy to cure mental illness
dissipated in the second half of the nineteenth century, scientific
advancements in other fields of medicine suggested that psychiatry was falling
by the wayside and had little to offer in terms of understanding, treating, or
curing mental illness. Dementia praecox, however, represented to many
alienists, as psychiatrists were then called, a source of newfound optimism and
excitement, an entry into the world of modern science that would allow them to
do more than simply "manage" the insane inside the walls of the
asylum.
Noll shows that the impact of the new disease in the
United States would be far-reaching. By the First World War, "dementia
praecox was identified as the primary mental health problem to be addressed in
the asylum practices of alienists, in laboratory research in psychiatry, in the
eugenics movement, in the mental hygiene movement, and in the courts through
its infiltration into medical jurisprudence" (p. 4). Little would change
with regard to treatment, yet Kraepelin's classification system and emphasis on
patient longitudinal study had offered a solution to the malaise or
"therapeutic nihilism" (p. 95) of psychiatry, and to the provocative
question posed by Weir Mitchell to the profession in 1894: "What is the
matter?" (p. 18). Furthermore, it gave psychiatrists an expedient and
powerful label that could help them explain prognosis to families of patients
while mitigating their inability to cure or treat madness. Indeed, the
convenience of the term led to its widespread adoption by those wielding the
power of diagnosis. According to Noll, "in the year 1895 no one in the
United States suffered from the disease of dementia praecox. By 1905 the number
of people who had been given such a diagnosis could be counted in the
thousands" (p.
109).
In spite of the resonance of the term _dementia praecox_,
Noll reveals that Kraepelin's ideas would not be transplanted in a neat and
tidy manner to the United States. Rather, Noll elucidates the ways in which
many aspects of Kraepelin's theories were inadvertently transformed,
reformulated, and rejected (often by individuals who had never met him or read
his original publications), and thus an understanding of dementia praecox that
reflected eclecticism and pluritheoreticism emerged in the United States.
Furthermore, as Noll shows, the unique features of dementia praecox in the
United States would eventually lead to it becoming mistakenly synonymous with
schizophrenia in the 1910s and entrenched as such in _The Statistical Manual
for the Use of Institutions for the Insane_ in 1918. Initially dementia praecox
and schizophrenia would mean the same thing to many American psychiatrists, but
gradually almost all found the latter term more expedient for economic,
political, and professional reasons. Nevertheless, as Noll argues,
schizophrenia, just like dementia praecox, would be a term riddled with
ambiguity.
Noll addresses other factors that contributed to what he
sees as the unique trajectory of American psychiatry at the time, which in
retrospect prevented the profession from modernizing and following the path of
other medical sciences. In particular, Noll shows that Meyer eventually
resisted Kraepelin's classification system, feared an overuse of his terms by
superintendents desperate for a diagnosis, and sought to promote instead his
own theories. Perhaps most importantly, Meyer rejected the idea of disease
specificity in psychiatry and thereby "derationalized the profession [in
the United States], pulling it in a direction opposite that of the historical
trajectories of the other branches of medicine" (p. 167). Even though he
studied with Kraepelin, Meyer's rejection of disease classification,and his
emphasis on the need to study a patient's attributes before mental illness
manifested, prevented American psychiatry from shedding anachronistic vestiges
that kept it apart from scientific medicine, turned the American psychiatric
profession's attention away from experimental psychology and biological
research to etiology, and opened the door to psychoanalysis. Noll argues that
Meyer's emphasis on case history and predisposed personality types would
further help distinguish American views of dementia praecox from European ones.
It was not until the 1970s that American psychiatrists would return to the
notion of disease specificity "after decades of erosion by Meyerians and
Freudians" (p. 168).
In _American Madness_, Noll tells the story of prominent
medical men.
Nevertheless, he does not depict this history as linear
or progressive, one based on expanding knowledge and scientific insight.
Weaving the medical history of dementia praecox across
national boundaries, he illuminates the ebb and flow of ideas to create an
in-depth understanding of the complexities behind the disorder and the
transmission and transmutation of medical discourse and ideas in different
contexts. Additionally, he challenges a number of conventional interpretations
amongst historians of psychiatry. For example, Noll's careful reading of
debates shows how psychiatrists in the early twentieth century were not simply
divided between those who held to psychogenic theories concerning the origin of
disease and those who believed causation lay in brain disease. According to
Noll, a third paradigm of disease theory for dementia praecox existed and was
espoused by Kraepelin, autointoxication (or self-poisoning of the body), which
would encourage the turn to laboratory research. This was yet another theory
that was rejected by powerful psychiatrists who were shaping the profession in
the United States in the early twentieth century.
_American Madness_ is essential reading for scholars
interested in the history of twentieth-century mental illness and the history
of the psychiatric profession. Certainly, however, there are other dimensions
to this history that need to be examined by scholars. In particular, the
experiences and perspectives of patients who were diagnosed with dementia
praecox warrants examination, as well as the power behind the medical gaze. As
psychiatrists in the United States tried to demonstrate their efficacy in
"treating" or understanding dementia praecox, many individuals were
labeled, isolated, and forced to undergo often brutal and deadly
"treatments" that were based on little more than speculative theory.
Their lives deserve attention and, with Noll's book, scholars will find a
foundational work upon which to build.
Notes
[1]. Roy Porter, _Madness: A Brief History_ (New York:
Oxford University Press, 2002), 185.
[2]. The fifth edition of _Diagnostic and Statistical
Manual of Mental Disorders _(DSM-5) is scheduled for publication in May 2013.
Citation: Janet Miron. Review of Noll, Richard, _American
Madness:
The Rise and Fall of Dementia Praecox_. H-Disability,
H-Net Reviews.
January, 2013.
This work is licensed under a Creative Commons
Attribution-Noncommercial-No Derivative Works 3.0 United States License.