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. 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. 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 émigré 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.
. Roy Porter, Madness: A Brief History (New York: Oxford University Press, 2002), 185.
. The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is scheduled for publication in May 2013.
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Janet Miron. Review of Noll, Richard, American Madness: The Rise and Fall of Dementia Praecox.
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