November 2011

Evan McMurry


American Madness: The Rise and Fall of Dementia Praecox by Richard Noll

From its discovery in 1896 until its eventual mid-century collapse into the competing idea of schizophrenia, dementia praecox accounted for thousands of mental illness diagnoses in the United States. Richard Noll's American Madness: The Rise and Fall of Dementia Praecox is not only a biography of the condition, but also of its dominant role in the development of psychology as a discipline and a science, revealing the many ways that power, personality, language, and even architecture collaborate in the evolution of a discourse. Hot on the heels of Sybil Exposed, Debbie Nathan's exploration of the entrepreneurial side of diagnosis, American Madness treads carefully the line between skepticism and cynicism, critical of men who think they've captured knowledge even as it lauds their ceaseless efforts to do so. 

Dementia praecox (roughly translated as precocious dementia, though nobody was ever satisfied with the term) was introduced to the world by Emil Kraepelin, a German psychiatrist who wrote the first textbook of mental illnesses, Psychiatrie, an embryonic version of our DSM volumes. The condition was one of necessity: a set of behaviors, including hallucinations, delusions, and antisocial spells, had been isolated by physicians, but didn't fit into mania, melancholia, or any of the other hapless nineteenth-century mental health categories. Kraepelin seemed to light this dark area of the mind. 

A careful and self-aware thinker, always ready to revise his opinions, Kraepelin's definition of dementia praecox was intentionally tenuous. Moreover, his method of tracking the condition's course rather than looking at a snapshot of its symptoms was initially as important as the condition itself. Noll writes, with his own italics: "What Kahlbaum did -- and this was truly remarkable -- was introduce the element of time into psychiatry." This forward-looking method instigated a growth spurt in the adolescent field of psychology, as the study of a patient's development renewed interest in the thousands of people who had been left in asylums to rot. But as the prognosis of dementia praecox was an irreversible decent into insanity and death, Kraepelin's method rediscovered patients only to doom them. 

Dementia praecox was carried to the United States by Adolf Meyer. The head of various psychiatric institutions and organizations during the first quarter of the twentieth century, Meyer was the most influential man in American psychology. He reformed the overcrowded asylum system, upgrading the facilities from dumping grounds of criminals and misfits into houses of scientific inquiry. As he did so, Meyer disseminated Kraepelin's ideas and methods. The result: dementia praecox was diagnosed at an exponential rate, sometimes accounting for more than half of all new patients. What had been a strange term in a German textbook only a few years before was now a mental health epidemic. 

Through its crisp early chapters, American Madness viscerally recreates the alienist, a pre-psychiatrist asylum physician who was responsible for applying the theories (or simplified versions thereof) of men like Meyer and Kraepelin on a patient-by-patient basis. Alienists were often poorly trained, unversed in the German or French required to read up on their profession, and assigned hundreds, if not thousands, of patients on their rounds. While quick to condemn over-diagnosis in all its forms, Noll remains sympathetic to the alienist's impossible situation, in which a diagnosis answered more the bureaucratic need of what to do with a patient than the medical question of how to help them. The protean dementia praecox became a "useful" definition for the overworked alienist, a label that could be placed upon the patient in much the same sloppy way that mania had been used before. That Kraepelin's tenuous definition measured over time became a rigid one applied in the moment is but one of the many ironies dementia praecox accrued as it traveled from academic journals to underserved asylums. Lest we judge too quickly, Noll points out, again in his own italics, that the convenience of definition is still a professional malady: "To this day something called schizophrenia... is diagnosed by psychiatrists because it is expected." 

Noll is adept at portraying both the human and sociological sides of this story. He locates telling details of his protagonists, noting how physical deficiencies prohibited both Kraepelin and Meyer from mainstream scientific work -- eye-problems prevented Kraepelin from using the microscope, while unsteady hands kept Meyer from becoming a surgeon -- setbacks the men used as spurs to their intellect. And Noll has an attuned ear for the hypertrophic medical language of yore, days when patients were said to be "wrecked upon the cliffs of puberty," brains looked "alike as Chinamen," and it was perfectly acceptable to inject inmates with cobra venom on the off chance that it might cure them. Such eccentricities were not confined to the local practitioner's office, either: discovered among the APA's various arguments for ditching the category of dementia praecox was schizophrenia's greater ability to become an adjective. "Schizophrenic" simply played better than the Kraepelin's clunky precursor. 

Further impressive are Noll's Foucaultian examinations of buildings in the construction of power and knowledge. Each advancement of psychological knowledge in his text is preceded by the renovation of hospitals and the construction of laboratories. In fact, the most common scene in American Madness is a doctor -- be it Kraepelin, Meyer, or the few others featured -- walking into a rundown facility and immediately ordering its cleaning. Noll also charts how the introduction of laboratories to psychiatric facilities presaged the changing view of psychologists from attendants of the mentally ill to pioneering scientists, a switch neatly encapsulated when the American Journal of Insanity one day became the American Journal of Psychiatry. But even as mental health facilities were upgrading the status of psychology, they were also determining the power structures of the nascent discipline. Reformed asylums were beholden to the prejudices of their superintendents, which, in the case of Meyer at least, became increasingly eccentric, and efforts to standardize the asylum system included a winnowing of psychological definitions, sacrificing the accuracy of diagnosis for the efficiency of process. 

If there is one complaint of this capacious narrative, it is the same that was leveled at Kraepelin himself by an observant intern: Noll seems to care little for the victims of dementia praecox. Noll, like Kraepelin, is fascinated in the condition almost to the exclusion of the people it attacked. Indeed, we are 196 pages into American Madness before the first human being with dementia praecox appears in flesh and blood, and the poor man doesn't live through the page. In an epilogue, Noll, an associate professor of psychology at DeSales University and a former ward psychologist, testifies to his deep sympathy for sufferers of neurological disorders. There is no reason to doubt him. But Noll fails to recreate dementia praecox for the reader in the way he did rural asylums and Bavarian laboratories. Without ever seeing the awful debilitation that instigated this whole quest, we are robbed of the patients' tragedy when a psychiatrist in 1923 finally asks, "What if dementia praecox simply does not exist?" 

American Madness: The Rise and Fall of Dementia Praecox by Richard Noll
Harvard University Press
ISBN: 978-0674047396
408 pages