I have reviewed over one hundred books for journals. Some books have been a pleasure to review, and some a chore, but I have rarely read a book for review which was such a joyful intellectual pleasure to read as American Madness: the Rise and Fall of Dementia Praecox.
The topic is announced in the title. The book is about dementia praecox in the United States. Note that it is not about schizophrenia in the United States, for as Noll demonstrates very well, dementia praecox and schizophrenia had significant differences. It is clearly about Kraepelin's concept of dementia praecox as it developed in this country.
Noll begins with a mise-en-scene examination of "the world of the American alienist" in the years before Adolf Meyer in the United States. It is hard to do justice to a profession and its practitioners over decades and a wide geographic dispersal over a few pages, but Noll largely succeeds. He describes several problematic features of the time, most notably a lack of any universal or reasonable system of medical records. He cites S. Weir Mitchell's well-known critique of American psychiatry, which had a profound effect on the profession. Indeed, he says that Mitchell "zeroed in for the kill" in this address to psychiatrists. In fact, Mitchell's address, though devastating, was well intentioned toward alienists. (Several neurological critiques of psychiatry at this time, notably Spitzka's, were far more hostile.)
The author then depicts the profound role of Adolf Meyer, founding chair at Johns Hopkins, in the professionalization and progress of American psychiatry. Meyer was instrumental in setting standards for the profession and encouraging research. Meyer's own theories were convoluted, poorly expressed, and difficult to follow -- and, often, very laborious to read. He did bring Kraepelin's concept of dementia praecox to the United States, though he was hardly a tireless advocate for it.
One theme of the book is the absence of a nosology in the United States, and Meyer certainly retarded efforts to produce one. Though he was highly involved in the committee which delivered an official nosology in 1918, he refused to sign the document after all the deliberations. Meyer believed that every psychiatric syndrome is shaped by the person's history and being; hence, every psychiatric illness is different -- no two are alike. (And this is wonderfully and heuristically incorporated into Engel's biopsychosocial model.) He wrote of "reactions" of certain types, including a dementia praecox type. He believed that psychiatry offered "perspectives" in its various approaches to patients, including diagnostic ones. This concept of perspectives has not been lost at Johns Hopkins, as evidenced by the work of McHugh and Slavney (1). Noll nails it: "Meyer can be generously categorized as 'eclectic', but in truth he was temperamentally unsuited to follow any other man or his ideas. The only problem was he didn't have many original ideas of his own."
Meyer remains a key figure in the book, as does Emil Kraepelin. Noll does an excellent job of depicting the central importance of Kraepelin, then and now. He was a remarkable clinician and a remarkable scientist, and he understood the need to systematize psychiatry if it were to advance clinically or in research. While Kraepelin is often cast as a believer in brain-based pathology, he actually led psychiatry a bit away from the neuropathology which defined its research at the time. Kraepelin believed that it was important to think of psychopathology as related to the brain interacting with other organs and systems. (Indeed, Kraepelin suspected until his death that dementia praecox was a metabolic disease.) In the historical context of the rise of bacteriology and serology, Kraepelin and others wondered whether toxins formed by microbes, rather than the microbes themselves, might cause some diseases. This was the "autointoxication" hypothesis which was so appealing to Kraepelin and many others. (And it has its modern affiliates, immunological reactions in the brain, to bacteria, which can give rise to obsessive-compulsive disorder and perhaps other disorders) (2).
Some of the excitement which Kraepelin's approach brought to the field is captured by the great American psychiatrist, William Alanson White, quoted in the book: "When … Kraepelin's classification, based on a new descriptive symptomatology and the course and outcome of the disease process, came to be known, it was hailed everywhere with joy. Here was a new lease of life for all of us, a new interest in psychiatry, new points of view. The whole subject was revivified and made more alive, and the patients correspondingly became more interesting."
This last comment, about the patients becoming more interesting, becomes another theme of the book and is certainly striking. The Hawthorne Effect, in which patients do well when they are being studied by investigators, with interest, is well known and much studied. Unfortunately, it may have been of little benefit to those with dementia praecox.
The concept of this disorder developed differently in the United States than it did in Europe, based on newly developing cultures of psychiatry in the United States. Noll points out that we know the thoughts of American psychiatrists who wrote (and read the literature), but that most of the profession wrote nothing and read little, so that it is difficult to know how affected most of them were by the introduction of dementia praecox. It became very widely diagnosed, but the concept may have been poorly understood.
With the advent of psychoanalysis, the field split into psychodynamic and biological camps, with many psychiatrists attempting (completely unsuccessfully) to bridge the difference. The great psychiatrist and neuropathologist, Elmer Southard, named this split the divide of the "mind twist and the brain spot" men, a good name. Carl Jung proposed that dementia praecox was caused by an autointoxication (i.e. was a metabolic disease) but could be cured by psychoanalysis. Jeliffe, an early American convert to psychoanalysis, suggested turning to the novels of Henry James to understand the psychogenesis of psychosis. Hoch, another convert to analysis, succeeded Meyer in New York. Kempf, who tried to bridge the gap, wrote a book on psychopathology which included (unsuccessfully) both camps. Noll states, "The volume makes for compelling reading -- if one is in the right mood." This incredible and rapid retreat from science is fascinating.
But science continued, and the old biological work is even more fascinating.
Some of this work, such as Diefendorf and Dodge's description of "ocular reactions of the insane" has been rediscovered -- and is largely accurate -- in much more recent years.
Some of the work was marred by false beliefs about the science of the time. The Abderhalden reaction was false or even fraudulent, but many psychiatric and medical investigators, viewing it as highly scientific (as was thought to be the case), used it in their biological work on dementia praecox and other syndromes.
Noll spends a chapter on the life and work of Bayard Taylor Holmes, a Chicago physician whose son developed dementia praecox. Holmes was disgusted by the fact that no one among his colleagues or friends asked about his mentally-ill son -- undoubtedly the norm for the time about children with severe psychiatric illness: "It seems hardly likely to me that had I had a daughter and she had blazenly gone into public prostitution, would my colleagues have been as silent."
Holmes made a very serious effort to study dementia praecox scientifically. He rejected the genetic hypothesis of dementia praecox on the grounds that it had been the primary proposed etiology of both tuberculosis and syphilis until the causative agents were found. Holmes, trained as a bacteriologist as well as a surgeon, and his colleagues described five organic signs which they believed were pathognomonic of dementia praecox: adrenal mydriasis, hand cyanosis, Lundvall blood "crisis", positive Abderhalden test, and positive response to artificial hyperleukocytosis induced by injections of sodium nucleate. He founded a journal, Dementia Praecox Studies and, with the other editors, proposed in the first edition their "faith" in the hypothesis that "disease of the mind is the result of organic disease of the body".
Based on his hypothesis that dementia praecox could result from a build-up of endogenous ergot metabolites which could affect the brain, Holmes searched for them. . He and his colleagues then found histamine in the feces of dementia praecox patients, without finding it in controls. This work on histamine represented the best science of the day -- in fact, rigorous science limited in retrospect by the state of clinical chemistry at the time. They used the new radiologic technic of barium swallows and found that the duration of passage was longer for dementia praecox patients than for controls. Holmes developed an operation to create a stoma in the cecum, which was intermittently irrigated with water and magnesium sulfate, as a therapeutic intervention. In pre-antibiotic days, this operation led to the death of his son.
We look at such treatments with derision or horror, but they were based on the very best science of a century ago. Attacks on such science by psychoanalysis were rapid, common and nasty. Kempf wrote about Holmes, as quoted in the book, "… I learned that his prejudice was … related to repressions…"
There were other surgical interventions for dementia praecox, including a large number of ovariotomies. These were not based on science and are best forgotten -- or remembered as very bad examples.
As dementia praecox entered into medicine, there were also efforts at patient education. One of the worst, from 1922, was a pamphlet entitled, "Will your boy or girl develop dementia praecox?".
One of the most intriguing characters in this book is Elmer Southard, a Boston psychiatrist/neuropathologist. He, indeed, suggested that the word psychiatrist replace alienist, in 1917. Southard had a heuristic model of neuropathological research on the brains of patients with dementia praecox. He actually expected these brains to be normal and was surprised to find that they were not, with multiple areas of mild neuropathology. His findings are consistent with the disease being "neurodevelopmental", although that term was coined a great deal later. Southard was aware of trends in research: "… One often runs across some scheme devised con amore by somebody … for a few months or even years. Then the wind blows from a new direction." Plus ca change, plus c'est la meme chose.
Southard's early death was a blow to the field.
Noll finishes with an account of the transition from the concept of dementia praecox to Bleuler's concept of schizophrenia, which was quite different and more psychodynamic. Part of the adoption of the new diagnosis and purported structure of the disease may have had to do with Kraepelin's post-World War I German nationalism, for which he was unapologetic, and his antipathy toward psychoanalysis. Noll's account of Kraepelin's (ultimately successful) efforts to find American support for his Institute, in his last days, is poignant.
There are trivial errors of fact in the book, which do not detract from it at all. Noll's portrayal of Meyer as a force who retarded American psychiatry in the research realm is accurate, but I must make the point that Meyer was a fine clinician and a very kind man. Indeed, as Noll points out, he offered to review the records of Bayard Holmes' son, though Holmes had disdain for his positions. Psychiatrically ill psychiatrists, including Freud's American protégé, sought out Meyer for treatment, and it was often effective treatment.
I found this book deeply moving and truly fascinating. It poses implicit challenges as we consider current research and diagnosis. I give it my highest recommendation. In his acknowledgments, the author states, "I wanted to communicate my excitement about the history of psychiatry in a descriptive narrative style." He succeeds superbly.
(1) McHugh, P. R., and P. R. Slavney, The Perspectives of Psychiatry, 2nd edition, Johns Hopkins University Press, (1998)
(2) Swedo, S. E., Leonard, H. L., Garvey, M., et al., pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical descriptions of the first 50 cases, Am J. Psychiat., 155: 264 -- 271, (1998)
© 2014 Lloyd A. Wells
Lloyd A. Wells, Ph.D., M.D., Emeritus Consultant, Department of Psychiatry and Psychology. Mayo Clinic