Abstract
With DSM-5 due in 2013, it is reassuring to note that debates about how to define, explain and treat mental illness were also raging in US psychiatry a century ago. It is also sobering (or perhaps encouraging) to realize that two of the most prominent American mental disorders then, neurasthenia and dementia praecox, were nearly forgotten by the 1930s. As such, it is appropriate that there are two new books on the history of these disorders of times past. But while American Madness and Neurasthenic Nation appear superficially to fit perfectly with one another, they are in fact remarkably different books, not only in terms of methodology, but also with respect to their overall message about what history suggests regarding the nature of mental illness.
As part of Rutgers University Press’s ‘Critical Issues in Health and Medicine’ series, Schuster, a historian, is keen to situate his study in the wider context of how mental illness was understood and experienced. Neurasthenia, ‘the characteristic illness of its day‘ (p. 2), was a particularly American disorder, not only because it was first described by Americans, but also because it was an adverse consequence of the growth and success of the US nation. Sufferers even saw their diagnosis as a badge of honour, an indication of one’s dedication to excellence in one’s area of work.
Neurasthenia was also a nebulous condition, the causes of which were various and could result in symptoms ranging from gastrointestinal problems to mental illness. Given its versatility and its paradoxically positive connotations, resembling what Ilana Löwy (1992) might call a ‘loose concept’, neurasthenia quickly became popular in both the medical and commercial spheres, where cures for the condition were marketed. Although this fluidity contributed to neurasthenia’s ubiquity, it also contributed to its downfall, when medicine became more professionalized and advertising became subject to stricter regulations during the early twentieth century. What remained, however, and what connects neurasthenia with today’s ‘pathologies of progress’, such as chronic fatigue syndrome, post-traumatic stress disorder and irritable bowel syndrome, is the American ‘struggle to create a more perfect union through the pursuit of health, happiness, and comfort’ and ‘the expectation that good health could be obtained through therapeutic activities and purchases’ (p. 6).
Schuster begins by investigating neurasthenia’s medical origins, contrasting how alienists such as Edwin Van Deusen (1828–1909) and neurologists such as George Miller Beard (1839–83) and Silas Weir Mitchell (1829–1914) conceptualized the condition. Although Schuster states that Van Deusen was the first to publish on neurasthenia, he argues that the prevailing perception that psychiatry was outdated and out of touch prevented Van Deusen from being more influential. Instead, it was neurologists Beard and Mitchell, representing a new, exciting field of medicine, who became synonymous with the condition.
Schuster describes Beard as a man whose enthusiasm for science, ambition and ability to tap into the prevailing Zeitgeist made up for his not being ‘particularly brilliant’ (p. 15). In terms of treatment, Beard advocated a non-invasive form of electrotherapy, but warned that neurasthenia would only be cured by fundamental changes in US society and, specifically, by easing the pressures of modern life and allowing people to focus on activities suited to their abilities and interests. Notably, blacks, Native Indians and the working class need not worry about neurasthenia, since their lives, according to Beard, were not dominated by mental strain.
Schuster’s depiction of Beard as a myopic, evangelical and not ‘particularly brilliant’ character jars somewhat with his description of Mitchell, who took up the banner of neurasthenia when Beard died in 1883, aged 43. The ‘distinguished’ and ‘consummate physician’ Mitchell (p. 25) stressed that each case of neurasthenia had individual causes and, as such, advocated that a patient’s history was of paramount importance, an inclination that foreshadowed psychoanalysis. Mitchell advocated invigorating activities, ranging from painting to hiking, to revitalize his patients, prescribed rest cures in desperate cases, and treated many high-profile neurasthenics, thus boosting the condition’s profile.
Through Beard and Mitchell’s efforts, neurasthenia’s popularity mushroomed. It soon became a common feature of popular health manuals, beginning with Mitchell’s Wear and Tear (1871). Purveyors of health products also capitalized on the condition, marketing cures ranging from the Heidelberg Electric Belt (an advertisement for which graces the cover of Neurasthenic Nation) to tonics, such as Restorative Nervine, ‘a brain and nerve food and medicine, which soothes and quiets the brain and nervous system while it furnishes nourishment and strength’ (p. 50). Neurasthenia also entered contemporary literature and, much like today’s mental disorders, people were quick to identify with the condition and what it implied about their troubles. By the end of the nineteenth century, Americans were attributing everything, from depression to indigestion, to neurasthenia, and were turning inwards for existential explanations.
Schuster argues that, by looking inward, many neurasthenics began examining the connection between their spiritual and their physical condition – a somewhat ironic development given Beard’s previous preoccupation with debunking spiritualism. Many important themes arise in Schuster’s discussion of therapeutic spirituality, including the power relationship between physician and patient (especially female patients), the emergence of psychotherapy, and the uncomfortable relationship between religion and science. Unfortunately, Schuster is not afforded the space to situate his arguments into the broader historical framework. The relationship between therapeutic spirituality and psychotherapy, a key concept, is not made clear enough, largely because the pertinent religious and psychological landscape is not mapped out in detail. We are given one case study, that of Susan Elizabeth Blow, to convince us of the connection, but the bigger picture should be made clearer.
Schuster’s discussion of neurasthenia and gender, in contrast, is more insightful. He presents case studies of male and female neurasthenics which demonstrate how neurasthenia helped to shape notions of masculinity and femininity. For men, neurasthenia – a somewhat desirable condition, it should be remembered – undermined typical Victorian ideals of masculinity such as self-control, strength and confidence. For women, neurasthenia could suggest that feminine domesticity could actually be harmful, and that independence, freedom and the challenge of new experiences, rather than merely rest, was the key to recovery. Changing one’s routine in the interest of health might not merely involve a holiday; it could also require challenging assumptions about what constituted a meaningful life for both men and women.
Similarly, the relationship between neurasthenia and the idea of a balanced lifestyle, in which physical exercise, exposure to nature and artistic pursuits were essential, also involved existential questions. Life could not be all about work; indeed, the Protestant work ethic could be pathological. Instead, leisure, whether it be in the form of cycling, handicrafts or camping, was central to preventing neurasthenia, and was crucial to a life well-lived. Such thinking inspired one of the first American environmentalists, the Scottish-born John Muir, and the rugged, outdoorsy Theodore Roosevelt, who made the creation of national parks a foundation of his presidential platform.
Although achieving a balanced lifestyle would remain an important, if elusive, goal for Americans, the concept of neurasthenia would not. By the 1920s, neurasthenia was seen as passé, ‘an overly vague, cumbersome label’ (p. 141) that was not in keeping with medicine’s attempt to become more scientific. The re-emergence of psychiatry as a major force within US medicine also meant that neurasthenia’s symptoms were increasingly seen as symptomatic of mental disorder, rather than the exhaustion of nervous energy. Simultaneously, the discovery of hormones and vitamins allowed physicians to re-conceptualize the more metaphysical notion of ‘energy’ in a more scientific and quantifiable manner. Finally, the marketing of neurasthenia by drug companies was curtailed after the American Medical Association successfully lobbied to limit pharmaceutical advertising and thus reduce the sales of so-called ‘secret nostrums’ (p. 153).
However, if neurasthenia had faded away, the underlying fear that the American lifestyle was pathological, resulting in nervous breakdowns, chronic fatigue, depression and a whole host of associated physical symptoms, had not. Again, Schuster needs more space to discuss this legacy. He highlights how the ‘shadows of neurasthenia’ have been far-reaching in both American science and culture (p. 165), but more details, perhaps emphasizing why the search for health, happiness and comfort has been such an American preoccupation, would have been welcome. Nevertheless, Neurasthenic Nation is a captivating read that holds a mirror up to the present as much as it does to the past, emphasizing the strong link between social experience and mental health.
Richard Noll traces the rise and fall of another fin-de-siècle disorder in American Madness, but dementia praecox presented both patient and physician with a drastically different phenomenon. Whereas physicians saw neurasthenia as a curable condition, dementia praecox was ‘the terminal cancer of mental disorders’, a ‘diagnosis of hopelessness’ that foretold ‘permanent disability and no hope of complete recovery’ (pp. 3–4). Characterized by confusion, depression, hallucinations and physiological abnormalities, dementia praecox meant an unremitting deterioration of cognitive functioning that typically condemned sufferers to life in an asylum.
As Noll observes, many psychiatrists have interpreted dementia praecox as synonymous with schizophrenia. Noll’s purpose in writing American Madness is partly to debunk this assumption, and also to depict how the disorder, first described by the German psychiatrist Emil Kraepelin (1856–1926) in 1896, took root in the USA and what repercussions this had for US psychiatry. He begins by providing the context for US psychiatric practice during the late nineteenth century, which centred on the asylum and the work of alienists, or asylum doctors. Noll argues that psychiatry during this period was unique among other medical specialities in that it was trapped, to a large degree, by the walls of the asylum itself. Those who worked outside these walls treating neurasthenic patients, for example, were not typically psychiatrists, but rather neurologists, as Schuster also notes. Alienists were not only physically removed from the rest of the medical profession, but their very work was also discrete from the curative role of other physicians; the chronic state of institutionalized patients meant that most alienists could only aspire to manage their condition. Describing alienists as having ‘an impossible job’, which alienated them from the rest of medicine at a time of professionalization, Noll suggests that dementia praecox helped to bring order and rationality to the chaotic world of the asylum (p. 35).
Having portrayed the state of the American alienist, Noll proceeds to introduce Emil Kraepelin and Adolf Meyer (1866–1950), protagonist and antagonist, respectively, of his story. Following a ‘fact-finding mission’ to Europe that included a visit to Kraepelin’s Heidelberg clinic, Meyer brought the concept of dementia praecox to the USA during the 1890s (p. 48). It is somewhat odd that Noll’s chapter on Meyer precedes the Kraepelin chapter for reasons of chronology, but this is a fairly minor quibble. What is more irksome, yet also revealing, is Noll’s negative depiction of Meyer, which seems to rest more on the author’s personal perceptions rather than direct evidence. Unlike Jack Pressman’s more sympathetic characterization of Meyer in Last Resort (1998), Noll describes the Swiss-American as lucky, conniving, ambitious, fastidious, neurotic, arrogant and vain, having ‘a knack for bureaucracy’ (p. 37) and a ‘confidence that outstripped his competence’ (p. 38), a man more comfortable with his ‘jars of brains than with living patients’ (p. 40). In contrast, Kraepelin receives a warm appraisal; he is depicted as a talented physician who overcame significant obstacles to become one of the most influential figures in psychiatry. Noll’s portrayal of Meyer as the villain of the piece, responsible for delaying both the wholesale adoption of Kraepelian classification systems in the USA and the development of a scientifically-respectable psychiatry, tarnishes what is an exhaustive and insightful analysis of a largely-forgotten mental disorder, and makes it difficult for the reader to trust his interpretations.
Nevertheless, Noll does succeed in elucidating the complex process by which Kraepelian ideas entered the American psychiatric imagination. Beginning with a review of Psychiatrie in 1896, Meyer, along with fellow Swiss émigré August Hoch (1868–1919), would be central in transforming Kraepelin’s dementia praecox into a uniquely American madness, but the process did not stop with them. Initially, American alienists were reluctant to replace their traditional conceptualizations, such as melancholia, mania and dementia, with Kraepelian diagnoses. Once articles on Kraepelin began to be published in American medical journals in 1900, however, dementia praecox became a powerful heuristic for much of the misery and hopelessness in American asylums, and the idea was adopted – and extended – by many American alienists and neurologists, who tended to ‘accept, simplify, and apply’, rather than critique it as Meyer did (p. 101). Dementia praecox, along with other Kraepelian diagnoses, such as manic-depressive insanity, soon became the most common psychiatric diagnoses, accounting for up to half of all institutionalized patients.
There were good reasons for this. When applied in retrospect, a dementia praecox diagnosis helped explain why so many patients remained uncured. It also seemed to apply to many new, especially young, male patients. Finally, it gave patients and their families a better idea of the course, however dire, of the disorder. It provided both a sense of order and closure for physicians and patients.
But what actually caused this ubiquitous and tragic disorder? For Kraepelin, dementia praecox was a type of autointoxication that linked the brain to other systems of the body, indicating the existence, according to Noll, of a ‘lost biological psychiatry’, which paralleled the rise of Freudian psychogenic theories (p. 109). Such biological legitimacy helped transform the disorder from a captivating idea for American psychiatrists into ‘a legitimate, real disease’, rooted in laboratory investigations as well as clinical observations, and not dissimilar to other physical diseases that were being reconceptualized during the bacteriological revolution in the late nineteenth century (p. 115).
That is not to say that everyone embraced such conceptualizations. Meyer, who had never accepted Kraepelin’s explanations for dementia praecox as unreservedly as his American colleagues, had ‘turned his back’ on Kraepelin and his classification system by 1903 (p. 167). Instead, Meyer and his fellow ‘mind twist men’ formulated psychogenic explanations for dementia praecox, which would come to prominence in the 1910s. Although Noll contends that Meyer’s rebuffing of Kraepelin kept American psychiatry in a ‘scientific swamp’, forever trying to catch up with the rest of medicine (p. 168), others, such as Pressman, have been more sympathetic, insisting that Meyer was justifiably advocating a more pluralistic, individualistic and flexible approach to mental illness, one that might be welcome today.
Meyer’s psychogenic theories notwithstanding, many intent on treating dementia praecox remained focused on the issue of autointoxication. The tragic story of surgeon Bayard Taylor Holmes (1852–1924), whose son was stricken by the disorder, is relayed by Noll to show the lengths to which heroic treatments were taken. Repelled by his son’s treatment in an asylum, Holmes began investigating the autointoxication explanation for dementia praecox, centring on the idea that a focal infection in the large intestine was the source of the problem. The ‘radically rational treatment’ for such an infection was abdominal surgery followed by intestinal irrigation over a period of months (p. 194). Holmes performed the first such operation on his own son in 1916, and it caused the young man’s death. Despite this tragedy, Holmes continued to perform the surgery, often at the request of desperate parents.
Ironically, while Holmes was performing his surgeries, a new disorder was being introduced to American psychiatrists, the prognosis for which might have rendered such heroic surgeries unnecessary. Schizophrenia, coined by Eugen Bleuler (1857–1939), seemed very much like dementia praecox, but lacked its irreversibility and incurability. Schizophrenia could be treated. Just as dementia praecox provided a justification for the funding of asylums – those diagnosed would never recover, so facilities were required to house such sufferers – schizophrenia rationalized funding psychiatric research into treatments. While the two terms would co-exist during the interwar period, dementia praecox would ultimately disappear, although Kraepelin is once again seen as the guiding force in American psychiatry and Meyer, justifiably, according to Noll, has become a ‘ghost’ and ‘specter’ (p. 279).
In his Acknowledgements, Noll states that his book on dementia praecox ‘is the book I’ve always wanted to read’ (p. 381, original italics). While it is fine to see an author so happy about his work, it does not mean that everyone will have the same reaction to American Madness. Despite Noll’s attempts to contextualize and his odd passing statement about social constructivism, his take on dementia praecox and American psychiatry will seem – and is admittedly – ‘old fashioned’ (p. 379). Although Noll claims to have kept ‘his interpretative framework to a minimum’ (p. 379), the book ultimately comes across as a judgemental, Whiggish, top-down, patient-free history of psychiatry that does not tend to get written any more, unless you happen to be Edward Shorter. Noll seems to think that his psychiatric background gives him a greater insight into the reality of mental illness than historians might have. That may be the case, but it does not necessarily make him a better historian of psychiatry. History is not an objective science, but nor is psychiatry, as Noll’s history demonstrates; both are influenced by a priori assumptions, ideological grounding and personal beliefs. The difference is that historians of the past few decades either make their biases plain to see, or do their best to minimize (or perhaps disguise) the influence of them. All of this does not mean that American Madness is an unwelcome addition to the history of psychiatry. It will certainly foment much more debate than the mild, yet stimulating, Neurasthenic Nation, and raises important questions about how history can and should be used in informing psychiatry’s future. But it is also a return to a type of history of medicine that might make some historians feel uncomfortable.