Harvard University Press Blog

The Rise and Fall of American Madness

Richard Noll’s American Madness describes the electric rise and fall of the psychiatric diagnosis of the mysterious disorder known as “dementia praecox.” As the first specified disease of psychiatry, dementia praecox’s curious history has a great deal to teach us about the nature of the field. As the American Psychiatric Association engages in the vexed process of revising its Diagnostic and Statistical Manual of Mental Disorders, American Madness is a more timely study than many in the discipline would probably like to admit. We invited Noll to answer a few questions about what we can learn from the story.

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Q: Prior to your work, the last time “dementia praecox” appeared in the title of a book published in English was 1950. Clearly it has slipped into our cultural unconscious. Briefly, what is the narrative of the rise and fall of dementia praecox?

Ah, yes . . . dementia praecox is indeed a vanished kingdom of suffering and despair. Hundreds of thousands of Americans who received this diagnosis between 1896 and 1952 were stigmatized by both physicians and everyday people as incurably insane. One only has to remember how frequently it was invoked in the culture of that era (such as in the Tennessee Williams play Suddenly, Last Summer) to get a sense of how terrifying those two words once were.

As the influential psychiatrist Adolf Meyer once said, the history of dementia praecox is the history of psychiatry. American Madness is, at one level, the biography of a disease, but most importantly I regard it as the story of how, in the late 1890s, American alienists (as they called themselves) strove to rejoin an American medical profession that was moving toward a science-based, laboratory-driven moral economy founded on a new (circa 1860) European concept of diseases as separate, biologically-specifiable entities with specific biological mechanisms and typical courses and outcomes. For American psychiatry to survive as an accepted branch of medicine, and not remain as a queer survival of a nineteenth-century therapeutic sect, its legitimacy and authority depended upon adopting this doctrine. In an era where one was either sane, nervous, or insane, most alienists and neurologists assumed insanity was a hydra, a single monster with many faces, not separate creatures.

In 1896 German psychiatrist Emil Kraepelin proposed a classification of mental diseases based on this new fundamental medical principle, and described dementia praecox as a psychotic process that began in the decade after puberty with a distinctive course and outcome. Mental deterioration, weakness and defect worsened and became permanent. It was a hopeless diagnosis. But Kraepelin argued that dementia praecox, as well as other major mental diseases that he created, would one day be found to be rooted in natural, biological disease processes. This claim, in part, made Kraepelinian classification attractive to American alienists who desired to retain their status as physicians. There is a co-dependency of the psychiatric profession and a biological disease concept that persists today.

Beginning in 1896, as one American asylum after another slowly introduced dementia praecox as a diagnostic box, it became the most frequently diagnosed condition, labeling a quarter to a half of all patients in each institution. How American psychiatrists were making this diagnosis is anyone’s guess—they were probably just snap decisions based on whether someone was suffering from a “good prognosis madness” (such as manic depression) or a “bad prognosis madness” (dementia praecox). What we do know is that being young and male made it more likely someone would receive this diagnosis.

As dementia praecox and its successor (a uniquely American re-interpretation of the Swiss psychiatrist Eugen Bleuler’s concept of schizophrenia) became the natural focus of biological research for much of the twentieth century, American Madness also provides the heretofore untold story of the rise of biological psychiatry and laboratory research in the United States. By 1927 schizophrenia became the preferred term for inexplicable madness, but the Americans reframed Bleuler’s disease concept as a primarily functional or psychogenic condition that was caused by mothers or maladjustments to social reality. When Bleuler visited the United States in 1929 he was horrified to see what the Americans were calling schizophrenia. He insisted it was a physical disease with a chronic course characterized by exacerbations and remissions of hallucinations, delusions and bizarre behaviors.

Q: Is it possible to speak of a “typical” case of dementia praecox?

No. The label was so frequently used in an inchoate medical environment absent of consensual agreement on classification and nomenclature that we have little historical evidence as to how, on a daily basis, an individual physician applied these social constructions in his or her practice. Historian Gerald Grob termed this problem for historians of psychiatry as that of the “Invisible Patient.” Knowing the diagnosis of a person of the past tells us next to nothing about their history, signs or symptoms. Alienists and neurologists operated on a gut-feeling level. Diagnosis was not based on an explicit cognitive exercise, like running down a checklist of signs and symptoms, but was more like the experience of recognizing a melody or a scent. A “precox” patient evoked an uncanny feeling of remoteness or of the “bizarre” in a physician, and that was the most important basis of a diagnosis.

Q: How should American Madness help us to understand the sort of epistemic crisis currently confronting American psychiatry?

As everyone knows, the American Psychiatric Association is involved in a highly controversial effort to revise its diagnostic manual. DSM-5 (as it will be called when it appears in 2013) reflects the fact that scientific medicine has not yet solved the problem identified by American alienists a century ago: the linkage of clusters of signs, symptoms, and clinical history to biologically specified disease concepts. The proposed diagnostic criteria in DSM-5 requires a “bottom-up” differentiation of patients, which can be achieved only through an objective biological test (or tests). Until such a tool is developed for schizophrenia, a heuristic associated with an unimaginable assortment of confusing biological findings, we can neither validate nor invalidate our era’s schizophrenia concept. Genetic tests will almost certainly not be the answer, nor will the exclusive emphasis on the brain. As Sabine Bahn and her associates at the University of Cambridge are demonstrating with their new biomarker-based blood test for schizophrenia, severe psychotic disorders might be due to a life-long smoldering systemic or “whole body” disease process that involves glucose metabolism and immune system dysfunction. This is what Kraepelin proposed for dementia praecox, and it might be true for our era’s schizophrenia as well.

From the Protestant Reformation to the Failure of Modernity

Brad S. Gregory’s new book, The Unintended Reformation: How a Religious Revolution Secularized Society, is very much in the tradition of and in conversation with Charles Taylor’s A Secular Age. Both are large, sweeping books that change the way we understand modernity and the world in which we live. For Gregory, that new understanding comes from looking all the way back to the Protestant Reformation, and connecting all that’s come since in ways that scholars have thus far resisted.

He discussed the book with us in a recent episode of the Harvard Press Podcast, which you can hear or download via the player below.

During that conversation, he explained the ways in which he understands modern Western life as stemming from developments of the 16th and 17th centuries:

I don’t think anyone who’s self-reflective about it would deny the rather banal claim that the world that we’re living in today is the product of the past. The issue is what aspects of the past help us to understand and to explain the character of the situation in which we find ourselves. What’s unusual about my book is that it parts ways from the normal methods and the normal assumptions by which even professional historians tend to explain the present. That is, it tends to be assumed that we can account for the world in which we’re living today in the West—North America and Europe—this side, as it were, of the scientific revolution, the Enlightenment, the industrial revolution, the French and American revolutions in the late eighteenth century. And, one of the central arguments I’m making in The Unintended Reformation is that that is not the case, and that all of those developments indeed are critical to understanding where we are today, but what we really need to understand are the religious disagreements of the Reformation era, and the unintended processes that they set in motion, without which we will not understand the character of the problems that we’re facing in the early twenty-first century.

It’s Gregory’s claim that the Western world today is “an extraordinarily complex, tangled product of rejections, retentions, and transformations of medieval Western Christianity.” Our failure to understand that lineage, he argues, prevents us from fully recognizing the disaggregation that our society has experienced. From The Unintended Reformation:

On the eve of the Reformation, Latin Christianity comprised for good or ill the far from homogeneous yet institutionalized worldview within which the overwhelming majority of Europeans lived and made sense of their lives. Diversely, early twenty-first-century Westerners live in and think with and even feel through the historical results of its variegated rejections and appropriations in such knotted ways that it is difficult even to see, much less to analyze, them. In getting from the early sixteenth to the early twenty-first century, this study develops the claim from my first book that “incompatible, deeply held, concretely expressed religious convictions paved a path to a secular society.”

Feather-Capped and Back-Patted

We’ve begun this year with a number of nice honors for books we published in the last. Seems that 2011 was a particularly nice year for HUP biographies. One of them, Robert Douglas-Fairhurst’s Becoming Dickens: The Invention of a Novelist, has been shortlisted for the 2011 Duff Cooper Prize, which celebrates the best in non-fiction writing. The winner will be announced at a party given at the French Embassy in London on Wednesday, February 29th. This welcome accolade joins many others for Douglas-Fairhurst’s unconventional look at Dickens, which was recognized as a favorite of 2011 by such publications as The Wall Street Journal, The Times Literary Supplement, and The Telegraph.

We’re also proud to see another biography, Ezra F. Vogel’s Deng Xiaoping and the Transformation of China, earning wide praise. Having already been named a highlight of 2011 by The Economist, Washington Post, and others, Vogel’s masterful look at China’s boldest strategist has also been named a Finalist for the National Book Critics Circle award for biography. In what was an exceptional year for the category, Vogel’s book keeps great company among co-Finalists such as Manning Marable’s Malcolm X and John Lewis Gaddis’s take on George F. Kennan.

Deng Xiaoping and the Transformation of China has also been longlisted for the 2012 Lionel Gelber Prize, which celebrates the best non-fiction book on foreign affairs published in English. And joining Vogel on the Gelber longlist is Sean McMeekin’s The Russian Origins of the First World War, which boldly upends the conventional understanding of Russia’s part in the Great War. The Gelber list will be shortened in early February, and the winner of the $15,000 Prize will be announced on March 12th.

We’re also honored to note that Daniel Blatman’s The Death Marches: The Final Phase of Nazi Genocide was named Co-Winner of the Yad Vashem International Book Prize for Holocaust Research, for which 2011 was the inaugural year. The Book Prize Committee praised The Death Marches as “an important, path breaking new study on a well-known yet largely unstudied part of the Holocaust,” and described the book as “masterly, a veritable tour de force, and truly a pioneering study and an example of outstanding scholarship.”

And we’d also like to note the awarding of the American Historical Association’s 2011 George Louis Beer Prize to David Ciarlo, for Advertising Empire: Race and Visual Culture in Imperial Germany. The award, given in recognition of outstanding historical writing on any phase of European international history since 1895, is open to any scholar who is a U.S. citizen or permanent resident. Ciarlo recently discussed his innovative visual history of the German colonial worldview with the folks at New Books in History, where you can listen to the conversation.

On our website, you can scroll through other recent awards for HUP books, and we’ve also collected the Book of the Year citations given to over two dozen HUP works released in 2011. We’re continually honored to be working with such talented scholars, and we’re very proud to see their wonderful work recognized so widely.

Matthew Kirschenbaum's Literary History of Word Processing

Matthew G. Kirschenbaum, Associate Professor in the Department of English at the University of Maryland and Associate Director of the Maryland Institute for Technology in the Humanities, is working on a new book entitled Track Changes: A Literary History of Word Processing. The book will explore how the adoption of word processing technology changed the way that writers practiced their craft, a project that reflects a growing scholarly interest in how writing tools affect literary output. Kirschenbaum recently gave a talk at the New York Public Library based on the book’s first chapter, which you can listen to here.

We’re excited to be publishing the book sometime in the next couple of years, and equally excited to watch it take shape along the way. And you can help! On his website, Kirschenbaum has put out a call for assistance:

I want to know who the early adopters were, and how they thought about the new digital technology in relation to their writing practice. I am interested in both “highbrow” and popular authors alike, fiction and non-fiction. I am also following the story through to the present day: many writers now have platforms on social media like blogs, Facebook, and Twitter. Some of my best information so far has come from word of mouth. That’s where I need your help. I would be very interested in hearing from:

• authors who were early adopters of computing and word prcocessing and/or social media (also authors who made a deliberate decision not to switch to a computer);
• editors, publishers, agents, and others in the business with relevant insights to contribute;
• technologists who worked on early word processing programs;
• anyone with relevant primary source materials to loan, share, or contribute; anyone who knows of interesting fictional renditions of computers and word processing (for example, King’s short story “Word Processor of the Gods”).

Kirschenbaum, pictured at right, has also created a new Tumblr blog with which to document and share some of the coverage of and developments with the project. And, after Jennifer Schuessler wrote of Kirschenbaum and Track Changes in the New York Times late last month, there’s certainly been a spike in activity, with additional coverage in the Guardian and at the Atlantic Wire, and a follow-up piece by Schuessler. One notable response came from Jerry Pournelle, a science fiction writer and journalist who for years contributed to Byte magazine. On his own site, Pournelle took issue with many of Kirschenbaum’s statements as reported by the Times. Kirschenbaum tweeted Pournelle’s piece, noting that Pournelle was “definitely high” on his list of people to talk to, and has since reported via Tumblr that Pournelle was “much nicer on the phone” than in his written critique.

It’s interesting to see how Kirschenbaum’s research on the effects of one technological innovation—word processing—is being so shaped by his own embrace of another, social networking. Until recently, it wasn’t often that we got to watch research unfold so publicly, but Kirschenbaum’s style of transparent, internet-based process documentation is becoming more and more common, especially among practitioners of the digital humanities. Follow along for yourself via Kirschenbaum’s Tumblr or twitter, or just keeps tabs on the #trackchanges hashtag. You could also just sit back and wait for the book, but, really, where’s the change in that?

Someday All This Will Be Yours

In a piece published this weekend, Hendrik Hartog, author of Someday All This Will Be Yours, explained that the predominant view of the history of elder care in America isn’t actually very accurate. When thinking of the time before social security, senior homes, and assisted living, people too often imagine families in which children cared for aging parents out of familial love and filial duty, routinely piling three generations into houses together.

But, as Hartog writes, “this portrait is too rosy”:

If we confront what old-age support once looked like — what actually happened when care was almost fully privatized, when the old depended on their families, without the bureaucratic structures and the (under)paid caregivers we take for granted — a different picture emerges.

For the past decade I have been researching cases of family conflict over old-age care in the decades before Social Security. I have found extraordinary testimony about the intimate management of family care: how the old negotiated with the young for what they called retirement, and the exertions of caregiving at a time when support by relatives was the only sustenance available for the old.

In that world, older people could not rely on habit or culture or nature if they wanted their children to support them when they became frail. In an America strongly identified with economic and physical mobility, parents had to offer inducements. Usually, the bait they used was the promise of an inheritance: stay and take care of me and your mother, and someday you will get the house and the farm or the store or the bank account.

But of course what was at stake was never just an economic bargain between rational actors. Older people negotiated with the young to receive love, to be cared for with affection, not just self-interest.

Someday All This Will Be Yours presents the decade of research Hartog conducted, a project he first undertook during an extended stay near his own elderly mother. He eventually assembled a database of more than 200 cases in which a caretaker brought suit, alleging that the deceased had failed to make good on a promise of quid pro quo. In each case, the plaintiff claimed to have been promised, either implicitly or explicitly, that, in exchange for late-life care of their relative, employer, neighbor, or friend, they’d been promised some later recompense such as money or land. As Hartog explains, in order to win the case the aggrieved would have to prove both that a bargain existed and that they’d upheld their half. More often than not, they were unable to do so and were left with nothing.

Such cases, Hartog found, were essentially standard legal business; run-of-the-mill trials evidencing a social dynamic that we’ve somehow largely forgotten in our age of social services. Hartog’s goal for the project was to better understand this history of intimate transaction:

Michael Dummett (1925-2011)

Influential British philosopher Sir Michael Dummett died at 86 in the last days of 2011. Over the years we’ve been the publisher of many of Dummett’s books, including his classic studies of the 19th-century German philosopher and mathematician Gottlob Frege. The Internet Encyclopedia of Philosophy notes the importance of Dummett’s work on Frege:

Dummett has argued that analytical philosophy is based on Frege’s insight that the correct way to study thought is to study language. He holds that Frege advocated a realist semantic theory. According to such a theory every sentence (and thus every thought we are capable of expressing) is determinately true or false, even though we may not have any means of discovering which it is.

Perhaps Dummett’s own most significant work was the development of “anti-realism,” a way of thinking that took issue with Frege’s realist theory. From The Guardian’s obituary of Dummett:

Dummett believed that Frege made certain assumptions concerning truth and falsehood that could be called into question. Frege allowed for the possibility of a thought that was neither true nor false. An example would be the thought that Father Christmas smokes. Given that there is no such person as Father Christmas, then neither is there anything to make this thought true or false. But Frege was not in the least reluctant to admit that a thought could be true or false without our having any way of telling which. An example might be the thought that Plato would have enjoyed smoking. This is what caused Dummett to pause.

He did not see how we could understand a sentence without having some way of manifesting our understanding. And he did not see how we could manifest this without being able to tell whether the thought expressed was true or false. So the assumption that a given thought could be true or false even though we had no way of telling which – an assumption that Dummett called "realism" concerning the thought – was immediately problematical.

In another of his influential works, Origins of Analytical Philosophy, Dummett sought to help bridge the divide between analytic and Continental philosophy by revisiting the moment when the traditions diverged. Simon Critchley quotes the following passage from Origins in a recent appreciation:

I do not mean to pretend that one should pretend that philosophy in the two traditions is basically the same; obviously that would be ridiculous. We can re-establish communication only by going back to the point of divergence. It’s no use now shouting across the gulf. It is obvious that philosophers will never reach agreement. It is a pity, however, if they can no longer talk to one another or understand one another. It is difficult to achieve such understanding, because if you think people are on the wrong track, you may have no great desire to talk with them or to take the trouble to criticize their views. But we have reached a point at which it is as if we’re working in different subjects.

At the NYT Opinionator, you can read reflections on Dummett from over two dozen fellow philosophers, including Timothy Williamson, Dorothy Edgington, and Hilary Putnam, who notes of Dummett that he “cared about ideas, he cared about people, he cared about society, and he rightly connected caring about any one of the three and caring about the other two.”

The Murty Classical Library of India Has Its Design

Designer Andrea Stranger observes that “most designers have a book fetish.”

She came by hers honestly: while a student at San Francisco’s Academy of Art University, she worked “less than part time” at the venerable Alexander Book Company. This past fall, her former employer there emailed to alert her to the contest we were holding to design the Murty Classical Library of India. Stranger took up the challenge, and you can see more of her elegant winning design over at the MCLI site. 

Stranger, who has done design work for clients as diverse as Kate Spade, financial services companies, and internet startups, has a broad interest in design—she says, “I’ll take pretty much any project you throw at me”—and relishes the creativity required to work in different arenas. Her primary objective is identifying a client’s needs.

In the case of the MCLI, which will present up-to-date English translations of classical works in languages ranging from Bengali and Kannada and Marathi to Persian, Sanskrit, Telugu, and Urdu, with the text in the appropriate regional script provided on the facing page, Stranger realized that the most important criteria were flexibility—MCLI required a design that could adequately represent diverse texts—and a look that honored both Western and Indian traditions.

She started by doing research on Indian visual culture, and shared some images from those and other inspirations with us to talk about how the design developed. 

 

 

Stranger saw the galley pictured at right while working at the Alexander Book Company. She was so struck by the text-driven cover that she read the book, and hung onto the galley, which she dug out from her parents’ basement for this photo. She says, “The simplicity of the design and materials stuck with me—and influenced the type-driven approach of the Murty design.”

 

 

 

 

 

 

Stranger says, “I looked at a lot of Indian architecture and found inspiration in the recurring shapes, color and intense use of pattern.” She passed along the image at right as an example.

 

 

 

 

 

When Stranger began researching Indian cultures for the project, she noticed that “the elephant is everywhere,” and realized that powerful cross-cultural associations with the animal, a symbol of wisdom, longevity, and strength in the West, made it “a worthy subject for logo exploration.”

 

 

 

 

 

 

“Textiles, like architecture, offered a lot of fodder for color usage and patterning.”

 

 

 

 

 

 

 

“The Kannada language,” she told us, “served as inspiration for a concept that did not move forward, but the letterforms (like all Indian languages) reinforced the idea of an organic beauty that seemed present in every aspect of my research of Indian design.”

 

 

 

You can see elements of each of these images in Stranger’s final design:

At the MCLI website you can view a slideshow of additional images of the design, and also read thoughts on Stranger’s work from MCLI General Editor Sheldon Pollock, design contest judges such as Peter Mendelsund, and Rohan Narayana Murty, whose endowment gift to Harvard funded the library’s creation.

We’re looking forward to seeing Stranger’s design in print on the first volumes of the Murty Classical Library of India in 2013, and we’re extremely grateful to her and to all of the other talented designers who submitted their work to the contest.