Archive for the ‘ books ’ Category

New book – Therapeutic Fascism. Experiencing the Violence of the Nazi New Order

9780198784586

The book Therapeutic Fascism: Experiencing the Violence of the Nazi New Order by Ana Antić could be of interest to H-madness readers. This information was retrieved from la vie des idees who published a review about this book. The abstract on the website of Oxford University Press reads:

During World War Two, death and violence permeated all aspects of the everyday lives of ordinary people in Eastern Europe. Throughout the region, the realities of mass murder and incarceration meant that people learnt to live with daily public hangings of civilian hostages and stumbled on corpses of their neighbors. Entire populations were drawn into fierce and uncompromising political and ideological conflicts, and many ended up being more than mere victims or observers: they themselves became perpetrators or facilitators of violence, often to protect their own lives, but also to gain various benefits. Yugoslavia in particular saw a gradual culmination of a complex and brutal civil war, which ultimately killed more civilians than those killed by the foreign occupying armies.

Therapeutic Fascism tells a story of the tremendous impact of such pervasive and multi-layered political violence, and looks at ordinary citizens’ attempts to negotiate these extraordinary wartime political pressures. It examines Yugoslav psychiatric documents as unique windows into this harrowing history, and provides an original perspective on the effects of wartime violence and occupation through the history of psychiatry, mental illness, and personal experience. Using previously unexplored resources, such as patients’ case files, state and institutional archives, and the professional medical literature of the time, this volume explores the socio-cultural history of wartime through the eyes of (mainly lower-class) psychiatric patients. Ana Antic examines how the experiences of observing, suffering, and committing political violence affected the understanding of human psychology, pathology, and normality in wartime and post-war Balkans and Europe.

Book review – Spannungsherde. Psychochirurgie nach dem zweiten Weltkrieg

Screenshot from 2016-05-31 13-41-34Von Viola Balz

Ende August 1946 reiste Manfred Bleuler, Leiter der Züricher Universitätspsychiatrie Burghölzli nach Skandinavien und ließ sich dort eine größere Zahl von leukotomisierten Fällen zeigen. Von seinem klinischen Eindruck der dort operierten Patient_innen überzeugt beschloss er schließlich, die Eingriffe auch in der Schweiz durchzuführen. Marietta Meier macht die Debatte um die Psychochirurgie in der Schweiz zum Ausgangspunkt ihrer Monographie, ergänzt diese aber auch durch Diskurse aus dem europäischen Ausland. Damit legt sie erstmals eine Untersuchung der Psychochirurgie im deutschsprachigen Kontext vor. Während sich zwei bekannte US-amerikanische Studien aus den 1990er Jahren vor allem der Frage nach der Entwicklung therapeutischer Verfahren in der Psychiatrie von den frühen Versuchen bis zur verifizierten Therapie und der Frage nach der Co-Konstruktion der Effektivität der Leukotomie durch Arzt und Patient in der klinischen Praxis widmen,   fragt Meier nach der Metapher des „affektiven Stachels“, also der Frage, wo der Stachel der affektiven Spannung steckt: Was empfand man in der Nachkriegszeit als Stachel, was sollte durch einen psychochirurgischen Eingriff entfernt werden? Marietta Meier versucht dieser Frage mit Foucaults Konzept der Problematisierung nachzugehen. Diesem Konzept folgend analysiert die Autorin, wie und warum bestimmte Phänomene zu einem Problem wurden. Dabei untersucht sie vor allem drei Ebenen: Zuerst fragt sie, auf welche Umstände die Leukotomie eine Antwort geben sollte, darüber hinaus möchte sie wissen in welchem Wechselverhältnis Kontinuitäten und Wandel, Ordnung und Veränderung hier miteinander stehen ohne diese zugleich als chronologische Abfolge begreifen zu müssen und schließlich möchte sie anhand von Quellen aus unterschiedlichen Kontexten wie Publikationen und Krankenakten herausarbeiten, welche unterschiedlichen Facetten debattiert und welches Verhalten je nach Kontext zum Problem wurde. Die Autorin versteht ihren Ansatz dabei als kulturhistorischen, der danach fragt, wie die Akteure ihrem Handeln Sinn verleihen (S. 17-19). Meier gliedert ihre Untersuchung dabei in neun Kapitel. Im ersten Kapitel schildert sie die Einführung des Verfahrens in der Schweiz und die ersten Behandlungsfälle und kontextualisiert diese insbesondere mit den somatischen Verfahren. Das zweite Kapitel widmet sich der Frage, wie die Psychiater_innen sich die Wirkung des Verfahrens erklärten. Dabei arbeitet Meier heraus, dass die Psychochirurgie sich erst dann weiter durchsetzen konnte, als eine wissenschaftliche überzeugende Begründung vorgelegt werden konnte. Argumentierte der „Entdecker“ der Psychochirurgie, der Portugiese Antonio Egas Moniz noch damit, mit dem Eingriff fixierte Nervenbahnen zu durchtrennen und verortete die Technik deshalb in einer vielen Psychiater_innen als veraltet geltenden Lokalisationslehre, gelang es den amerikanischen Psychiater_innen Freemann und Watts schließlich ein Erklärungsmodell vorzulegen, das auf die Verbindung von Thalamus und Frontallappen als Regulationsinstanz für die Intensität von Gefühlen rekurrierte und auf die Unterbrechung der affektiven Spannung durch die deren Durchtrennung hinwies. Diese Verbindung des Verfahrens mit der Beeinflussung von Emotionen sorgte nach Meier dafür, dass sich die affektive Spannung als boundary concept zwischen Hirnforschung, klinischer Forschung und psychiatrischer Praxis durchsetzen konnte. Im dritten Kapitel beschreibt Meier die Verbreitung der Leukotomie in Europa und insbesondere in der Schweiz als Folge der aktuellen Probleme der Nachkriegspsychiatrie, die wiederholt für eine Überfüllung der Anstalt sorgte und deshalb die affektiven Spannungen der Patient_innen verstärkte und in einem neuen Licht erscheinen ließ. Anschließend diskutiert sie im vierten Kapitel die wissenschaftliche Debatte zur Psychochirurgie. Dabei wurde v.a. über den Preis der Eingriffe ins Gehirn, die schon damals als letzter Behandlungsschritt galten und selbst von den Befürworter_innen nur mit ca. 1/3 angegeben wurden diskutiert. War ein sozialer Erfolg schon dann erreicht, wenn die Patient_innen weniger störten? Wie bewertete man die damit einhergehende irreversible Persönlichkeitsveränderung? Nicht zuletzt über letzte Fragen diskutierten Psychiater, Philosophen und Theologen kontrovers. Wie und nach welchen Kriterien Patienten der unruhigen Station zum Fall wurden ist Teil des fünften Kapitels. Insbesondere rückt hier ins Zentrum der Analyse, wann die affektiven Spannungen als so schwerwiegend angesehen wurden, dass sie eine Leukotomie rechtfertigten. Meier fragt hier nach der Semantik der Problematisierungen und arbeitet anhand ihres Quellenkorpus von 300 Krankenakten Schlüsselbegriffe heraus und kontextualisiert sie im zeitlichen Verlauf der Einträge um zu zeigen, wie ein kohärentes Bild eines Patienten entstand, der zum Fall für eine Leukotomie werden konnte. Wie dargestellt wird, waren die Erregungszustände der Patient_innen das maßgebliche Argument für einen operativen Eingriff, unabhängig von ihrem sozioökonomischen Status und der Diagnose, denn oft wurden die Patienten vor allem aus der pflegerischen Indikation heraus operiert. Im sechsten Kapitel zum zirkulierendem Wissen widmet sich Meier der Frage, wie die Psychiater_innen den Laien – Angehörigen und der interessierten Öffentlichkeit –den Eingriff zu plausibilisieren versuchten. Gegenüber den genannten Gruppen wurde statt Spannung eher der Begriff der Erregung gebraucht. Besondere Aufmerksamkeit widmet die Autorin schließlich der Frage, warum im Wesentlichen Frauen für einen operativen Eingriff ausgewählt wurden. Sie erklärt diese Entscheidung mit dem Doppelstandard seelischer Gesundheit, der störendes Verhalten von Frauen eine besondere Bedeutung zumaß. Auch kann Meier aufzeigen, dass auf der Mikroebene das störende Verhalten auf den Frauenstationen die Anstaltsordnung erheblicher störte und eine Leukotomie auch der Wiederherstellung dieser Ordnung und der pflegerischen Vereinfachung diente. Das vorletzte Kapitel widmet sich der Produktion wissenschaftlicher Erkenntnisse. Hier gelingt es der Autorin ausgesprochen überzeugend, den Prozess der klinischen Wissensbildung von der Reduktion der differenzierten Schilderung in der Akte in eine kasuistische Berichtsform (Erzählen), der Bildung neuer quantifizierbarer Kategorien aus diesen Kasuistiken (Zählen) und den Versuchen, die Effekte zu verobjektivieren (Lehren) zu verdeutlichen. Im letzten Kapitel beschreibt die Autorin schließlich den langsamen Niedergang der Psychochirurgie im Kontext neuer Behandlungsverfahren. Anders als in klassischen Fortschrittsnarrativen ausgeführt wird, beurteilt sie die Einführung neuer medikamentöser Verfahren in der Psychiatrie in den 1950er Jahren nicht als ursächlich für den Rückgang der Operationen. Viel entscheidender für eine abnehmende Zahl sei ein neuer Denkstil gewesen, der psychotherapeutischen Verfahren eine neue Bedeutung beimaß. Die Autorin schließt ihre Arbeit schließlich mit vier Thesen zur Nachkriegsgesellschaft. Erstens sei die Psychochirurgie als Symptom für die Debatten der Zeit um Technisierung und Entseelung der bewerten. Der Siegeszug der Leukotomie sei nur möglich gewesen, da erstens nach dem zweiten Weltkrieg ein hierarchisches Persönlichkeitskonzept dominierte, dass auf einem vagen, holistischen Persönlichkeitskonzept beruhte. Die Subjektvorstellungen der Zeit habe zudem zweitens die soziale Anpassung höher bewertet als die Individualität des Patienten. Der Kontext des zweiten Weltkrieges habe drittens das Ziel, Krankheiten zu heilen zu der Norm verschoben, Patienten wieder zu funktionierenden Staatsbürgern zu machen. Wie Meier schließt, sei aber viertens von einem diskontinuierlichen Wandel auszugehen, in dem auch kritische Stimmen sich seit den 1960er Jahren wieder Gehör verschaffen konnten.

Meier legt mit dieser Studie eine sehr gut geschriebene, souverän durchgeführte und wissenschaftshistorisch auf dem neusten Stand argumentierende Studie vor. Insbesondere das Konzept der affektiven Spannungen wird als Konzept konsequent umgesetzt. Die Studie sei also jedem, der sich für die Nachkriegspsychiatrie interessiert unbedingt zur Lektüre empfohlen.

Ein Kritikpunkt sei hier dennoch erwähnt: Meier räumt zwar verschiedenen Protagonist_innen in der Diskussion um die Lobotomie (Ärzten, Pflegepersonal, Angehörigen und Laien) einen größeren Raum ein, die Patient_innen selber bleiben aber seltsam stumm bzw. die Patientengeschichten werden eher aus einem ärztlichen Blick geschildert. Lediglich anhand zweier Beispiele versucht Meier einen Einblick in die Selbsterzählungen der Patient_innen zu geben. Dies ist umso erstaunlicher, da die Autorin angibt, dass solche Selbstzeugnisse in ca. 20% der Akten, also ca. 50, vorhanden waren. Das Argument, dass diese Stimmen von den Ärzten zwar gesammelt wurden, für die Entscheidung über die Erfolge einer Lobotomie aber nicht maßgeblich waren und kein Gehör fanden ist zwar vermutlich richtig, überzeugt aber als Argument gegen eine Analyse dieser Dokumente nicht. Diese Begründung verdoppelt die historische Sichtweise der Ärzte und das geschilderte asymmetrische Machtverhältnis eher, statt die Vielstimmigkeit und die unterschiedlichen Sichtweisen transparent zu machen. In gewisser Weise hat die Autorin den Patient_innen damit auch den affektiven Stachel genommen.

Marietta Meier: Spannungsherde. Psychochirurgie nach dem zweiten Weltkrieg. Göttingen: Wallstein 2015

 

Announcement of New Book: Work, Psychiatry, and Society 1750-2010 (ed. W. Ernst)

Screen Shot 2015-10-09 at 2.23.58 PM

The editors at h-madness have received the following notification of a new book due out in a few months:

This book offers the first systematic critical appraisal of the uses of work and work therapy in psychiatric institutions across the globe, from the late eighteenth to the end of the twentieth century. Contributors explore the daily routine in psychiatric institutions and ask whether work was therapy, part of a regime of punishment or a means of exploiting free labour. By focusing on mental patients’ day-to-day life in closed institutions, the authors fill a gap in the history of psychiatric regimes. The geographical scope is wide, ranging from Northern America to Japan, India and Western as well as Eastern Europe, and the authors engage with broad historical questions, such as the impact of colonialism and communism and the effect of the World Wars. The book presents an alternative history of the emergence of occupational therapy and will be of interest not only to academics in the fields of history and sociology but also to health professionals.

(hb 978-0-7190-9769-0 £75.00 January 2016 234x156mm 440pp 20 illustrations, black and white)

Book review – David Frank Allen, Critique de la raison psychiatrique

screenshot-from-2015-03-09-150753L’auteur, maitre de conférences en psychopathologie à l’université de Rennes et psychanalyste, présente ici la réédition d’un texte paru en 1999 dont la démarche historienne est intéressante à plus d’un titre. L’ouvrage est composé comme son sous titre l’indique d’ « éléments » historiques – brève chronologie, courts essais, focus bibliographiques – qui amèneront le lecteur non prévenu contre cette démarche qui peut paraître pointilliste à partager l’objectif salutaire de l’auteur : contribuer à désacraliser le savoir psychiatrique en historisant les catégories qui en fondent l’existence. Plus d’un siècle après son admission dans la classification scientifique, la schizophrénie, c’est-à-dire la démence précoce apparue dans la classification allemande à la toute fin du XIXe siècle, rebaptisée et élargie par Eugen Bleuler quelques années avant la Première guerre mondiale, est évidemment un des objets adéquats pour mener à bien cette mission. A juste titre, David Frank Allen, s’appuie sur la faible stabilité théorique des hypothèses étiologiques la concernant. L’histoire de la schizophrénie apparaît bien comme un « cercle de propositions logiquement contradictoires qui brule sans cesse »(25), caractéristique qui incite l’auteur à faire sienne une maxime debordienne : dans le savoir psychiatrique – ou plutôt le non savoir – le vrai n’est qu’un moment du faux. Continue reading

Book Review – Anne Roekens (dir.), Des murs et des femmes. Cent ans de psychiatrie et d’espoir au Beau-Vallon (Presses Universitaires de Namur 2014)

FMProBy Valérie Leclercq

The psychiatric institution le Beau-Vallon was founded at the eve of the first World War by the catholic order of les Soeurs de la Charité de Jésus et de Marie. Located on one of the hills surrounding the Belgian city of Namur and dedicated to the exclusive care of women, Beau-Vallon was designed as the first pavilion asylum of Wallonia and rapidly developed into an imposing near-autonomous structure isolated from what was seen at the time as the poisonous influence of the city. On the day of its official inauguration in 1924, it was already comprised of eleven pavilions housing a total of 740 patients.
Today, the institution celebrates a century of existence with the release of a book entitled Des murs et des femmes: Cent ans de psychiatrie et d’espoir au Beau-Vallon. Edited by Anne Roekens, a professor of contemporary history at the University of Namur and also the (co-)author of five out of the book’s seven chapters, Des murs et des femmes showcases the penmanship of seven additional contributors, among whom three psychiatrists (Xavier de Longueville, Benoît Delatte and Jean-Paul Rousseaux, responsible for the seventh chapter), three young historians graduated from the Catholic University of Louvain (Nathalie Collignon, Lisa Lacroix and Mélanie De Brouwer) as well as historian Benoît Majerus who has published extensively on the history of psychiatry in Europe these last few years. The book also incorporated elements from the work of students from the UNamur history department who in 2012 and 2013 were given the opportunity to delve into the records of the institution.
Thematically structured, Des murs et des femmes explores different aspects of the history of the institution, from the context of its foundation to its present state, from its evolving spatial infrastructures and treatment procedures, to the specificities of its personnel and patient population. The book does a great job at revealing the slow processes behind some of the important changes that radically affected 20th-century psychiatry, such as the apparition of psychopharmacology, the professionalization and secularization of the medical personnel, deinstitutionalization, etc. Surprisingly, the history of Beau-Vallon (which would have been considered a second-class country asylum – ou “asile de province” – by the medical authorities of the capital) parallels that of western psychiatry more closely that one might think. In one instance it even seems to have anticipated change when the institution opened several residential facilities outside the hospital a decade before the launch of the 1991national plan to encourage the development of ‘MSP’ (Psychiatric Care Houses) and ‘IHP’ (Protected Homes Initiatives). This last fact the authors are of course eager to point out. But Des murs et des femmes is far from being the simple celebratory narrative that one might expect. Although never overtly critical of this particular institution, the authors do not shy away from sensible topics such as forced confinement, physical coercion, unresponsive physicians, suicide or social segregation inside the asylum, etc. The tone of the book is globally that adopted by most medical historians today who cautiously navigate between the radical anti-institutional acidity of the 60s/70s and the blind optimism of Whiggish medical-historical writing. This middle way is apparent when the authors expose the mutability of the totalitarian psychiatric space, recontextualize the use of mental therapeutics or brush aside the rigid physician-patient antagonism to highlight what Benoit Majerus in his book Parmi les fous (2013) already deemed the central relationship of the everyday institutional psychiatric experience: that of nurses and patients.
Des murs et des femmes, however, will probably prove a frustrating read for historians of psychiatry due to a somehow limited depth of analysis. It propounds no really innovative thesis. The book might be in this regard illustrative of a certain Belgian francophone approach to history: close to its rich source material but lacking in theoretical background and perspective. The two first chapters (Le temps des fondations & Espaces psychiatriques, espaces religieux) appear the strongest and tightest while the four following chapters, dealing respectively with the two world wars, the patient population, treatment and the asylum personnel, seem a bit more factual and loosely problematized. The last chapter, which is concerned with deinstitutionalization and was penned by the three medical authors, confidently recounts the progressive opening of Beau-Vallon and the evolving Belgian legal context in many interesting and necessary details but without never really questioning the process of deinstitutionalization itself. To be fair, the very nature of the project must have imposed some limitations to the contributors’ creativity. When medical historians decide to work on the records of a single medical institution, it is usually to study some or other aspects of medicine or psychiatry, and they are then usually free to narrow their focus as they think best for the relevance of their subject. In The Psychiatric Persuasion, for instance, Elizabeth Lunbeck used the records of the Boston Psychopathic Hospital to write about the psychiatrization of everyday life, just as a few years earlier Nancy Tomes in The Art of Asylum-Keeping dug through the archives of The Pennsylvania Hospital for the Insane only to reflect about the social significance of mid-19th century asylums [1]. But Des murs et des femmes is ultimately the history of the Beau-Vallon asylum itself, an object uneasily unified around a cardinal analytical argument. The study, as a result, covers the major aspects of the institution’s evolution in a thematic overview that still seems to have a lot of unexplored potential.
It is great, however, to see a medical institution collaborate with historians and work such as this being commissioned. And despite its limitations, Des murs et des femmes seems to achieve its purpose successfully. It is a carefully researched and well written effort that is also accessible for the layperson. This accessibility would seem essential for a centennial anniversary publication. The source material used by the different authors is incredibly rich and varied; it includes congregational and hospital archives, legislative texts, medical literature, private archives, oral history (most interviews have been conducted by Anne Roekens), photographs, etc. Moreover, long excerpts from archival documents are showcased in dark grey sidebars, giving the reader direct access to the words of various actors from the period – whether it be catholic nurses or nursing students, psychologists, a priest or a judge. This makes for an engaging read that will similarly please the general, medical and historian public. It is also worth noting that the history of sciences and medicine in Belgium is still in its infancy. In this regard, any contribution to this field is highly valuable, especially when it points out, as is the case here, the specificities of the Belgian situation (for instance the predominantly religious and hospital-centered character of 20th century Belgian psychiatry), possible archive material and new territories to explore while contributing to building the picture of a larger national historical context that no reference work has yet come to illuminate.
1. Elizabeth Lunbeck, The Psychiatric Persuasion : Knowledge, Gender, and Power in Modern America, Princeton: Princeton University Press, 1994; Nancy Tomes, The Art of Asylum Keeping: Thomas Story Kirkbride and the Origins of American Psychiatry, Philadelphia: University of Pennsylvania Press, 1994 (origin. ed. 1984)

 

Valerie Leclercq is a FNRS doctoral Research Fellow at the Free University of Brussels. Her areas of interest include 19th and 20th-century medicine, the history of patients, psychiatry and medical ethics. She is currently writing her dissertation on the therapeutic encounter at the turn of the 20th century.

Book Review – Jan Goldstein, Hysteria Complicated by Ecstasy: The Case of Nanette Leroux (Princeton University Press 2011)

Screen shot 2013-01-11 at 3.15.33 PMBy Michal Shapira

Jan Goldstein’s new book Hysteria Complicated by Ecstasy: The Case of Nanette Leroux is a compelling and intriguing demonstration of what can be gained by close study and analysis of one archival manuscript of a medical case history. The case in point tells the story of eighteen-year-old Nanette Leroux, a village girl from Savoy who fell ill in 1822 with diverse nervous symptoms (among them convulsions, lethargy, sleepwalking , and what her physicians called catalepsy, that is a muscular contraction that fixed her limbs and other body parts in their positions when the symptom took hold). Nanette’s doctors believed the girl to be suffering from “hysteria complicated by ecstasy” following repeated “frights” caused by a rural policeman said to have tried to “offend her modesty.” Goldstein discovered the lengthy (200 page) manuscript at the Institut de France in Paris, and she uses this archival find as a window into a wide-range of historical contexts and methodological questions. The book is divided into two parts which in themselves serve as an interesting model for a historical critical edition: the first half of the book is a meticulous exercise in micro-history providing context for and interpretation of the archival text, and the second half includes the translated and transcribed manuscript itself. Indeed, despite the manuscript’s obscurity, Goldstein is able to successfully “milk it for what it’s worth” and to demonstrate why it is noteworthy. Her ability to reveal and discuss early nineteenth century rural and small-town life in the Alpine region of Savoy and some of the medical debates and conceptualizations of the time is inspiring.

 

While the psychiatric case as a genre grew in length over the course of the nineteenth century, here we have a detailed, and therefore significant, archival example from early on in the century. Through the text, we learn about the patient herself. Described as a somewhat passive, simple village girl, she also had also her moments of wit, creative use of self-expression to assert some control over her situation, and even rebellion against medical practice. We also learn about her two French physicians, Alexandre Bertrand and Charles-Humbert-Antoine Despine, and their conflicting views as they produced the medical edition. The two men came from different backgrounds. Despine was a materially comfortable man of the provinces working for the medical administration of the state-run thermal baths at Aix-les-Bains.  Bertrand, on the other hand, was a young and struggling Parisian but a scientist of the big city. What brought these two physicians together was their mutual interest in animal magnetism and Despine’s search for a worldly colleague to help him in the writing of the case. Their relationship allows Goldstein to explore the production of science in the provinces and ties with metropolitan expertise. Despine first meets Nanette after she had already been examined by a local physician and was also helped by a supportive layman. Despine’s advice was that she should be bought to Aix-les-Bains for therapies such as baths, showers, and electro-magnetism. He approached her both as a doctor trying to cure her and as a scientist aiming to experiment with the case in order to produce scientific knowledge.

 

True to her goal of getting as much as possible out of the text, Goldstein uses this micro-history to artfully explore larger macro-historical trends. Indeed her thorough approach leads her to wonder when the historian needs to stop contextualizing or when is ever “enough context.” Her method is an exhaustive one. Like a true detective, she restores the different backgrounds to the manuscript, from the immediate textual contexts of the scientific debates at the time to the larger social, cultural, political, and economic circumstances in which Nanette, her doctors, and others mentioned throughout the case lived. The result is dazzling, demonstrating how with imaginative scholarly work a broader picture can be pieced together. For example, Goldstein offers fascinating facts about the Savoy region itself under the Old Regime, the Revolution and the Piedmontese restoration. She also reveals the spa at Aix-les-Bains as an interesting and unique setting where urbane, cosmopolitan, tourist crowds meet the provincial misfortunate in a new age of travel and consumerism.

 

The context Goldstein provides is so rich that at times it seems that she drifts too far away from the medical case itself. Yet, again and again she is able to demonstrate how seeing the whole setting is important to understanding the particular episode. For instance, she shows how the tension between the traditional ways of Nanette’s native life and the burgeoning modernity and consumer market culture that the girl experienced in the spa town in fact played out in her illness. Without studying the rich background of place and time, Goldstein argues, the case’s details would have remained unclear. For historians of science and medicine, the scientific debates of the time and the different diagnostic labels of catalepsy, hysteria, and ecstasy assigned to the case are of special interest. Goldstein points out that the concept of hysteria emerged in the 1820 but that at the time it was not necessarily a uterine malady and could still be considered gender-neutral and devoid of erotic connotations. She also reveals the complex and conflicting gender dynamics at the time both between Nannette and her caretakers and impressively also inside Despine’s household.

 

But beyond contextualizing the manuscript, Goldstein is also interested in analyzing and making sense of the case. It is here that the more theoretical and methodological questions of the book emerge. A key issue is trying to answer how contemporaries conceptualized Nanette’s illness. While for post-Freudian twenty-first century readers of the text it might seem as if Nanette is suffering from sexual trauma due to the assault of the policeman, Goldstein emphasizes how the concept of psychological trauma was not yet available to contemporaries, as it would only develop from the 1870s onwards. What the participants in the manuscript did believe was that Nanette’s experience of fright served as a trigger to her illness. This early nineteenth century belief, Goldstein insists, was manifested in a manner that was utterly different than in the fin de siècle. Nanette’s doctors, for example, were not interested in a more all-embracing psychological explanation of her illness as key to self-understanding, or in memory-recovery of the violent episodes. They only aimed to eradicate her symptoms and restore her health and to find out whether animal magnetism could accomplish such goals. While the two doctors shared interest in magnetism, they favored different explanations for it. Despine subscribed to the late 18th century tradition of Mesmer, believing that the cure is of a physicalist nature, while Bertrand preferred a mentalist view of magnetism, and at times was willing to look at the illness from a psychological point of view, seeing it as stemming from Nanette’s “ideas” or “imagination.”

 

Goldstein takes her work a step further when she proposes a twenty-first-century interpretation of the case, using both Michel Foucault and Sigmund Freud to reread it in a more theoretical fashion. She defends this approach in an appendix that one wishes was more developed, especially given the theoretical tensions between these two writers. Her rationale for advancing in such a direction is that Nanette’s physicians shared certain limitations in understanding her illness that Goldstein believes invite the historian to try to improve on their work. In trying to explain why the two doctors ignored the sexual elements in the case—so obvious to a twentieth-first century reader— Goldstein uses Foucault to claim that Despine and Bertrand lived in a transitional moment in the early nineteenth century, just on the threshold of “sexuality” as it was later understood. For them, sexuality was not yet turned into an object of scientific knowledge

and was not yet part of a causal scientific explanation of a wide array of human behaviors. Despine and Bertrand functioned in the era “before sexuality” as they did not automatically connect their patient’s pathology to sex and did not locate sex at the center of her being and of her illness. Their sensitivity to sexual matters was different than ours and their concept of hysteria therefore was not so closely tied to sexuality. Hence they saw no point in analyzing in depth what seemed to be attempted rape.

 

Goldstein then uses a Freudian approach to try to conceptualize Nanette’s own subjective understanding of her situation and the causes of her illness. In a sense here Goldstein brings the case “back to sexuality” – a reverse move from the Foucauldian reading she utilizes thus far and one that could have been elaborated upon further. Goldstein is guided by the psychoanalytic assumption that Nanette possessed an unconscious mind that enabled her to manipulate cultural symbols and discursive possibilities available to her for her own means. In this manner, for Goldstein, the fact that Nannette demanded a watch of her own “surely speaks of her wish—probably unconscious and hence articulated symbolically through the medium of symptom—for some freedom from society’s relentless demands on her biological performance [as a woman], some measure of self-regulation.” (p. 118) Such a hypothesis may not appeal to all historians and may raise the question of whether it is the role of the historian to explain the described illness by twentieth-first century standards. Yet such creative reading does enable a certain interesting interpretation of the case, according to which Nanette’s illness was an expression of an unconscious psychic conflict that centered on questions of rebellion, autonomy, and traditional patterns of behaviors and dependence for a woman in her era. Goldstein argues that Nannette’s taking refuge in illness had to do with the historical change of the post-revolutionary era that exposed her to alternative, and more egalitarian, visions of the future. Located between traditional and modern lifestyles, Nannette literally embodied the contradictions of her historical moment. As this elegantly written book combines an erudite survey of multiple historical contexts, a micro-history of early nineteenth-century French and Savoyard medicine, gender and politics, and an imaginative conceptualization of a medical case, it should be of interest to any serious historian.

 

Michal Shapira is a Thomas Arthur Arnold Research Fellow at the Department of History, Tel Aviv University. She is a modern European historian focusing on the impact of total war and the development of expert culture in the twentieth century. She is the author of the book The War Inside: Child Psychoanalysis, Total War and the Making of the Democratic Self in Postwar Britain (Cambridge University Press, 2013).

 

Book Review – Richard Noll, American Madness: The Rise and Fall of Dementia Praecox (Harvard 2011)

By Jesse Ballenger

As indicated by the controversies swirling around the proposed revisions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders due to be published next year, psychiatry is probably more concerned with the categorization of diseases under its purview than any other medical specialty. Yet solid knowledge of the causes and precise pathological mechanisms that might define mental illness remains more elusive than with any other sort of human affliction. In this richly detailed book, Richard Noll explores the historical predicament of psychiatry through the efforts of America’s early twentieth century psychiatric elite to integrate their field with the main currents of an emergent scientific medicine by creating a scientific classification of mental illness.

In the second half of the nineteenth century, culminating in the emergence of germ theory and the microbiological turn, medicine as a whole increasingly oriented itself around a concept of disease specificity. Disease was no longer thought of as a general process manifesting itself uniquely in each individual, but as a specific entity with distinctive signs, symptoms, cellular pathology, and a typical course and outcome. Medicine increasingly emphasized the rational investigation of biological mechanisms or physiological abnormalities in the laboratory or on the autopsy table.

By contrast, American alienism – the term used through the early twentieth century to describe the branch of medicine devoted to disorders of the mind – seemed left behind to grapple with the protean, inscrutable and seemingly intractable nature of insanity in increasingly overcrowded, understaffed and physically decaying asylums and state hospitals. Noll argues that by adopting and adapting the European concepts of dementia praecox to the American context, leading American psychiatrists transformed their field into a branch of modern medicine.

Historians of American psychiatry, pulled toward the historiographical black hole of conflicts between partisans of Freudian psychoanalysis and the bio-pharmacological turn of the past few decades, have paid far too little attention to the influence of German psychiatrist Emil Kraepelin in the first four decades of the twentieth century. Noll’s book goes a long way toward remedying that. He devotes an excellent chapter to describing how Kraepelin revolutionized psychiatry by replacing a static view of insanity as a single entity that could express itself in a number of characteristic forms in particular patients – melancholia, mania and finally terminal dementia – with the idea that mental disorders could be sorted into distinct categories based on a rigorous, quantitative study of how clinical symptoms manifested over time. This work established two main categories – manic-depressive inanity and dementia praecox – distinguished primarily on the basis of the deteriorating course and bleak prognosis of the latter. Manic depressives improved between acute episodes, and sometimes recovered completely. Patients with dementia praecox very seldom did.

Most of the remainder of the book explores how American psychiatrists like Adolph Meyer introduced and adapted Kraepelin’s methods and concepts into American psychiatry. From a series of increasingly influential positions – first as head of pathology at the Worcester Hospital in Massachusetts, then director of the New York Pathological Institute, and finally professor of psychiatry and head of the Phipps Psychiatric Clinic at Johns Hopkins, Meyer trained nearly every psychiatrist who rose to a senior administrative position in American asylums in the first half of the twentieth century.

Meyer learned Kraepelin’s methods and nosological system during a six week visit to his clinic in Heidelberg in 1896 just as the revolutionary fifth edition of Kraepelin’s textbook was published, and returned to the United States a confirmed Kraepelinian. He was enthusiastic about Kraepelin’s methods and concepts not only because they provided a scientific basis for psychiatric research, but because they provided a rationale for asylum doctors to take a more active interest in the patients who crowded their wards. Thanks to the influence of Meyer and a few other elite psychiatrists like August Hoch and E.E. Southard, dementia praecox, which did not exist in American psychiatry in 1895, became in the space of a decade the mental disorder most widely written about in American medical journals and most frequently diagnosed in American psychiatric institutions.

Although Noll’s book mostly focuses on the thought-world of elite psychiatrists, he recognizes that most American alienists practiced in a much different world in which limitations in their training, and the lack of resources and clinical demands of the institutions they worked in, made it very difficult for them to follow the psychiatric literature published in English, let alone read Kraepelin’s original work in German. Noll argues that in their hands, Kraepelin’s classification scheme became something of a diagnostic blunt instrument – with mixed results for patients. To the good, Kraepelin’s emphasis on clinical observation restored interest in patients and their symptoms, and Noll thinks it likely that some patients benefitted simply from the increased attention. Moreover, since the major categories of mental disorder were distinguished by prognosis, giving patients a diagnosis allowed alienists to say something about the future to patients and their families, and a diagnosis of manic-depressive insanity gave grounds for some hope of recovery. To the bad, Noll argues that the rising prominence of dementia praecox facilitated continued neglect. The dire prognosis of dementia praecox, which Noll estimates to have been the diagnosis for between one quarter to one half of institutionalized patients during this period, justified non-treatment or mistreatment.

Noll shows that American psychiatrists began to stretch the concept of dementia praecox almost from the moment it entered American psychiatry in 1896. In part, this reflected the relative isolation of workaday asylum alienists described above. But even elite American psychiatrists were dissatisfied with several ambiguous aspects of Kraepelin’s concept, and by 1904 Noll finds prominent neurologists and psychiatrists complaining that the term was so malleable that it could be applied to any young person with a serious mental disturbance. The imprecision with which psychiatrists used the term dementia praecox became an embarrassment to the profession when it was mocked in the sensational murder trial of Henry Kendall Thaw in 1907. As widely reported in newspapers around the world, numerous prominent alienists testified as expert witnesses for both sides in the trial and offered conflicting diagnoses, and the strange new term dementia praecox that many had used was lampooned in the closing statement of the defense attorney as “dementia Americana.”

In addition to the slipperiness of diagnosing dementia praecox, many leading psychiatrists, including Meyer, were frustrated that it implied nothing about the cause of mental illness. Kraepelin had rejected the “brain psychiatry” that developed in Germany in the 1860s and ‘70s because he thought its focus on finding the cause of mental illness in specific brain pathology was reductionist and premature. He thought that the first priority of a scientific psychiatry had to be using rigorous clinical observation to establish disease concepts that corresponded to natural disease entities. Kraepelin assumed that dementia praecox had a biological basis, probably in systemic autointoxication, but thought psychiatry should resist etiological speculation in favor of classification based on clinical observation.

Leading American psychiatrists could not easily abide such restraint. In the first two decades of the twentieth century, dozens of articles appeared in the psychiatric literature trying to establish a specific neuropathology for dementia praecox, or compiling laboratory data of various bodily functions of praecox patients to try and identify evidence of autointoxication or “endocrinopathy.”  Despite initial enthusiasm, none of these studies shed much light on the causes of madness, but Noll argues they did serve to demonstrate that psychiatry shared the sort of methods and concerns that characterized modern medicine as a whole. They also encouraged some unfortunate adventures in therapeutics. Convinced that the cause of dementia praecox was autointoxication, Bayard Taylor Holmes, a Chicago surgeon whose son was stricken with the disorder, developed a surgical treatment that involved removing part of the appendix and maintaining an open appendicostomy to allow for frequent direct irrigation of the bowel to remove the infectious material that he believed was the cause of mental derangement. Holmes’s first patient – his son – died of complications following the treatment, but he claimed modest success in the more than twenty patients he and his associates operated on. Others, most notably Henry Cotton at the Trenton State Hospital, developed similar surgical treatments that generated initial excitement, but ultimately failed to produce meaningful results. Hundreds of patients suffered the painful and often fatal consequences of the therapeutic optimism fostered by biological theories of dementia praecox.

Meanwhile, many other American psychiatrists, led by Meyer, grew scornful of narrow laboratory approaches to psychiatry and began to approach dementia praecox as a psychodynamic disorder whose origins could be found in a pre-morbid personality type marked by psychosocial introversion, disorganized habits, and maladaptive psychological reactions to the biological, social and emotional challenges of life. The search for psychogenic causes of dementia praecox led Meyer and his followers to pay increasing attention to the peculiarities of individual patients, thus moving them away from mainstream medicine’s concept of diseases as discrete entities that could be isolated from the particularities of individual patients. By the late 1920s, most psychiatrists intent on finding the psychogenic roots of insanity began to use the term schizophrenia rather than dementia praecox. Noll argues that this represents more than a simple change in nomenclature, as is often suggested, but a fundamentally different approach to psychiatry that emphasized psychological reactions as holding both the key to diagnosis and a potential means of treatment. The concept of schizophrenia proved especially attractive to more doctrinaire followers of Freudian psychoanalysis who became the dominant force in American psychiatry in the 1940s.

In an epilogue, Noll makes explicit the critique of eclecticism in American psychiatry implicit throughout the book. During the period in question, psychiatric elites like Adolf Meyer embraced ambiguity, making room under Meyer’s capacious notion of “psychobiology” for conflicting theories and practices, ranging from psychosurgery to psychoanalysis. Noll acknowledges that Meyer’s eclecticism was in part at least a “pragmatic response to clinical perplexities” that “imposed a fragile peace on rivals in the service of “the greater goal of restoring maladjusted individuals to society” (276). Though Meyer and even more the early psychoanalysts were committed to a psychogenic approach, they understood that biological research and somatic treatments were essential for the prestige of the profession.

But Noll argues that this eclecticism kept alive a tendency to emphasize the peculiar expression of disease in each individual rather than identifying the general characteristics that other branches of medicine used to demarcate specific disease entities, and ultimately marginalized laboratory research and statistical methods, and inhibited psychiatry’s integration into the increasingly powerful and prestigious modern medicine. The enforcement of doctrinaire psychoanalysis in the 1940s and ‘50s was an attempt to solve the problem by constructing a rigorous theory of psychogenic disease that could rival the explanatory and therapeutic power of biomedicine. But psychoanalysis was plagued by ambiguity and paradox and ultimately failed. From the 1960s on, progress in biomedical research into brain chemistry, psychopharmacology and genetics provided the basis for the rationalization of psychiatry that culminated in the triumphant return of Kraepelinian psychiatry as embodied in the DSM-III of 1980.

Many historians will take issue with some or all of Noll’s critique. I tend to take the clinical perplexities psychiatry has always faced more seriously than Noll, and find grounds for skepticism whenever psychiatric theories of any stripe have arrogantly asserted that the fundamental ambiguity of mental disorder has finally been vanquished by science. But the great strength of this book is that it invites intellectual engagement. Noll does not allow his own interpretive commitments to overwhelm the narrative; his representation of the world of American psychiatry during this critical period is so rich and nuanced that readers are able to develop alternative interpretations even as they consider his. In other words, it generates much more light than heat and should be widely read by historians, neuroscientists, clinicians, social scientists and educated general readers interested in understanding medicine’s efforts to come to terms with mental illness. Given the issues at play in the upcoming revision of the DSM, a work of mature, responsible historical scholarship is a timely and valuable contribution to the broad discussion we need to be having about what is at stake in psychiatric classification.

 

Jesse Ballenger is an associate professor in the Science, Technology, and Society program at Penn State University. He is the author of, among other works, Self, Senility and Alzheimer’s Disease in Modern America: A History (Johns Hopkins University Press 2006).

 

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