Abstract
The movement of a pendulum is often used as a metaphor to represent the history of twentieth century American psychiatry. On this view, American psychiatry evolved by swinging back and forth between two schools of thought in constant competition: somatic accounts of mental illness and psychodynamic ones. I argue that this narrative partly misrepresents the actual development of American psychiatry. I suggest that there were some important exchanges of ideas and practices in the transition from German biological approaches to American psychodynamic approaches. In particular, two kinds of pragmatism played an important role in this transition: Kraepelin’s methodological pragmatism, and pragmatic values present in the American psychiatric context, due in part to the influence of William James. From a historical standpoint, I suggest that the metaphor of the pendulum doesn’t capture the full complexities of this shift in psychiatry at the turn of the century; from a philosophical standpoint, my discussion brings to light two strands of pragmatism salient to scientific psychiatry.
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Notes
For more on the neurological dimensions of Harvey’s work, see (Hunter & Macalpine, 1957).
John Haslam described three cases of general paresis in Observations on Insanity (Haslam, 1798).
However, this stands out as a vivid instance of the winners writing the history textbooks by weaving an elegant narrative exemplifying their paradigm of choice. Given the sheer number of nosological categories and mechanistic accounts proposed throughout the second half of the nineteenth century, one of them was bound to hit the target. As Gach aptly puts it, “by emphasizing [the one] that won the lottery and forgetting the rest, we not so much falsify the past as reconstruct it in an image pleasing to us now” (Gach, 2008, p. 392).
More damning yet, cortical changes observed at post-mortem in mentally ill patients, a cornerstone of biological psychiatric research, often turned out to be artefacts (Hoch, 1898).
See especially (Chang, 2004, chapter 5) for the presentation of his abstract framework.
Danek et al., (1989) is a helpful study of von Gudden, that outlines his contributions to neuroanatomy, neurology, and psychiatry, as well as his influence on a second generation of biological psychiatrists like Kraepelin and Nissl.
For an examination of some theoretical, instead of empirical, shortcomings of some of the major neuroanatomists of the time—including Griesinger, Meynert, and Wernicke—see (Marx, 1970).
For Kraepelin’s collected writings during his time in Dorpat, from 1886 to 1891, see (Kraepelin, 2003).
In the 1880s and 90s, Kraepelin placed much importance on experimental psychology (e.g. the use of psycho-physics), having been trained in 1882 by Wilhem Wundt. (Engstrom, 2003, pp. 127–130, chapter 6) argues for the strategic importance of psychological psychiatry of the 1890s as a reaction to first-generation German biological psychiatry. For the importance of experimental psychology to the trajectory of Kraepelin’s work, see (Berrios & Hauser, 1988; Engstrom, 2016a; Rotzoll & Grüner, 2020).
Jablensky, (2007) offers a neighbouring reading of Kraepelin’s inaugural lecture: he highlights the importance placed on physical etiology, stresses the importance of individual clinical cases and of experimental psychology, but does not focus on the anti-foundationalist character of Kraepelin’s attack on Griesinger.
In the context of Chang’s epistemology, coherentism is defined in two parts: first as the denial that “any beliefs are self-justifying”, and second that “beliefs are justified in so far as they belong to a system of beliefs that are mutually supportive.” (Chang, 2004, p. 223) Note that the first part is simply a denial of foundationalism, such that anti-foundationalism naturally goes hand in hand with coherentism.
For Kraepelin’s collected writings during his time in Heidelberg (1891–1903), see Kraepelin, (2005).
Ewald Hecker should be credited with one of the first statements of the importance of disease course. He was a close colleague of Karl Kahlbaum, who was an important influence on Kraepelin. This suggests a clear origin of the of notion of disease course, which Kraepelin would extensively use throughout his career (Engstrom, 2003, pp. 128–130).
Berrios & Hauser, (1988) and Weber & Engstrom, (1997) offer important nuance about Kraepelinian diagnostic cards. They note that Kraepelin was not the first to invent diagnostic cards, which originated in industrial age management of insane populations (among other things), nor were these cards pure recordings of symptoms and disease course free of preconceived ideas about mental illness. This, however, does not detract from my point: the epistemological significance of diagnostic cards lay in their expression of a certain stage of knowledge-construction, which necessarily comes packaged with a prior conceptual understanding of mental illness. Their importance, on the current view, is that they reflected the iterative and self-corrective methodological basis of Kraepelin’s research.
In-depth studies of Kraepelin’s Zählkarten can be found in the German literature—see especially (Engstrom, 2005). It turns out that these diagnostic cards were but one component of a complex and interrelated card system (Kartothek) that included “ward reports, patient records, diagnostic lists and research cards.” (Engstrom, 2007, p. 392) As a whole, these documents represented a wealth of clinical information Kraepelin used in constructing his diagnostic system (cf. (Kraepelin, 2006, pp. 40–42)).
Interestingly, some scholars have suggested that these clinical tools were deployed to overcome the limitations of Kraepelin’s earlier experimental work in the 1880s. Synchronic data could not describe a full picture of a disease due to its temporally limited scope, hence the construction of a clinical information system allowing for longitudinal analysis in the 1890s. See, e.g., (Engstrom, 2007; Trede et al., 2005).
In his later memoir, Kraepelin wrote that “[in] this manner we were able to get an overview and see which diagnoses had been incorrect and the reasons that had led us to this false conception.” (Kraepelin, 1987, pp. 68–69) This suggests that, in his mature view, self-correction was essential to his research methodology.
Trede et al., (2005) offer a rigorous and in-depth analysis of the evolution of Kraepelin’s concept of manic-depressive illness throughout the different editions of his textbook. The authors’ findings support the current narrative by stressing the evolving, iterative, and uncertain conceptualizations involved in making sense of complex and often contradictory evidence concerning manic-depressive illness.
Shepherd (1995) paints Kraepelin as having two opposing faces: one representing the ideal disinterested scientist, the other a political reactionary. Engstrom (2007) improves on the picture by merging Kraepelin’s multifarious views into one sophisticated outlook; I follow Engstrom here in trying to make sense of Kraepelin in unified fashion.
Cf. (Kraepelin, 2007 [1908], p. 401). On crime as social disease and its connection to willpower, see e.g., Kraepelin, (1880, 1987, p. 149), Engstrom, (1991, pp. 111–114) and references therein, and Wetzell, (2009). On alcohol, see Engstrom, (1991, pp. 115–120) and references therein. Kraepelin’s experimental work in Dorpat led him to classify alcohol as an etiological factor leading to mental illness—see the 1896 edition of his textbook. On syphilis, see Engstrom, (1991, pp. 119–123). Kraepelin installed a serological laboratory in the Munich university clinic for the study of syphilis in 1907. In 1914, he began discussions with the military to conduct large-scale studies to understand and combat the presence of syphilis in the German forces. See Kraepelin, (1987) for more on its unfolding.
I understand the term ‘objectivist’ loosely here, as capturing the thought that scientific knowledge aims at mind-independent truth and can in principle be produced untainted by social elements. Whether such a principled separation survives scrutiny is an interesting further question. Descriptively, there is good reason to think that Kraepelin’s objectivist ideals weren’t met, as we find social norms and beliefs influencing his scientific research. Degeneration theory exemplifies this nicely. See Roelcke, (1997) and Roelcke, (2001) on this point. Whether we ought to subscribe to such an objectivist view of science is another further question which I don’t address.
This is a common—if implicit—thread in the historiographical literature on Kraepelin’s social and political activities: Kraepelin deployed or exploited the fruits of his research to social problems he thought were amenable to medico-scientific solutions.
And indeed, these sorts of views were in vogue at the time in medical circles (Hoff, 2008).
See especially (Engstrom 2007, chapter 5), and references therein.
In fact, it was exactly these contentions over who had control over patient transfers—the State or Heidelberg—that pushed Kraepelin to leave for a position in Munich, in 1902/3. The Institute in Munich allowed for a fuller decoupling of the university clinic from the State’s system (Engstrom 2007, p. 140).
Recall that the endogenous psychoses were grouped according to whether they were curable (manic depressive illness) or incurable (dementia praecox).
A natural extension of this line of thought is to understand Kraepelin’s epidemiological methods after 1903 in similar fashion. Kraepelin’s interest in affective disorders throughout his career (especially in the context of manic-depressive illness) casts some light on why he developed large-scale data collection methods extending beyond the clinic, in Munich. Just as experimental research was limitative and prompted clinical work to record the course and outcome of disease entities, these clinical practices couldn’t detect more subtle subclinical states. Kraepelin’s growing interest in temperaments and personality traits in the twentieth century, intended to make sense of mixed states that resisted his classificatory system, motivated collecting data beyond the clinic. Specifically, he sought information contained in prisons, schools, and military documents. See Engstrom, (2016b) and Trede et al., (2005) on Kraepelin’s research into affective disorders. I leave open the question of extending the present analysis to Kraepelin’s later practices. Prima facie at least, Chang’s model of epistemic iteration might account nicely for Kraepelin’s widening the scope and nature of psychiatric data after 1903.
Several authors have noted in passing that psychiatry in the United States at the beginning of the twentieth century was importantly pragmatic. For instance, Harrington, (2019, p. xv) writes that biological psychiatry took a “distinctly pragmatic turn”; Wallace offers a Jamesian pragmatic view of American psychiatry in Browning & Evison, (1991, pp. 72–120), Gifford, (2008) briefly looks at the role played by pragmatists like Royce and James in the rise of psychoanalysis in America. These all leave the exact way in which psychiatry was pragmatic underdefined—I hope, in this section, to characterize it more precisely.
For a more general discussion of asylums in America in the nineteenth century, see Grob, (1973, 2019) and (Jimenez, 1987). These examine, among other themes, how the asylum was simultaneously a therapeutic hospital and an instrument of social control. Tomes, (1984, 1994) considers how the mental hospital could still foster good for the community by studying the interplay between the public, doctors, and patients through the lens of Thomas Kirkbride’s work. For more critical commentary on asylum psychiatry, see Rothman, (1971, 2002).
Thanks to an anonymous reviewer for pointing me to this fact.
‘Neurasthenia’ was the American umbrella-term for most forms of functional mental disorders. Prevalent symptoms included nervousness, dizziness, nausea, and nervousness. See, for instance, Brown’s detailing of Beard’s electroshock therapy (Brown, 1980).
For evidence of neurologists interest in social reform, note that in 1878, the ANA banded with members of the National Conference of Charities and Corrections, a group of charity reformers concerned with public health.
During the nineteenth century, American alienists had divided mental illness into those with physical causes and those with “moral” causes—the latter subsumed most kinds of deviant social behaviour, including masturbation, marital problems, jealousy, and pride (Grob, 1973, pp. 150–165, 2008, p. 535). In so doing, they introduced moral values into etiological thinking. “Moral management” logically followed as an appropriate solution to “moral” disease. For more on moral management and asylum care, see (Grob, 2019), especially chapters one and two, Scull, (1991), and Sicherman, (1976), whose discussion connects with American mental hygiene in the late nineteenth century.
For instance, the American Journal of Psychology wrote that “the death of William James has taken from American psychology its most distinguished representative, and from American psychologists the colleague held in highest and most affectionate regard” (“William James,” 1910).
Letter from William James to Clifford W. Beers, Cambridge, April 21 1907 (James, 2011, p. 483).
The larger historical context should be noted here. In the late 1870s and throughout the 1880s, American psychiatry was witness to an extremely bitter conflict between asylum superintendents and neurologists. This competition between the two groups contextualizes James’ intervention, as the larger conflict a decade earlier partly concerned who had legal and professional authority over the American mentally ill. Medical licensing was a contested battleground and a powerful tool to control this psychiatric landscape. For more on the conflict, see Brown, (2008), Sicherman, (1980), Bonnie Ellen Blustein’s contribution to Scull, (1981), and Grob, (2019).
Letter from William James to the Boston Transcript, March 24th 1894 issue.
The Banner of Light, March 12 1898.
James wrote, in a letter to Beers on July 1 1906, that “it is the best written out case that I have seen; and you no doubt have put your finger on the weak spots of our treatment of the insane, and suggested the right line of remedy. I have long thought that if I were a millionaire, with money to leave for public purposes, I should endow “Insanity” exclusively.” Quoted from Dain, (1980, p. 72).
Sidis should potentially be omitted from this list of biological psychiatrists who turned toward psychodynamics later in their careers. For one, he is said to have opposed Freud (thanks to an anonymous reviewer for this). But, he investigated, among other phenomena, the subconscious mind, suggestibility, and the psychological basis of self. See, for instance, Sidis, (1898, 1901). These, it seems, are a far cry from the subject matter of paradigmatic biological psychiatric research. Still, his methods were staunchly experimental and scientific, and his work fell squarely under the umbrella of experimental psychology and scientific psychopathology. In any case, Sidis does not play a major role in the rest of this paper. I bracket these complications for the time being.
See Marx, (2016) for Theodore Lidz’s take on Meyer’s pragmatism. Lidz was one of Meyer’s most prominent students. Lidz, (1985), Scull & Schulkin, (2009) are helpful studies of Meyer’s influence on American psychiatry, and Meyer,( 1948) nicely displays the development of Meyer’s thought and practice.
See, in particular, the letters between James and Putnam in (W. James, 2012).
This strategy had a distinctively Kraepelinian quality to it: by constructing disease entities on the basis of regularities that outstripped behavioural symptoms, he was hoping to separate accidental patterns from fundamental ones. This same logic drove Kraepelin to include psychological clinical data to ground his nosology instead of neuropathological observations.
Thanks to an anonymous reviewer for stressing this point.
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Rattray, D. Kraepelin’s psychiatry in the pragmatic age. HPLS 44, 2 (2022). https://doi.org/10.1007/s40656-021-00480-w
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DOI: https://doi.org/10.1007/s40656-021-00480-w