Manufacturing depression

by Gary Greenberg

  Emil Kraepelin embarked on his career as a psychiatrist with an interest in his patients’ inner lives. His doctoral dissertation, published in 1879, was “The Place of Psychology in Psychiatry,” and early on he rebelled against his mentor, who believed that only the microscope could reveal anything important about mental illness. But within a few years, he was convinced that psychiatry, and perhaps the world in general, was much better off without psychology.

  The problem, as Kraepelin saw it, was that the only source of psychological information about insanity was the patient, and the patient was, well, insane. So, he concluded, “we cannot afford to pay much attention to the patient’s account of his experiences.” Neither did he think that it was a good idea to indulge in “poetic interpretation of the patient’s mental process. This we call empathy,” he said, warning that a science-minded doctor employed it only at his own peril.

  Trying to understand another human being’s emotional life is fraught with potential error. This is true in healthy people and much more so in sick ones. “Intuition” is indispensable in the fields of human relations and poetic creativity, but it can lead to gross self-deception in research.

  Kraepelin felt that even his own interior was unworthy of exploration. When he published an analysis of his dreams, it was not to ferret out their meaning but to illustrate the way that the language of dreams resembled the language of insanity.

  Kraepelin eventually landed a job in an asylum in Estonia, whose natives spoke a language that he didn’t understand. Now that it was impossible to listen to his patients’ stories, he was free to focus on the subject that he thought could put psychiatry on an equal footing with the rest of medicine: mental illnesses themselves, uncontaminated by unreliable psychology and fickle empathy. By the time he returned to Germany from the Baltic hinterlands, Kraepelin had given the modern world a conception of depression that fit the newly emerging medical model: it was, he said, a disease like any other. Indeed, he told his students, “from the medical point of view, it is disturbances in the physical foundations of mental life which should occupy most of our attention.”

  With this proposal, Kraepelin was entering treacherous territory. Although scientists had begun to identify brain structures that appeared to underlie specific faculties of mind—notably language—both this knowledge and the technology used to obtain it were rudimentary. Even more important, some doctors had already suggested that the mind could be reduced to a function of the brain, and they had landed in hot water as a result. The Parisian doctor Julien Offray de La Mettrie, for instance, had proposed in 1745 that the brain was a machine that produced consciousness, and that it was in this respect no different from the rest of the body: “it possesses muscles for thinking as the legs do for walking.” For suggesting that the mind was nothing more than the output of a “machine that winds itself up, a living picture of perpetual motion,” and the soul merely a “vain term,” and for prophesying that doctors would soon understand the clockworks so well that “everything can be explained, even the surprising effects of the disease of the imagination,” La Mettrie was exiled to Holland, from which he fled for Prussia, where he died in 1751.

  Intolerance of materialism wasn’t limited to the French and the Dutch. Fifty or so years later, Franz Josef Gall had run afoul of the Viennese authorities by proposing that the brain was divided into twenty-seven organs, each of which produced a different aspect of the mind, and all of which Gall claimed to have mapped. What’s more, he said, a careful observation of the skull—measuring it, feeling its protuberances, taking a practiced look at its shape—would reveal the brain that lay beneath and with it the character and intellect of its owner. Gall’s organology resembled in some ways the physiognomy already being practiced across Europe, but he was the first to claim that cranial features were expressive not of the immaterial soul, but of the flesh-and-blood brain, which in turn was the seat of the soul. His reward was a letter from the Emperor Franz II. “This doctrine concerning the head, which is talked about with enthusiasm, will perhaps cause a few to lose their heads,” he wrote. Because Gall’s materialism threatened “the first principles of morality and religion”—not to mention the delicate sensibilities of the women of Vienna—Franz II banned him from delivering further lectures.

  The ban was good for Gall’s business. The ensuing sensation made his European tour, on which he dissected brains, read skulls, and displayed his collection of skulls of the rich and famous, a huge hit. “There is always unending applause at all the public demonstrations,” Gall wrote to a friend back home. But it was terrible for science, especially when Johann Spurzheim, one of his lab assistants, broke away. Gall’s cartography, Spurzheim announced, was inaccurate, especially insofar as it included too many territories of evil—there was a region, for instance, for murderousness—and no room for redrawing the boundaries or to rectify deficiencies. Spurzheim claimed that people were not so bad as Gall had said, and that to the extent that their brains were weak, he could show people how to cultivate and improve them. He gave his version of organology a new name—phrenology—and took his show on the road, playing to even fuller houses than Gall had, not as a scientist, however, but as an entertainer.

  So by the time Kraepelin proposed that doctors look to the brain to understand the mind’s troubles, this idea was associated more with scandal and spectacle than with science. Kraepelin had done his part to make psychiatry more like the medicine that was emerging in the wake of the magic-bullet revolution. He had, for instance, determined that nearly half the mental patients at Berlin’s Charité hospital were suffering from syphilis. But such discoveries were hard to come by, especially for Kraepelin, whose eyes were too weak for microscope work, and he was doubtful that anyone else was going to parse the newly apparent complexities of neuroanatomy anytime soon. It was one thing to find a bacillus in a blood cell and quite another to figure out what was going on in that tangle of neurons and fibers.

  Kraepelin saw the problem: psychiatry risked being left in the dust as the rest of medicine galloped along on the back of science. This disadvantage was nowhere more evident than in the chaotic state of psychiatric diagnostics. When Kraepelin moved to Estonia in 1886, psychiatry was a professional Babel. No one really knew if Dr. A’s case of “masturbatory insanity” was the same as Dr. B’s, or perhaps closer to Dr. C’s patient with “wedding night psychosis.” Without a reliable nosology—a systematic way to name the varieties of insanity—doctors could neither communicate with one another or, more important, demonstrate to a patient, his family, and the general public that they knew what they were talking about when they rendered a diagnosis. “Pathological anatomy”—the kind of findings that allowed physicians to proclaim that a sore resulted from smallpox and not syphilis—may have offered “the safest foundation for a classification,” but Kraepelin thought there was another way to get at the diseases that lurked just behind patients’ unreliable and idiosyncratic accounts.

  Kraepelin’s elegant solution rested on his insight that the advent of scientific medicine granted doctors the power not only to treat disease—which was still a mostly unrealized promise—but also, and perhaps more importantly, to give accurate names to human suffering, to render diagnoses. To the extent that doctors relied on scientific instruments to determine those names, they could claim that their diagnoses were based on empirical observation rather than whim or superstition or tradition, and that they therefore got to the truth of our suffering. Modern diagnostics eliminated the metaphysics of the ancient doctors by disclosing a world of pathogens behind the world of symptoms, a verifiable reality behind the appearance of disease. To use these findings to carve up the landscape of suffering into its diagnostic regions was thus to map the natural order of illness. So when a doctor pronounced the name of his patient’s suffering, he was invoking something that existed in that hidden world: a disease that could be seen and touched, if only by specially equipped scientists. By virtue of his special tools and advanced training, the d
octor could claim to know something about his patients’ suffering that they themselves—or, for that matter, laymen in general—could not.

  Kraepelin also realized that doctors didn’t have to look at a stained specimen—or show one to their patients—to exercise their diagnostic power. They only had to know the disease’s signature symptoms, which were the arrows pointing to those pathogens. The names themselves carried the authority of the microscope. And, he thought, there was no reason that psychiatrists couldn’t have this kind of certainty. All they needed was the kind of reliable and comprehensive list of diseases they would undoubtedly derive from a pathological anatomy if one were available. They could, in other words, have the form of science, if not its content. He may have only had appearances to work with, but Kraepelin believed that by observing them carefully enough, he could discern the natural order that symptoms pointed to.

  There was powerful precedent for this approach. In the 1730s, the Swedish botanist Carl Linnaeus had published his Systema Naturae, dividing the natural world into three kingdoms, each of which had its own phyla, classes, orders, families, genera, and species. “Deus creavit, Linnaeus disposuit” (“God created, Linnaeus organized”), he wrote, and in case the point wasn’t clear, he depicted himself on the cover of his book naming the creatures in Eden, as if he were improving on Adam’s first attempt. His grandiosity may have been justified, however, because in naming and sorting the natural world, Linnaeus created the common language that made plant science possible. For 250 years, until DNA testing came along, Linnaeus’s classification of plants reigned supreme in botany.

  Linnaeus faced a problem similar to Kraepelin’s: he had nothing to work with except appearances and his senses. His job was to use what he saw and felt and smelled to establish the links and discontinuities in the botanical world. Many plants have thorns, for instance. But only some also have a thick stem with shiny green leaves. And only some of those blossom into a fragrant, voluptuous flower that turns into a hard, sour fruit. This cluster of appearances and, even more important, the course of a plant’s life, is its unique signature, the set of data that separates a rose from a cactus or crown of thorns. Once you establish these associations, said Linnaeus, you can not only pronounce the name of a plant and its relation to other plants with authority, you can also know the ultimate fate of the tiniest sprout.

  Kraepelin knew that most insane people had delusions. But for some, the delusions came on a few years after a bout of syphilis and led inexorably to dementia, paralysis, and death. For others, they began as hallucinations in adolescence, remitted occasionally, and rarely affected general health. Still other insane patients were driven to bed by their delusions, then flung into a frenzy of activity, and later back into a stupor. In each case, however, the disease had a particular course and outcome that could be observed over time. By looking at what happened to the patient a doctor could judge with certainty the variety of madness that had been manifest in the patient’s condition; the patient’s fate would tell the doctor what disease he had in the first place. And by the same reasoning that Linnaeus used, Kraepelin argued that once you know enough about the appearance and progress of a particular form of insanity, you can determine the likely fate of a patient from the first delusion. You don’t have to know the biology of the process to claim that you know what will happen next. With enough observation and corroboration, you can, as Linnaeus might have put it, accurately separate the fruits from the nuts.

  The important biography, then, was not of the patient—the particulars of which, between the unreliability of the insane person’s account and the dangers of empathy, merely confused the issue—but of the disease. And Kraepelin set out to write those biographies by making careful observations of what the diseases did to patients over the long haul. By 1890, when he landed a job in Heidelberg, he had developed a notion of how, by matching symptoms to one another and then to outcomes, he would, as he put it, “cut nature at its joints” and identify the discrete diseases of the mind.

  His method was straightforward. For every patient who entered the asylum, he started a note card. On it, he wrote down the patient’s history and condition and rendered a diagnosis. The card went into the “diagnosis box” with all the other cards, and the information went on a list. During the patient’s stay, Kraepelin and his staff would revisit the cards, revise the diagnoses, and make the appropriate entries, tracking the progress of symptoms and diagnoses until discharge. Eventually, he built up what we would call a database, which he took home on weekends and away with him on vacation, sorting and resorting until he felt certain that he had laid out the symptoms and course of a particular disease. In 1893, he began to present his results in his Lehrbuch der Psychiatrie, an often-revised textbook intended to allow physicians to diagnose their patients reliably and to give families of the afflicted what, at least according to Kraepelin, they wanted most: a prognosis.

  Of course, that’s probably not precisely what was desired by the parents of the young man, diagnosed by Kraepelin as hopelessly ill with dementia praecox, who saw a raven at his window waiting to eat his flesh, or by the wife of the farmer, so ridden with guilt about having “practiced uncleanness” with himself (and, the farmer said, with a cow) that he couldn’t get out of bed, whom Kraepelin diagnosed with involution psychosis. They probably wanted a cure. Kraepelin, on the other hand, didn’t think this was a reasonable goal because mental illnesses, like roses and pine trees, had to run their natural course. Some were caused by toxins like alcohol or syphilis and, at least in the pre-Salvarsan era, nothing could be done about them except avoiding the poison. The rest were inherited rather than acquired, and you couldn’t make a constitutionally insane person sane any more than you could get a rose to bloom from a pinecone. On the other hand, knowing what a pinecone will become tells you something important: what kind of soil it needs, whether you should plant it in full sun or shade, how you should feed it. Likewise, the point of a taxonomy of insanity—beyond the satisfaction of naming God’s critters—was to figure out what to do with the patient, not for the patient.

  Kraepelin’s concern about how to dispose of patients grew urgent as the end of the century approached. His audit of German asylums indicated that the numbers of the insane were swelling, in proportion as well as in absolute terms, and, as he told a group of doctors in 1899, the potential consequences to society were dire. “All the insane are dangerous. Mental derangement is the cause of…sexual crimes and arson, and, to a lesser extent, dangerous assaults, thefts, and impostures,” he warned. “Numberless families are ruined by their afflicted members.” Perhaps most regrettable, Kraepelin added, was the fact that “only a certain number of those who do not recover succumb at once…[and] the effects strike deeply into our national life.” That left doctors with important responsibilities:

  to prevent the marriage of the insane…to secure a proper education and choice of occupation for children predisposed to disease…to recognize dangerous symptoms in time, and, by their prompt action, to prevent suicides and accidents and obviate the short-sighted procrastination which so often keeps patients from coming under the care of an expert alienist.

  To Kraepelin, the point of a reliable classification scheme was to give a doctor a way to determine whom to send to the asylum so they could neither commit mayhem nor, even worse, breed. Accurate diagnosis, he told his listeners, was thus the best, if not the final, solution to the problem of “the growing degeneration of our race in the future.”

  To judge from subsequent events, Kraepelin didn’t succeed at allaying Germans’ fears about the future of their race, although he did leave a clue as to what they would eventually do about their worries. But his intertwined motivations—identification and segregation of the mentally ill and removal of their genetic stock from the race—were quickly lost to history. So was his therapeutic nihilism, his conviction that nosology was enough, that when it came to mental illness, there was nothing to be done for the patient. In fact, Kraepelin in gener
al was soon forgotten, eclipsed by Freud and his notions that mental illnesses begged to be understood (and cured) through language and empathy. And when, in the 1970s, American doctors returned to Kraepelin’s taxonomic approach in order to save their profession from a gathering storm, they conveniently forgot about the nihilism that gave birth to it in the first place.

  That’s the great thing about aligning your cause with the forces of science. You can claim that you are just describing the natural order, the way things are for all time, and that as a result history doesn’t matter.

  Unless, that is, it favors you.

  There isn’t a historical account of depression that doesn’t hearken back to the sixth edition of Kraepelin’s Lehrbuch, published in 1899, as a crucial step in proving that depression is indeed a disease. By the time the book came out, Kraepelinian nosology was all the rage in psychiatric circles; a standardized language had been just what the doctor ordered, and psychiatrists everywhere awaited every new edition with great anticipation. But the master of classification was not infallible, and Kraepelin was forced to issue a recantation in the sixth edition. Previously, he had distinguished various forms of melancholia, the malady that first appeared in the Hippocratic corpus, and separated those from what he called “mania” and “circular insanity.” But now the cards revealed that he had been in error. “In the course of years,” he wrote in the Lehrbuch, “I have become more and more convinced that all the pictures mentioned are merely forms of one single disease process…Certain fundamental traits recur in the same shape, notwithstanding manifold superficial differences.”