Manufacturing depression

by Gary Greenberg

  Meyer was eager to work at the Kankakee asylum because it had an ample supply of exactly what he needed: diseased brains and insane people. Back in Europe, Kraepelin was still looking for the pathological anatomy that would anchor his diagnostic scheme. Correlating brain pathology to insanity seemed to be the key to understanding both normal and abnormal mental functioning, and Kankakee, with its busy wards and autopsy labs, offered a perfect opportunity to make those connections, or so Meyer thought.

  But he soon developed doubts about the soundness of his enterprise. Part of the problem was purely administrative: a hospital staff “hopelessly sunk into routine and perfectly satisfied with it” was not interested in exploring the physiological basis of mental illness. Indeed, they had despaired of even agreeing on their patients’ diagnoses and as a result had developed an “unwillingness to really collect facts needed for diagnostic decisions.” Ten years later, he still complained that

  their reasoning for diagnosis followed rather general impressions than definite and precise statements of fact, and failed to make a sufficiently clear distinction between what was actually found and what was merely supposed to exist.

  What the staff really wanted to do was dissect brains, which led Meyer to believe that “the existence of a pathologist in a hospital for the insane was a poor remedy for that which was actually needed.”

  At a coroner’s inquest, Meyer made clear what he had come to think was a better remedy. He had just presented his analysis of the brain of an inmate (who had died from a heart attack) when a juror said, “Now, doctor, show us what you find in the mind.” Meyer responded, “There [are] more mental findings in the history than the brain.” Even if, as one American psychiatrist had put it in 1870, “mind cannot be diseased, only body,” it was a mistake to ignore mind; its ravings may have been meaningless in themselves, but, as Kraepelin said, they revealed the nature of the disease that caused them. Doctors should dissect the disease as carefully as the tissue, Meyer thought; especially given the state of knowledge about the brain and the difficulty of neuroanatomical research, this was the more fruitful avenue. Meyer, in other words, meant to spread the Kraepelinian gospel—not only to Kankakee but to all of American psychiatry.

  As Meyer taught his colleagues the art of taking patient histories, making close observations of symptoms, course, and outcome, and rendering accurate diagnoses, he ascended the professional ranks and was soon fulfilling his ambition—teaching at the University of Chicago, delivering papers around the country, hobnobbing with politicians responsible for funding his asylums. But he was still deeply troubled by his mother’s depression. He thought of his meteoric ascent and the changes he was trying to make as a response to his “lasting wish that I might pay back and give some compensation during her life, something more than gratitude.” The career that he devoted to his mother was more than illustrious. Inspired in part by her recovery, Adolf Meyer changed American psychiatry in ways that he never would have imagined.

  * * *

  While Adolf Meyer was bringing European nosology to the New World, America was working its charms on him. Kraepelin’s therapeutic nihilism, his sense that there was nothing to be done besides diagnosis and segregation, didn’t square well with American sensibilities. John Winthrop’s vision of America as a City upon a Hill, built through individual efforts at self-improvement, had, by the end of the nineteenth century, turned into the dynamic, bustling free-for-all of entrepreneurial capitalism. The pursuit of happiness—in the original, economic sense of that phrase—was turning out to be not the privilege of only a few, but the opportunity and perhaps even the imperative for everyone. The idea that mental illness was forever, that a class of people, by dint of constitution alone, couldn’t improve themselves and would thus be excluded from the hunt for freedom and riches, didn’t square with Thomas Jefferson’s egalitarian promise. It was only a matter of time before therapies evolved to resolve that conflict.

  You never know exactly why a person gets the ideas he does, but it is significant that within a couple of years of arriving in Chicago, Meyer met Jane Addams. In 1894, he spent a week as her guest at Hull House, where Addams was helping poor people improve themselves. She was also campaigning for the protection of children from exploitative employers, violent parents, and all the other ravages of poverty. A year later, Meyer published a paper in which he raised the question of whether it was really true that parents had to “accept the disposition of the child as a gift that must be taken without grumbling”; perhaps, he said, there was a “period of plasticity” during which character was formed. If so, then “early prevention of danger,” the phrase he used to title his paper, was possible and even crucial.

  The implications of this line of thought went well beyond child-rearing practices. American psychiatry, no less than European, was bound by the conviction that mental illnesses were either endogenous, an immutable property of the individual’s constitution, or exogenous, the result of damage done by injuries or toxins like alcohol or syphilis. In either case, the disease was the result of impersonal, biological factors. Patients in the grip of insanity were no more responsible for contracting it or for how it made them behave than doctors were for curing it. But if, as Meyer was beginning to think, parents could influence the outcome of their children’s mental lives, then by extension perhaps life events in general could play a role in the development and healing of mental illness.

  Meyer was ready to answer the nature/nurture question with a resounding “yes.” “The human organism can never exist without its setting in the world. All we are and do is of the world and in the world,” he said. And he wanted to leave such hoary philosophical questions—something Meyer associated with his native continent—at that. “Steering clear of useless puzzles liberates a new mass of energy,” he said. “The question why is mind mind, and just what it is, can be as little answered as what gold is and why it is, and why it should be so.” In his newfound pragmatism Meyer revealed the influence of another Chicagoan, whom he met shortly after Jane Addams: John Dewey, who in turn introduced him to his friends Charles Peirce and William James—whose Principles of Psychology, which also rejected nature and nurture as the only possible explanations for human behavior, appeared in 1890. Influenced by this trinity of American pragmatism, Meyer declared that the job of psychiatrists was to understand people in their natural setting and help them adapt to it. Exogenous/endogenous, nature/nurture, mind/body—none of these tiresome questions was going to tell us much about life as we lived it, which was as an active force trying to grapple with all the complexities of everyday life.

  Meyer’s head was filled with these new ideas when he returned to Europe in 1896. There he found his mother recovered from her depression, which now appeared in a new light. Perhaps it had not been the result of a constitutional or anatomical defect, but a reaction—not only to his departure, but to loss. Perhaps her “delusion” that Meyer was dead was an accurate reflection of her experience, one that made sense of her depression, that provided it with meaning. After all, within a few years, her husband and daughter had died, her son Hermann had moved to the French side of the country, and her remaining son, Adolf, had left for America. Maybe it felt to her like Adolf was dead—or maybe, as Sigmund Freud would suggest twenty years later, her depression was her only way of expressing her anger toward him for abandoning her. And perhaps her reactions to her “natural setting” had changed. Perhaps she had, as Meyer would later say, adjusted.

  Meyer spared his mother’s psyche too much exposure, so we can’t know these specifics. But we do know that after his visit home, he went to Heidelberg to spend six weeks with Emil Kraepelin, who had just published the fifth edition of his Lehrbuch. His sojourn at Heidelberg did nothing to restore his faith in Kraepelinian nosology, and by the time he returned to America he was ready to renounce it. The idea of finding patterns of symptoms was a good one, he said. But all too often, he thought, “the supposed disease back of it all is a myth and merely a self-prot
ective term for an insufficient knowledge of the conditions of reaction and inadequacy of our present remedial skill.” Indeed, Kraepelin’s vaunted diagnostic system was filled with what Meyer would come to call “neurologizing tautologies.”

  Meyer had an idea about how to correct Kraepelin’s error, and it was much more in keeping with life in his adopted home. Instead of relying on a specious classification of diseases, he asked,

  can we not use general principles and valuable deductions without pulling them into the service of a vicious attitude of mind, the attitude of that medical conceit which delights in surrounding the diagnosing and prescribing with a mystic halo so much adored by the patients trained to see wonders in the wise terms? Why not regard the “diagnosis” as merely a convenient term for the actually ascertained facts which…tell a clear and plain story?

  In other words, instead of anchoring diagnosis in a yet-to-be-discovered neuroanatomy, why not simply tie it to life as it is lived? Why not move beyond the “appeal to cell-biology and correlation of sciences” and toward the “plain facts of history and the reactions of the patient”?

  Meyer wasn’t merely modifying Kraepelin or reinterpreting his statistics. He was repudiating the German master, reversing his dictum to ignore the patient and eschew empathy in favor of a psychiatry that listened, and listened carefully, to the actual experience of his patient. “There is no advantage,” he told his fellow doctors, in merely looking for “‘symptoms’ of set ‘disease entities’ that would allow us to dump all the facts of each case under one term or heading” [emphasis original]. Searching for pathology, a doctor “surrenders his commonsense attitude” and fails

  to view the abnormal mental trend as a genuine but faulty attempt to meet situations, an attempt worthy of being analyzed as we would analyze the blundering of a distracted pupil, or the panic of a frightened person, or the bumbling of one who reacts poorly in trying to meet an unusual situation.

  The cure for mental illness was not to breed insanity out of the human race. Rather, psychic suffering should be seen as a sign that a person was having difficulty doing what we all have to do: adapt to a demanding environment. It wasn’t long before Meyer concluded that people, even psychologically troubled people, could reinvent themselves, and psychiatrists, in Meyer’s view, could and should help them to do it.

  It took Meyer only a few years from the time he arrived in America to figure out something important about his adopted country. “The public here believe in drugs,” he wrote to the governor of Illinois in 1895, “and consider prescription as the aim and end of medical skill.” Americans, that is, wanted their doctors to do something for them. That was the last thing that psychiatrists, with their life-sentence diagnoses, could offer.

  Just before he made his report to the governor, Meyer visited the Battle Creek Sanitarium in Michigan. Battle Creek was one of the biggest spas that sprang up in the last half of the nineteenth century in the United States and Europe, where doctors, but not psychiatrists, offered multifarious treatment for nervous disorders. There Meyer saw doctors doing all kinds of something for (and to) their patients: enforced bed rest, cold baths, tonics, enemas, electric therapy, pelvic massage, and, of course, lots and lots of corn flakes, which the Kellogg brothers, who ran Battle Creek, invented.

  Convinced by all that prescribing, Meyer formed an Association of Assistant Physicians of Hospitals for the Insane, which he envisioned as a forum to “give us a clue for progress” toward actually helping patients. (This was in some ways a rearguard action; there was already an Association of Superintendents of Hospitals for the Insane—which would eventually become the American Psychiatric Association—but Meyer thought it was too much concerned with administrative rather than clinical matters.) But with his nascent ideas about mental illness as a maladaptive reaction to the world, he couldn’t have failed to notice that this was exactly how Battle Creek’s doctors thought of their patients’ problems—as the result not of constitutional weaknesses or infections like syphilis, but of the difficulties of everyday life. And he must also have noticed that these doctors, who were more than willing to minister to their patients’ psychic suffering, were not psychiatrists but members of other specialties, especially neurology.

  In Europe, neurologists had already cornered the market for treating life’s problems. Even as Kraepelin was tweaking his categories and Ehrlich was concocting his potions, neurologists like Sigmund Freud and his French mentor Jean Charcot were treating respectable, educated, and well-heeled people whose suffering stopped well short of the kinds of madness that landed patients in the asylum. These neurologists were glad to reassure their patients that they were not insane, but merely nervenkranken (“nervous patients”), as the Germans called them, and suffering from illnesses like l’erithisme nerveux (“nervous weakness”)—a malady characterized by irritability, avoidance, and depression—and to treat them in Nervenkliniks, or in private offices, rather than asylums.

  Successful as they were, however, the Europeans paled in comparison to the Kelloggs and their colleagues in the United States, who by the turn of the century had built a thriving industry on treating nerves, and especially a single nervous disorder: neurasthenia, or, as George M. Beard, neurologist and inventor of the diagnosis called it, “American nervousness.” Beard’s book by that title came out in 1881. It was the Listening to Prozac of its day, a runaway bestseller in which a doctor gave voice to common, if not yet articulated, worries about emotional life and what doctors proposed to do about it.

  The ranks of the afflicted were legion. William James, his brother Henry, and their sister Alice, Theodore Roosevelt, Edith Wharton, W. E. B. DuBois, Frederic Remington, Mary Baker Eddy, Jacob Riis, Emma Goldman, Samuel Clemens—“the list,” says one scholar, “could go on until it included the majority of well-known cultural producers of the time”—not to mention the regular people, most of them affluent, whose doctors told them they had neurasthenia. And no wonder so many of them received the diagnosis! Beard’s list of symptoms takes up two pages of American Nervousness, from “Insomnia, flushing, drowsiness, bad dreams” through “ticklishness, vague pains and flying neuralgias” to “exhaustion after defecation and urination,” and, finally, just in case he missed something, “etc.”

  The cause of all this trouble, Beard said, was a failure of the nervous system to keep up with the demands of “modern civilization,” which he listed as: “steam power, the periodical press, the telegraph, the sciences, [and] the mental activity of women. When civilization, plus these five factors, invades any nation,” he wrote, “it must carry nervousness and nervous diseases along with it.” The main disease vector, apparently, was one young man, Thomas Edison, whose “experiments, inventions, and discoveries…are making constant and exhausting draughts on the nervous forces of America…[and keeping] millions in capital and thousands of capitalists in suspense and distress.” But even without Edison, rapid innovation and industry had become a whirlwind that was leaving Americans dizzy. Put Edison together with democracy and the rise of “agnostic philosophy” inspired by the rise of Darwinism—which, Beard said, had led to an expectation that everyone would become “an expert in politics and theology”—throw in “the liberty allowed…to Americans to rise out of the position in which they were born,” and cap it off with the possibility of knowing instantaneously what is going on everywhere and anywhere in the world, and the next thing you know, you have an epidemic of severely overworked nervous systems on your hands.

  Not that Beard thought there was anything wrong with modernity. His catalog of stresses was not a jeremiad, but a celebration of progress. He prophesied not social and moral collapse but exhaustion, which was, with the help of doctors, eminently treatable. Neurasthenia was not a sign of degeneracy but the mark of the elect—the “brain workers” whose refined nature both qualified them to manage the new world and made them susceptible to its difficulties. It was the new white man’s burden, the stigma of the elite. “Of our fifty millions,” Bea
rd estimated, “but a few millions have reached that elevation where they are likely to be nervous.” Our natural allotment of nervous energy may have been sufficient for “the lower orders,” but for “the very highest classes” these demands were like a new set of lamps interposed in an electrical circuit:

  Sooner or later…the amount of force is insufficient to keep all the lamps actively burning; those that are weakest go out entirely, or, as more frequently happens, burn faint and feebly—they do not expire, but give an insufficient and unstable light.

  It was up to the doctors to “bulk up the blood,” as Beard put it, in order to increase the output of our dynamos.

  Charlotte Perkins Gilman made the nerve doctors infamous with her chilling story “The Yellow Wallpaper,” in which she chronicled the descent of a neurasthenic woman through her regime of “tonics, and journeys, and air, and exercise”—and an absolute prohibition of work—into a psychotic obsession with her sickroom’s wallpaper. But her doctors had help.

  If a physician of high standing, and one’s own husband, assures friends and relatives that there is really nothing the matter with one but temporary nervous depression—a slight hysterical tendency—what is one to do?