He applied the “Page 99 Test” to his latest book, American Madness: The Rise and Fall of Dementia Praecox, and reported the following:
From Page 99:Learn more about American Madness at the Harvard University Press website.
Two things immediately strike the reader of Noble’s paper. The first is that he does not regard the fact as troubling that he is finding more dementia praecox at his institution than Kraepelin is finding at his. He believes he understands Kraepelin’s diagnostic concepts and that he and his medical staff are applying them correctly. Exactly how they are doing this is left unsaid. Noble instead alludes to possible demographic differences between Heidelberg and Middletown. Second, he is equally untroubled by the fact that, prior to introducing Kraepelin’s classification into Middletown, the diagnoses of mania and melancholia made up 50 percent (and often more) of the admissions. Dementia praecox and periodical insanity (later manic-depressive illness) simply took their place in the statistical tables of that asylum. Half of the madness in an asylum could be accounted for by either of two terms. Where Kraepelin’s terms seemed to have an advantage— perhaps the only advantage over the older terms— is that they implied something about prognosis.Much to my amusement, the Page 99 Test worked! The two paragraphs on page 99 were fractals of themes reiterated throughout the entire book: the arbitrary and unreliable application of diagnostic concepts for inexplicable, incurable madness, which seem to wax and wane depending on who applied them and where they were being applied; and the dual medical and bureacratic nature of diagnosis, which in the case of dementia praecox meant that a presumedly incurable mental disease could be invoked to justify the progressive deterioration and neglect of patients in asylums and state hospitals. But suppose dementia praecox simply didn't exist? These are the issues I raise in my book.
This had two advantages to American alienists toiling away in asylums, one humane and one inhumane. First, both patients and their family members could be told something about the future. Would the patient get better? A diagnosis of manic- depressive insanity would give qualified hope. Second, and this is the shadow that dementia praecox would cast over the next century, Kraepelin’s dire prognosis for as much as a quarter to a half of the institutionalized insane rationalized their nontreatment, mistreatment, and failure to improve. From the political perspective of asylum management, dementia praecox could be a useful construct.