Here’s a poem from 1899:
He has been poisoned
blown up by infernal machines
but for his spirit
He can eat volcanoes
carries his brain on his shoulder
the heart’s voice speaks of power and riches
the ear’s voice makes patronizing remarks.
In the sky there appears a white star
pictures of saints
Christ on the cross.
Flames flare up
Human heads are in the food, worms in the soup.
cocks crow, chains rattle, music plays
People know his thoughts.
There are revelations
In the room there is a vapor
electric currents circulate in his body.
Other people’s blood is pumped into his head
and his penis made stiff.
The bed makes gestures.
And one more:
Their eyes are dazzled with mirrors
black owlets go flying past.
Whispering voices of mankind:
“She eats and does not work,”
“She is to be skinned.”
In his breast he has a glass diamond
the sex organs speak
the spinal cord aches
the body is seen double.
These “poems” are actually the recorded statements of persons in whom Emil Kraepelin (1856-1926) had diagnosed (respectively) the paranoid, catatonic, and hebephrenic forms of dementia praecox.1(pp129,121,113) I have only altered the punctuation, capitalization, and word spacing in order to accentuate an underappreciated aspect of the international success, a century ago, of the 6th edition of Kraepelin’s textbook Psychiatrie (1899): its literary contribution to clinical utility.2
Kraepelin understood the level of psychiatric expertise among the physicians of his time — it was practically nil. Realizing that he was writing for all physicians, and not just for those in his medical specialty who mostly worked in asylums or (in Germany) short-term–care “university clinics,” Kraepelin wrote in a knapp und klar (concise and clear) fashion, which often showed more than it told. For each category of mental disease, he composed thick paragraphs listing, in an almost telegraphic style, dozens of rich examples of typical statements, actions, and expressed feelings of patients culled from his index cards and case files. These mosaic-like, poetically incongruous compilations colorfully punctuated the meaning behind his clinical vocabulary.
A novice clinician could skim past the technical jargon and recognize, in these passages, the melodies of madness flowing from the bodies of his or her own patients. Experienced physicians finally found meaning in psychiatric diagnosis for the first time in their careers. Many are on record for saying so. But it was not just Kraepelin’s newly created diseases (such as dementia praecox or manic-depressive insanity) nor his classification system or linkage of diagnosis to prognosis that found admirers, it was the clarity and utility of his writing style. The living essence of disorder is more intimately conveyed by “the bed makes gestures” than by the empty abstraction, “bizarre delusions.”
Throughout the 20th century, particularly in the US and Britain, Kraepelin and his textbooks had been vilified by readers as cold, impersonal, and lacking empathy for the “whole” person. But were they even reading Kraepelin? Indeed, unless a physician could fluently read German (and few could), often the only access to Kraepelin’s textbooks was through the uninspired and mutilated English-language translations of 1902 and 1907 by the American alienist Allen Ross Diefendorf3,4 (1871-1943) of the Connecticut Hospital for the Insane in Middletown. Diefendorf squeezed all the poetry out of Kraepelin’s prose. The bed no longer made gestures.3(p243)
But much of this criticism came from psychiatrists who rejected Kraepelin’s contention that biologically specifiable disease concepts would eventually be found to correspond to the patterns of age of onset, signs, symptoms, courses, and outcomes of the insanities he identified through longitudinal clinical research. For psychiatry to be a legitimate branch of general medicine, the ancient focus on the unique, idiosyncratic physical, geographical, social, and experiential situation of an individual patient had to be sacrificed to the greater goal of finding generalizations, such as diagnostic categories and disease concepts. As a result, there are no case histories of individual patients in Kraepelin’s textbooks, only fleeting moments of illness lifted from the context of personal history, like bars of musical notation cut from a symphonic score.
Even so, when pasted into new arrangements in Kraepelin’s paragraphs, the voices sing.
In a few months, we will bid farewell to the descendants of Kraepelin’s paranoid, catatonic, and hebephrenic forms of madness. DSM-5 will no longer offer paranoid, catatonic, or disorganized subtypes of schizophrenia. Kraepelin’s song has ended. There will be only schizophrenia, a mysterious anchor at the center of its own oceanic spectrum of related mysteries. Kraepelin’s dementia praecox was a markedly different disease concept than the wide, marshy landscapes of the schizophrenias of Eugen Bleuler (1857-1939),5 and neither of them resembles the thin, remarkably stark checklist of diagnostic criteria for our era’s schizophrenia. Our schizophrenia is more of a heuristic than a disease concept, less of a living demon than an algorithmic skeleton.
There will be no poetry in DSM-5. But beds will still make gestures.