DYLAN EVANS

Dylan Evans is in the Department of Philosophy, Logic and Scientific Method, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK.

A Century of Psychiatry, Volumes I and II
edited by Hugh Freeman
Mosby-Wolfe: 1999. 360 pp. $120, £59.95

The history of psychiatry is a complex and fascinating affair, but it has not been easy for the general reader to obtain an accurate picture of it. Most accounts have been either accurate and academic, or popular and tendentious. With A Century of Psychiatry, the general reader now has a reference source that is both accessible and balanced.

This multi-author, twin-volume work does not shrink from the darker moments in the history of psychiatry, from the reckless enthusiasm for poorly tested remedies in the 1930s and 1940s, to the political abuse of psychiatry in the former Soviet Union. However, these are not the basis for any sweeping pronouncements about the nefarious purposes of psychiatry à la Michel Foucault. Rather, the constant references to the wider social and scientific context in which these events occurred helps to make them understandable, even if not always excusable.

In his excellent chapter on the origins of convulsive therapy, for example, Max Fink makes palpable the sense of impotence felt by psychiatrists in the first decades of this century, when no effective treatment for the psychoses was known. Fink also explains the reasoning that led doctors to the idea of treating schizophrenia with artificially induced fits: they were guided by the theory of the antagonism of diseases, and thought that schizophrenia was antagonistic to epilepsy (an idea that also led to the converse therapy, namely the attempt to halt epilepsy with transfusions of the blood of psychotic patients). This is a welcome corrective to the misleading images of convulsive therapy perpetuated by popular culture.

The balanced approach is evident throughout the book. The sections on the emergence of psychoanalysis and Sigmund Freud by Martin Stanton, for example, avoid the extremes of hagiography and demonography that typically afflict works on these subjects. Anyone who baulks at the idea of including Freud in a history of psychiatry should read Gerald Grob's section on American psychiatry in the 1960s, which makes clear the extent to which psychoanalytic ideas dominated the treatment of mental disorder there for several decades. As Charles Cahn's section on the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) shows, it was not until the publication of DSM-III in 1980 that most psychoanalytic concepts were formally excluded from psychiatric orthodoxy in America. DSM-III replaced the old psychoanalytic concept of 'neurosis', which had been central to DSM-I and DSM-II , with the more general one of 'disorder' (although the word 'neurosis' was restored in parentheses after protests by psychoanalysts fighting a rearguard action).

The organization of the text is partly chronological and partly thematic. There are 10 chapters, each dedicated to one decade of the twentieth century. Each chapter consists of various sections which cover particular themes, such as a form of treatment, a diagnostic category, a famous psychiatrist, or some wider social or national development. Each section can be read on its own, making the book a handy reference tool. There is inevitably a degree of overlap between the various sections, but this is not a serious defect. The book is amply illustrated with archive photographs, which bring the stories vividly to life. There are no references in the text, as befits a non-academic work, but there are plenty of suggestions for further reading at the end of each chapter.

Perhaps the most interesting thing to emerge from this collection of historical essays is a real sense of the nitty-gritty of scientific discovery. The mental disorders are such terribly complex phenomena that they are still poorly understood today. As this book shows, there has been real progress in understanding and treating mental illness during the past century, but it has been a very haphazard advance. Many therapies that initially seemed promising turned out to be dead-ends, while the few therapies that have stood the test of time, such as neuroleptics and antidepressants, were largely discovered by accident.

Intuition and enthusiasm have played as important a role as theory in driving psychiatry forward, and the history of the discipline is correspondingly peppered with colourful characters and leaps of imagination. The fact that psychiatry has had more than its fair share of eccentric geniuses may be one of the reasons for its failure to shake off its image as the least respectable branch of medicine, but what progress there has been is almost entirely due to these mavericks. There is a view of scientific progress that downplays the context of discovery. The history of psychiatry favours a different view, one that sees nature's mysteries as giving way to an odd combination of brilliant mental leaps, accident and sheer, dogged persistence.