Book Review
A History of Psychiatry: From the era of the asylum to the age of Prozac
N Engl J Med 1997; 337:58July 3, 1997
- Article
A History of Psychiatry: From the era of the asylum to the age of Prozac
By Edward Shorter. 436 pp. New York, John Wiley, 1997. $30. ISBN: 0-471-15749-XIt was with some trepidation that I opened Edward Shorter's new book, A History of Psychiatry, fearing that I would find a tedious and turgid tome. But no. Here is a crisp, feisty account that never loses momentum, is frequently entertaining, yet is always meticulously researched. Shorter pulls no punches as he takes us through the triumphs and catastrophes, treatments brilliant and bizarre, that have punctuated psychiatry over the past 200 years. There was hydrotherapy, the rest cure, the transorbital lobotomy, and the “Georgia Power Cocktail” (a form of punitive electroconvulsive therapy prescribed at the 10,000-bed Georgia State Sanatorium, a snake pit of the asylum era). But there were also bold and astonishing successes, such as Wagner-Jauregg's successful treatment of neurosyphilis — until then a hopeless disease — by injecting patients with malaria-infected blood. Few modern physicians know of this remarkable discovery. Yet, in Shorter's words, it “broke the therapeutic nihilism that had dominated psychiatry in previous generations” and earned Wagner-Jauregg the Nobel prize in 1927. There were the intrepid experiments of Cerletti and Bini, culminating in their first human trial of electroconvulsive therapy in an isolated equipment room on the second floor of their clinic in Rome. As an assistant stood outside in the corridor to guard against intruders and a nurse held the electrodes to the patient's head, they tried first 80 volts, then 90, and finally 100, at last producing a classic tonic–clonic grand mal seizure and thus opening a new era in psychiatric treatment (the patient, an engineer with an acute psychosis, returned home in virtual remission after 11 treatments). And then there was one of the greatest examples of serendipity in the history of medicine, when Cade stumbled upon the possibility that lithium might be effective against manic-depressive illness and in a matter of days successfully treated several patients who had displayed unremitting mania for months or years.
Surveying psychiatry from the broader vantage point of the historian, Shorter shows us the interplay of prudence and folly, the struggles of science and shamanism, that have marked the evolution of psychiatry. Which of today's fashionable therapies will seem silly, or even downright dangerous, when examined a generation or two from now? Which of our present philosophies of treatment will prove to have been motivated primarily by dubious political or economic considerations, as were so many of those of our predecessors? It is tempting to predict what they might be. At the least, A History of Psychiatry teaches us humility about our own parochial notions of psychiatric disorder and the ever-present risk of committing serious errors, even in today's more rigorous scientific climate.
Shorter is at his finest when he chronicles the rise and fall of psychoanalysis. His account will be particularly enlightening for those who grew up and trained in the heyday of this discipline, when it dominated American departments of psychiatry. Many of us would have had difficulty imagining, in those days, that psychoanalysis was only a hiatus (Shorter's word) in the evolution of psychiatry, because throughout the history of psychiatry before and after, people have readily accepted that medical illnesses were biologically based. In Shorter's incisive view, psychoanalysis “turned out to be the artifactual product of a distinctive era,” nurtured by the particular political and economic conditions of its time. The ingredients of its demise emerge clearly in retrospect. Among them were the advent of effective pharmacotherapies, the fiasco of the American Psychoanalytic Association's attempt to assess the efficacy of the technique, and emerging evidence of the bankruptcy of such notions as transference and the continuum view of all mental illness.
Late in his book, Shorter quotes Eysenck: “All sciences have to pass through an ordeal by quackery.” A cynical view, perhaps, but one amply supported by many of the narratives in A History of Psychiatry. It is good medicine for all of us to read this fascinating history, as psychiatry struggles to become a scientifically established medical discipline.
Harrison G. Pope, Jr., M.D.
Harvard Medical School, Boston, MA 02115- Citing Articles (2)
