Andrew Scull, Distinguished Professor of Sociology, Emeritus, at the University of California, San Diego, is the best historian of psychiatry known to me. He writes elegantly and without jargon, is fair-minded and grinds none of the more obvious axes (mercifully, Michel Foucault’s name does not appear even in the index), has a true writer’s eye for the dramatic detail, and is never dull. I do not recall ever having been disappointed by any of his books, and I was certainly not disappointed by this one.
Desperate Remedies is a history of American psychiatry (which cannot be entirely disentangled from the history of European psychiatry) from the asylum era to the present day. If it sometimes reads a little like a guided tour of a chamber of horrors, that is because the history of psychiatry is indeed replete with horrors. O sanity, what crimes have been committed in thy name!
Though Scull recognizes the great difficulties of dealing with the intractably disturbed in the absence even of tranquilizing drugs, he somewhat underplays these, making the desperate remedies of the title seem even worse than they were. Pre-medical methods of dealing with the chronically mad were not necessarily gentle; in one remote place known to me, the traditional method of dealing with the mad was to tie them to a tree for a few days and then bind them to a log and float them out to sea if they did not improve. Small-scale subsistence societies cannot afford to be humane, let alone sentimental.
It is also true that there is not much place given in this book to the kindness or conscientiousness that surely must sometimes have actuated doctors in their dealings with the mad, even if such kindnesses were often swamped by the numbers of patients, the underlying ignorance of causes, and the absence of remedies. Considering the plethora of organic conditions that can mimic psychiatric syndromes almost precisely, there must in earlier times have been many patients deemed incurably mad who were in fact suffering from physical illnesses. If I had been born a century and three quarters ago, for example, I should probably have been admitted in my thirties to an immense asylum, there to die an utter dement some time afterwards, having possibly gone through a phase of florid madness—and the condition, myxedema (severely underactive or inactive thyroid), from which I suffer is not an uncommon one.
In this connection, I could not help recalling the case of William Freeman, the son of a freed slave, who in 1846 entered the house of John G. Van Nest, in Auburn, New York, and slaughtered not only him, but three of his family, including a two-year-old child, all without apparent motive. At his trial, Dr. Amariah Brigham, one of the founders of what was to become the American Psychiatric Association, and also of the American Journal of Psychiatry, gave evidence in Freeman’s defense, though the local population was all for lynching the accused. He had examined Freeman and thought he was insane. Nevertheless, Freeman was sentenced to hang, but a retrial was ordered on a technicality. Before the trial could take place, Freeman died and an autopsy was carried out, which revealed serious brain disease, either syphilitic or tuberculous. Brigham, who had noted (correctly) that Freeman’s deafness predisposed him to paranoia, wrote: “[A]t the time of the trial of Freeman, I was very confident that he was insane, and that the heinous crime he committed was the consequence of mental derangement. I can now have no rational doubt of the entire correctness of that opinion.” One swallow does not make a summer, of course, but Dr. Brigham’s testimony was the outcome not of his own efforts alone but of long attempts by doctors to observe the mad carefully and classify their symptoms.
But to return to professor Scull’s chamber of horrors, which was certainly of greater social significance, in terms of numbers and influence, than all the cases combined of kindness and scrupulous testimony by alienists. Though one knows the author to be an honest and scrupulous historian, one reads of the cruelty, sometimes the brutality, of the psychiatric enterprise almost with incredulity.
Take eugenics, which was based on the idea that not only were madness and mental deficiency hereditary but that, by a process of germ-plasm degeneration, bad, self-destructive, and antisocial behavior could become ingrained in the population, to be rooted out only by the prevention of reproduction (or under the Nazis, by extermination). In the notorious Buck v. Bell (1927), Progressive Supreme Court Justice Oliver Wendell Holmes argued that compulsory sterilization was justified on utilitarian grounds. The impeccably social-democratic Swedes endorsed it until the 1970s.
Then there was the theory of focal sepsis as the cause of madness. Without any evidence that would nowadays be considered scientific, in the early 20th century a doctor named Henry Cotton (about whom Scull has written a riveting monograph, and a copy of whose lectures at Princeton I possess) decided to pull out the supposedly or potentially rotten teeth of hundreds if not thousands of patients—and later to remove their appendices and colons—in order to restore them to sanity and to improve the behavior of children as young as six. The death rate of these procedures was horrifically high—not surprisingly, since many of them were carried out by doctors without surgical training, in conditions that were, to put it mildly, suboptimal. Yet Cotton was for a long time lauded as a great pioneer, thanks to his own sloppy or mendacious follow-up studies.
Careless or astoundingly shoddy follow-up of patients permitted other horrifying treatments to be adopted rapidly and enthusiastically. After extirpatory surgery came insulin shock therapy, then induced fits, then psychosurgery in the form of lobotomy. People were deemed to have improved as a result of their treatment if the treating doctor said that they had, now recognized as a very inadequate criterion of success, for no one wants to see his efforts unrewarded by success. It was enough that a patient, previously aggressive or otherwise difficult to manage, was turned into a pliant, zombie-like creature.
Insulin shock therapy, used from the 1930s to the 1950s, in which a patient was injected with insulin to make his blood sugar level fall until he was unconscious, had a considerable death rate, and toxicological expert witnesses in trials for murder by insulin still trawl the insulin shock literature for statistics and other information on deaths from insulin poisoning. The therapy was difficult to perform, horrible to experience, and did no good, though for a time it was orthodox.
Epileptic fit therapy, used from the 1930s to the present day, and since greatly refined, was performed with almost sadistic enthusiasm, resulting, before muscle relaxation was introduced, in huge numbers of fractured vertebrae. Sometimes such fits, at first induced chemically and then electrically, were produced several times a day, up to totals in the hundreds; doctors talked of smashing up delusions as if they were physical objects.
Ironically, the idea of curative fits was based upon a false observation, namely, that epileptics were rarely psychotic. In fact, temporal lobe epilepsy is actually associated positively with psychosis, and now the therapy, a lot less alarming than it once was, is more or less confined to the severely melancholic, who are not numerous, and in whom it can be lifesaving. But I can remember whole rows of patients lying on their beds waiting for the “electric breakfast,” so called because they were not supposed to eat or drink before it.
I can also remember the lobotomy suites in mental hospitals, where the operation was performed as a minor procedure, with less fuss than that surrounding, say, a hemorrhoidectomy. Lobotomy survived as a procedure for severe obsessive-compulsive neurosis well into my lifetime. Again, the procedure was performed with what one might once have called gay abandon, with almost no concern for careful follow-up to estimate the effects, therapeutic or otherwise.
Here it is worth interjecting—though Scull himself does not—that the current vogue for transgenderism will provide rich material for a Scull of the future. We think we have done with the Henry Cottons and Walter Freemans of psychiatry, but we have not: they seem to spring eternal.
After lobotomy came the neuropharmacological revolution, that coincided with, if it did not cause, the emptying of those vast repositories of the mad or socially incapable, the mental hospitals. The back wards of these institutions were terrible; the beds were often crammed together, there was no privacy for the patients, the major occupation for them to wander the corridors like ghosts, cadging cigarettes (all psychotic patients smoked as much as they could). At the time I qualified as a doctor, there were still a few patients who had been retained in these hospitals for having had an illegitimate child 50 years earlier (only the mothers, of course). And yet, at their best, these institutions did offer some asylum from the pressures of outside life—their grounds were often magnificent and their external architecture majestic—and were more of a community than the so-called “community” into which the patients were soon to be decanted. Indeed, they were often the only community for miles around.
Psychotropic drugs undoubtedly constituted a great advance, if used judiciously. This was not always the case. Chlorpromazine syrup or suspension (thorazine) was once known in the prison in which I worked as the “liquid cosh,” used more for disciplinary and punitive purposes than therapeutic: which is not the same as saying, however, that it, its analogues, and successor drugs, had no therapeutic value. On the contrary, they are often of immense value, but the problem is that it is very difficult to keep prescriptions within proper bounds. All occasions conspire against it: time constraints, psychiatric mission creep, patient demands. I had older prisoners, for example, who were nostalgic for the days of the liquid cosh and asked for it to be applied to them once more.
Scull recounts the rise and fall of psychoanalysis in America (it still has two redoubts, France and Argentina). This, of course, was for well-heeled, not for pauper, lunatics. The story is richly comic, worthy of a chapter in Charles Mackay’s 1841 book, Memoirs of Extraordinary Popular Delusions and the Madness of Crowds. It is perhaps too soon to provide a full cultural history of psychoanalysis in America, but I recommend reading Sigmund Freud’s account of the Wolf Man if you want to know just how bizarre the cult was. Scull confines himself to a plain, unvarnished history of events.
The deinstitutionalization of chronically disturbed patients, from the 1960s to the present, was no triumph either. There was a kind of pincer movement between the cost-cutters on the Right and the anti-psychiatrists on the Left, that has brought about a seedy world of halfway houses (and street doorways) where the mad may molder until they commit a crime and are incarcerated for lack of anywhere else to put them. Scull thinks that the solution is a recognition of a fundamental human right to a certain standard of life, but they tried that in the Soviet Union and it didn’t work. This is not to say, however, that there is no alternative to our current policy of malign neglect.
One significant omission in this history is that of addiction. Considering that America has now lost many, many more lives to death from overdose to addictive drugs than in all its military operations combined since World War II, this is a surprising omission. The preposterous National Institute on Drug Abuse has spent billions, while an unprecedented epidemic has continued unabated. Considering the outspoken nature of the book, this might have been worth an animadversion or two.
Scull recognizes the inherent difficulties and ambiguities of psychiatric diagnosis and treatment. He does not go as far as the late Thomas Szasz, that all psychiatric disorders are but problems of living unless a definite physical causation for them can be proved. On the other hand, to equate all psychiatric disorders with brain diseases and nothing else (as insurance companies now de facto encourage or oblige doctors to do) is crude and shallow.
Has Psychiatry a future, asks Scull at the end of his book. Yes, because madness and self-destructive behavior do. Let me end with an anecdote. A mutual friend of mine and Szasz’s asked us to dinner because he wanted to hear us discuss the reality or otherwise of madness. It so happened that I had been on medical duty for the prison the night before. I was called to a prisoner with no previous history of psychiatric disturbance who had stripped himself naked, was talking gibberish to unseen interlocutors, and was trying to plug himself into the light socket. This was clearly dangerous. The most likely diagnosis was that he had taken drugs of some kind, but neither physical nor toxicological examination was possible, nor did questions elicit any comprehensible answer. I ordered that he be held down while I administered an antipsychotic sedative by injection. The next morning, he was perfectly normal. “What would you have done?” I asked Szasz. “You shouldn’t have been there,” he replied, his reason being that I was acting as a repressive agent of the state. I thought that this was the triumph of a single, admittedly powerful, idea over common sense and humanity.
What psychiatry requires is modesty combined with a degree of self-confidence, and the constant exercise of judgment to mediate between the two. If the past is a guide to the future, as described in Andrew Scull’s magisterial Desperate Remedies, this is unlikely to eventuate soon.