by Jack Lynch
The book brought together the best information on anatomy and physiology the age had to offer, and it quickly became the standard book in the field. The medical knowledge did Gray himself little good; he died at age thirty-four of “confluent smallpox” in June 1861. Carter’s post-Anatomy career was more fortunate. He took a position as principal of Grant Medical College in Bombay, India, where he did groundbreaking work on the nature of leprosy. But the book remains one of the classics in the field and has never gone out of print. When the thirteenth edition appeared in 1892, an advertisement declared that “Gray’s Anatomy has been the standard work used by students of medicine and practitioners in all English-speaking races.” The ad quotes the Cleveland Medical Gazette—“Teachers of anatomy are almost unanimous in recommending ‘Gray’ as the standard work”—and the University Medical Magazine—“the recognized text-book for the great majority of English-speaking students of medicine … the most perfect work of its kind extant.” Gray’s Anatomy is now in its fortieth edition, the work of eighty-five (properly credited) experts. Though none of Gray’s text or Carter’s illustrations remain, for generations of medical students, getting their copy has been a professional rite of passage.
The Diagnostic and Statistical Manual, better known as the DSM, is not much to look at—small, paperbound, nine inches high by six inches wide, and just 142 pages long. It does not even seem particularly controversial on first reading. It advances no theological heresies, no maxims for political revolutionaries, no threats to the established order. It simply tallies the recognized psychological disorders and assigns to each a number: childhood schizophrenic reaction is 000–x28, sleepwalking is 000–x74, and “psychophysiologic endocrine reaction” is 008–580. And yet how much power lies in that classification!
Classifying illnesses has a long history. François Boissier de Sauvages de Lacroix, a friend of Carl Linnaeus, compiled a Nosologia methodica in 1763, applying the Linnaean taxonomy of plants to diseases. Sauvages identified ten classes, including insanity as number eight. The various classes were all divided into genera and species, for a total of twenty-four hundred diseases.10 The International List of Causes of Death (1893), prepared by the International Statistical Institute, took recent medical thinking into account. As the nineteenth century turned into the twentieth, medicine became increasingly bureaucratic. Two forces pushed it toward statistics and classifications. The first was modern war, as more and more lethal weapons piled bodies higher and higher. Medical statistics in wartime translated into the ability to count, and perhaps thereby to reduce, various causes of mortality on the battlefield. The other was the insurance industry: the country doctor gave way to the bean counter, and the black bag was traded for red tape. Some of the world’s earliest health insurance statutes were introduced in Germany in 1883, the United Kingdom in 1911, and France in 1945; universal or near-universal health care plans followed in the Soviet Union in 1937, New Zealand in 1939–41, Canada in 1946, and the United Kingdom in 1948. In the United States, Blue Cross and the Ross-Loos Medical Group were both founded in 1929—the beginning of the reign of the big health insurance companies. All demanded extensive paperwork.
TITLE: Diagnostic & Statistical Manual, Mental Disorders
COMPILER: The Committee on Nomenclature and Statistics of the American Psychiatric Association: George N. Raines, Moses M. Frolich, Ernest S. Goddard, Baldwin L. Keyes, Mabel Ross, Robert S. Schwab, and Harvey J. Tompkins
PUBLISHED: Washington, D.C.: American Psychiatric Association Mental Hospital Service, 1952
PAGES: xii + 130
ENTRIES: 106 disorders
TOTAL WORDS: 25,000
SIZE: 6″ × 9″ (15.2 × 22.9 cm)
AREA: 53 ft2 (5 m2)
WEIGHT: 10 oz. (300 g)
LATEST EDITION: Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (Washington, D.C.: American Psychiatric Association, 18 May 2013), xliv + 947 pages
Classifying mental disorders, though, proved more challenging than classifying physical disorders. It is comparatively easy to agree on what is ailing those suffering from the large majority of physical problems; though physicians are still unable to cure many conditions, they usually agree that this bone is broken, that sore is infected, or this organ is inflamed. Disorders of the mind are infinitely more complicated. Are there different kinds of mental, emotional, psychic, or spiritual unsoundness? If so, what are the categories, and how can we tell which sufferers have which diseases?
Classifying mental disorders is also exceedingly consequential. Expert witnesses in criminal trials often have to base their claims in the collective wisdom of the psychiatric profession, and that collective wisdom is contained in the reference books authorized by the professional societies. In most criminal prosecutions, our legal system demands a mens rea, an intention to do wrong. A psychiatric diagnosis that a defendant is incapable of distinguishing right from wrong may be enough to save him from imprisonment, even execution. The right diagnosis can keep a killer from the electric chair; the wrong one, conversely, can keep an otherwise qualified diplomat from government service, or an otherwise qualified soldier from serving in the military. A code in a reference book might be responsible for locking someone in an asylum.
What constitutes a mental disorder, and who gets to say? Are soldiers who refuse to rush into battle victims of shell shock?—of battle fatigue?—of PTSD?—or are they, as some have called them, merely cowards hiding behind a diagnosis? The boundaries of insanity are ill-defined, and they are easily influenced by the worldview of those drawing the lines. In 1851, Samuel Cartwright, a physician based in Louisiana who wrote Diseases and Peculiarities of the Negro Race, developed a pair of mental diagnoses that he said were characteristic of black slaves. The first, “dysaesthesia aethiopica,” accounted for their laziness; the second, called “drapetomania,” was an unaccountable desire on the part of slaves to escape from servitude. With the right treatment, Cartwright maintained, “this troublesome practice that many Negroes have of running away can be almost entirely prevented.”11 He thus demonstrated that all manner of preconception or prejudice can be elevated to the level of quasiscientific diagnosis.
In the 1840s, the U.S. Census recognized just one variety of mental illness, identified as “idiocy” or “insanity.” The American Psychiatric Association devoted part of its founding year, 1844, to classifying patients in asylums, and began enumerating varieties of insanity.12 By 1880, the list of maladies recognized by the census had grown from one to seven: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.13 The Statistical Manual for the Use of Institutions for the Insane (1918), the first attempt of the National Committee for Mental Hygiene to classify psychological disorders, included twenty-two diagnoses.
The number continued to rise over the first half of the twentieth century, culminating in 1952 in the American Psychiatric Association’s Diagnostic and Statistical Manual, Mental Disorders, universally known as the DSM. It laid out a taxonomy of 106 mental disorders as understood in the early 1950s—that is, an essentially Freudian understanding of the world—backed up with epidemiological data. The word reaction appeared often in its pages, reflecting the understanding that most mental disorders were responses to stresses in the outside world—repressed trauma, unresolved tensions with family members, inadequately absolved guilt. When conditions in the International Statistical Classification of Diseases, concerned with somatic illnesses, had a connection to psychiatry, the DSM shared the appropriate code: nail biting is 324.3, cancerophobia is 313, weight loss is 788.4, and moral deficiency is 320.5. Much of the book is tabular:
PERSONALITY DISORDERS
–X DISORDERS OF PSYCHOGENIC ORIGIN OR WITHOUT CLEARLY DEFINED TANGIBLE CAUSE OR STRUCTURAL CHANGE
000–x40
Personality pattern disturbance
(320.7)*
000–x41
Inadequate personality
(320.3)
000–x42
Schizoid personality
(320.0)
000–x43
Cyclothymic personality
(320.2)
000–x44
Paranoid personality
(320.1)
The first edition of the DSM reveals much about the state of psychiatry at midcentury, but the interesting story appeared in its subsequent revisions. Fourteen years after the DSM came DSM-II. It was a little shorter than its predecessor—136 pages rather than 145—but included more conditions. Children’s behavioral disorders were recognized for the first time, including “hyperkinetic reaction,” akin to what would later be called attention deficit hyperactivity disorder. More telling, the word reaction got much less use in DSM-II, and an essay appended to the manual justified the exclusion: the editors did not want the book to reflect any particular school of thought, and “reaction” was too tightly bound to Freudian psychoanalysis.
DSM-II was a critical dud, and within a few years of publication, the discontent translated into plans for a third edition. In the meantime, several developments had prompted a change in thinking about mental pathologies. In 1972 a large comparative study of diagnosed cases of schizophrenia in both London and New York City revealed the incidence was twice as high in New York as in London—forcing psychiatrists to think hard about the need for precise diagnostic criteria. More important, medications were showing promise in controlling what had been conceived of as strictly mental disorders: mania and depression seemed to be responding to pharmaceuticals.
The result was a walloping increase in the number of conditions identified—and in the size of the DSM. The original edition had identified 106 conditions, the second 182. By 1980, DSM-III was 494 pages long and included 265 diagnoses, arranged in a new classification system. In the first two versions, psychopathologies were regarded as manifestations of underlying subconscious states. This makes diagnosis difficult, since one behavior might be an expression of dozens of underlying conditions. Starting in the 1980s, the editors strove for a classification system that would be agnostic on questions of etiology. Instead they proposed a taxonomy based strictly on symptoms—on objective expressions in the real world. The buzzwords were now “objectivity” and “truth,” and the manual was billed as a victory for science. Not everyone, though, regards DSM-III as a step forward. For some it was a victory not for science but for the pharmaceutical industry: the supposedly objective system of classification, dependent on no particular theory, paved the way for the medicalization, and therefore monetization, of many behaviors that had never before counted as pathologies.
Subsequent versions continued moving in the same direction. No sooner had DSM-III appeared than there were plans for DSM-IIIR (“revised”) in 1987. Seven years after that came a DSM-IV, and six years later a DSM-IV TR (“text revision”). By the time of the fourth edition, the book had grown to 886 pages, backed up by four volumes of sources, and the number of diagnoses now stood at 279. The ever-finer distinctions among diagnoses partly reflected the best scientific thinking, but they also represented the influence of insurance companies that demanded billing codes.
With each change, the sorts of behavior considered “normal” or “pathological” were readjusted, often with real-world consequences. Michael First, a Columbia University professor of psychiatry who worked on DSM-IV, described the stakes: “Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled.” There were dangers: “the more disorders you put in,” First continued, “the more people get labels, and the higher the risk that some get inappropriate treatment.”14 Many think psychiatry has gone overboard with “disorders” such as binge eating and gambling, while excluding Internet addiction and sex addiction.15 And as some putative mental illnesses are added, other long-familiar conditions simply disappear through fiat. Hysteria, a common diagnosis for millennia, was defined out of existence in the revision of 1980.
Probably the most controversial change in the history of the DSM was the editors’ decision that one condition was no longer to be considered a disorder. The original DSM included, as number 000–x63, “Sexual deviation,” with the instruction to “specify the type of the pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism and sexual sadism (including rape, sexual assault, mutilation).”16 This classification reflected the general, if not universal, consensus of the profession in the 1950s: psychoanalysis saw homosexuality as a pathological “inversion.” But times change, as do moral judgments about behavior. After Alfred Kinsey’s groundbreaking Sexual Behavior in the Human Male (1948) reported that 37 percent of otherwise “normal” men had at some time engaged in this “pathology,” though, it became more difficult to consider the behavior—increasingly thought of as an identity —as a “disorder.” The meeting of the American Psychiatric Association (APA) in 1970, just months after the so-called Stonewall riots, was marked by controversy: protesters were out in numbers; they blocked the entrance to the conference and destroyed a booth that sold equipment for “aversion therapy” to “cure” homosexuality. The APA responded, as bureaucracies are wont to do, by forming a committee, this one headed by Robert Spitzer. The committee’s report came to four conclusions:
(1) Expert opinion was divided over whether homosexuality was pathological;
(2) Many homosexuals seemed satisfied with their own sexual orientation;
(3) But there are also many homosexuals who want to change their orientation;
(4) It is possible to change the sexual orientation of some proportion of homosexuals.
Convinced that these findings were inconsistent with other pathologies, they ended by unanimously recommending that homosexuality be removed from the list of mental illnesses. In 1973, just four years after Stonewall, the professional consensus had changed: the sixth printing of DSM-II removed homosexuality from the list of diseases. Millions of “sick” people were instantly pronounced healthy.
Revision of the manual continues, and controversies about the classification system continue to grow. DSM-5 appeared in May 2013, the work of fifteen years by thirteen subcommittees, each working on its own subspecialty. The page count reached 947, and again the number of ailments—potentially treatable, and therefore potentially profitable—rose: the count now tops three hundred, although changes to the classification system make it impossible to come up with a precise number. New diagnoses include hoarding disorder, restless leg syndrome, and social communication disorder. Meanwhile, Asperger’s syndrome has dissolved into a more general “autism spectrum disorder,” leaving millions of families wondering what that will mean for the treatment of their children.
Some find the whole enterprise pointless. “Has there ever been a task more futile,” asked writer L. J. Davis about the DSM, “than the attempt to encompass, in the work of a single lifetime, let alone in a single work, the whole of human experience? … Not even Shakespeare could manage it.” The reductio ad absurdum leads inevitably to the conclusion that “human life is a form of mental illness.” Davis’s cynical interpretation is that the DSM is a “catalogue,” and “The merchandise consists of the psychiatric disorders described therein, the customers are the therapists, and this may be the only catalogue in the world that actually makes its customers money: each disorder, no matter how trivial, is accompanied by a billing code, enabling the therapist to fill out the relevant insurance form and receive an agreed upon reward.”17
Gray’s Anatomy and the DSM seem to be worlds apart. One is concerned with the body, the other with the mind; one tells a story of Victorian positivism, the other of postmodern insecurity about the limits of our knowledge. Both, though, reveal the power exercised by the classifying function of the reference book. Gray and the nearly forgotten Carter got to dete
rmine how generations of physicians approached the human body, and their decisions have shaped the thinking of medical professionals for a century and a half. The DSM, too, has been shaping thinking, but it has been easier to see the work that went into shaping it, and thus easier to see how contingent many of its judgments are. Both books offer an opportunity to think about how much depends on the decisions made by the writers of our handbooks.
CHAPTER 20 ½
INCOMPLETE AND ABANDONED PROJECTS
In the back alleys of intellectual history are scattered the abandoned wrecks of would-be dictionaries and encyclopedias. When publishing projects stretch out over decades, money runs out, editors die, publishers go out of business, manuscripts burn, wars intervene. The remarkable thing isn’t that some works peter out before they’re finished; more amazing is that any of these works ever make it to completion.
Some books never make it past the gleam-in-the-author’s-eye stage. Read literary biography and you’ll find no end of people who considered writing a dictionary or encyclopedia. Many poets thought about trying their hand at lexicography—only natural for people who devote their lives to language—but few have finished. Alexander Pope and Walt Whitman both dreamed of being lexicographers, but only a few notes survive of their planned dictionaries.1 Oliver Goldsmith—novelist, poet, playwright, historian, and journalist—“for some time … entertained the project of publishing a ‘Universal Dictionary of Arts and Sciences’ ” featuring contributions from friends including Samuel Johnson and Sir Joshua Reynolds—but, despite the progress he made on the proposals, he died before publishing any of it. One scholar discovered evidence of fifty-four English dictionaries that were conceived but abandoned between just 1755 and 1828.2
