Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (review)

The history of psychiatry (like that of the rest of medicine) has traditionally emphasized the evolution of theory. Presumably shaped by empirical data, theory in turn guided clinical practice. Yet in reality the relationship between theory and practice was (and remains) at best tenuous. Indeed, the history of clinical practice has been one of the least studied subjects in either psychiatry or other branches of medicine; assumptions and conjecture have governed writings dealing with this topic. In Mental Ills and Bodily Cures Joel Braslow has reversed the traditional preoccupation with theory and turned his attention to clinical practice. His training in both psychiatry and medicine stands him in good stead, and suggests that clinicians and historians can have a productive rather than an antagonistic relationship. Examining a judicious sample of patient case histories at two California state hospitals between 1900 and 1950, he has written a book that has major implications for historians and clinicians alike. Patient records—which occasionally include verbatim transcripts of interviews—hint at the nature of physician-patient relationships. More important, they illuminate the rationale employed by practicing psychiatrists in deploying interventions to deal with severely mentally ill institutionalized persons. What makes these records especially fascinating is that they were written by ordinary psychiatrists who published nothing and who spent most of their professional careers in relative obscurity.

Braslow examines a series of psychiatric somatic interventions, beginning with hydrotherapy and proceeding successively to sexual sterilization, malaria fever therapy, electroconvulsive therapy, and lobotomy. Rather than studying the writings of elite pioneers of these therapies, he probes their origins in California state hospitals, their meaning, and the ways in which social and cultural factors shaped the practice of somatic (i.e., biological) psychiatry in the first half of the twentieth century. His analysis offers fascinating insights into the biological universe of this period, for, as he notes, the manner in which physicians perceive of disease “is inescapably linked to how they treat disease” (p. 52).

Although early-twentieth-century psychiatrists employed sedatives and hypnotics, they did not regard them as therapeutic agents; such medications were simply a means of controlling the body. Hydrotherapy, on the other hand, permitted psychiatrists to identify disruptive behaviors as “the essence of disease” (p. 52), thus enabling them to make the body rather than the mind the primary object of therapeutic intervention. Sterilization, developed by eugenicists preoccupied with preventing the procreation of defective groups, was redefined by California psychiatrists: in their hands it became a therapeutic procedure that met the individual needs of their patients, thus weakening in part the linkage between behavior and therapy. Malaria fever therapy, by contrast, transformed physician-patient relationships. The object of psychiatric pathology shifted from disorderly or immoral conduct to a disease pathogen; under such circumstances, psychiatrists began to view patients in a more sympathetic light. Electroconvulsive therapy had more eclectic elements; it created “a complex interplay between care and control” (p. 123), in part because it was used with disruptive behavior that seemed to require control as well as a means of mitigating the internal world of patients’ despair.

Lobotomy, the most invasive therapy of the 1940s, reflected the transformation of behavior disorders into brain disease. With the problem defined in such terms, psychiatrists could act with impunity upon the bodies of their patients. Unlike other therapies that were gender-neutral, lobotomy was deployed largely on women. Psychiatrists accepted the traditional belief that “a woman’s mind, as compared with a man’s, was more dependent on the body” (p. 152). In so doing they elevated a cultural imperative into an invasive therapy.

Mental Ills and Bodily Cures poses fascinating questions for future scholars. Was institutional psychiatry in California representative of other states? To what extent is it possible to generalize from a single case study? Were psychiatric clinical styles uniform throughout the United States...