Book Review

Mental Ills and Bodily Cures: Psychiatric treatment in the first half of the twentieth century

N Engl J Med 1998; 338:204January 15, 1998

Article

Mental Ills and Bodily Cures: Psychiatric treatment in the first half of the twentieth century
(Medicine and Society. Vol. 8.) By Joel Braslow. 240 pp. Berkeley, Calif., University of California Press, 1997. $40. ISBN: 0-520-20547-2

Mental Ills and Bodily Cures is somewhat misleadingly titled: it is not a general history of the physical therapies, or bodily cures, that prevailed in psychiatry before the introduction of chlorpromazine, but rather an account of the use of these therapies in two California psychiatric institutions, Patton State Hospital and Stockton State Hospital. Braslow, like most historians of medicine, is generally hostile to the early therapies that ushered in biologic psychiatry, such as malaria-fever therapy, insulin coma, lobotomy, and similar treatments that acted on the physical substance of the brain. A practicing psychiatrist who also completed a Ph.D. in history (this book was his doctoral thesis), Braslow labored long reviewing patients' records at these two state hospitals, abstracting telling quotations from physicians' case notes, patients' letters, and verbatim transcripts of clinical interviews, in order to put together a comprehensive picture of the treatment of ward patients in the first half of this century.

It is not a pretty picture, according to Braslow, who faults these California physicians for choosing “looking over listening.” The story begins with a discussion of the physical restraints that were widely used around the time of World War I. This approach gave way to hydropathic treatment, an apparent therapy but in reality, according to Braslow, just an extension of the physicians' larger agenda of “discipline and control.” This antipsychiatric note — reminiscent of the work of Paris philosopher Michel Foucault — rings throughout the book, the doctors with their single-minded agenda of ordering and disciplining, willing to alter the nature of their “therapeutic rationale” with every innovation.

Next in the parade of physical therapies was malaria-fever therapy for neurosyphilis, developed in 1917, followed by the various shock therapies of the 1930s: insulin coma (or shock) therapy, metrazol (pentylenetetrazol) shock therapy, and electroconvulsive therapy. The first machine for electroconvulsive therapy arrived at Stockton State Hospital in 1943 and was immediately enlisted in efforts to control patients' behavior. This, indeed, is the main theme in the therapeutic interventions of psychiatry, according to Braslow: electroconvulsive therapy permitted psychiatrists to see disruptive behavior not just as a problem of order in the institution, but as a sign of illness, a treatable disease. In his view psychiatrists were not interested in diagnosis. Control was their real agenda, and in the case of electroconvulsive therapy this meant controlling excitement, agitation, and the like. (This strikes me as a not unreasonable therapeutic objective, given that excitement in mania, for example, could have a fatal outcome.)

On the heels of electroconvulsive therapy followed far worse — lobotomy — and Braslow presents an unremitting chronicle of the unscientific mutilation of patients. Strikingly, at Stockton State, 85 percent of those subjected to lobotomy were women (the rate was 60 percent nationwide). Why so many women? Braslow argues that these psychiatrists found the body of a female patient to be a “more concrete, objective entity and hence more amenable to surgical intervention” than a male patient's body. Although these doctors were blind to sexual cues coming from men, from women such cues gave rise to an operative orgy. They even performed a clitoridectomy on four of their patients who underwent lobotomy.

The book's larger theme concerns “the power of biological therapies to alter the way in which doctors perceive both their patients and the doctor-patient relationship.” There is truth in this, and Braslow's analysis of the experience of the women with some of these physical therapies is devastating. But his account is highly sectarian as well. Chlorpromazine, according to him, “was introduced in the early 1950s, because of its ability to control behavior.” Coming from the psychiatric left, he bears a deep grudge against any approach that situates psychiatric illness in the brain, and he slides over the fact that some of these physical therapies had the capacity vastly to ameliorate patients' symptoms.

There is one more thing. Braslow writes with a light touch, and the book makes riveting reading, particularly the bits of dialogue between psychiatrists and patients that he excerpted from the transcripts. Anyone interested in learning how the arrogance of science and pseudoscience can lead medicine over the brink will profit from reading this biased but rewarding study.

Edward Shorter, Ph.D.
University of Toronto Faculty of Medicine, Toronto, ON M5G 1L4, Canada