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

By Joel Braslow

Mental Ills and Bodily Cures depicts a time when psychiatric medicine went to lengths we now find extreme and perhaps even brutal ways to heal the mind by treating the body. From a treasure trove of California psychiatric hospital records, including many verbatim transcripts of patient interviews, Joel Braslow masterfully reconstructs the world of mental patients and their doctors in the first half of the twentieth century. Hydrotherapy, sterilization, electroshock, lobotomy, and clitoridectomy—these were among the drastic somatic treatments used in these hospitals.

By allowing the would-be healers and those in psychological and physical distress to speak for themselves, Braslow captures the intense and emotional interplay surrounding these therapies. His investigation combines revealing clinical detail with the immediacy of "being there" in the institutional setting while decisions are made, procedures undertaken, and results observed by all those involved. We learn how well-intentioned physicians could rationalize and regard as therapeutic treatments that often had dreadful consequences, and how much the social and cultural world is inscribed within the practice of biological psychiatry. The book will interest historians of medicine, practicing psychiatrists, and everyone who knows or has seen what it's like to be in mental distress.

This title is part of UC Press's Voices Revived program, which commemorates University of California Press's mission to seek out and cultivate the brightest minds and give them voice, reach, and impact. Drawing on a backlist dating to 1893, Voices Revived makes high-quality, peer-reviewed scholarship accessible once again using print-on-demand technology. This title was originally published in 1998.
Mental Ills and Bodily Cures depicts a time when psychiatric medicine went to lengths we now find extreme and perhaps even brutal ways to heal the mind by treating the body. From a treasure trove of California psychiatric hospital records, includin

• Language: English
• Publisher: University of California Press
• Release date: Sep 1, 2023
• ISBN: 9780520917934

Joel Braslow

Joel Braslow is a psychiatrist and historian whose work focuses on the social, cultural, and scientific constitution of therapeutic practices in medicine and psychiatry. He has been a faculty member in the UCLA Department of Psychiatry and Biobehavioral Sciences since 1992, and the UCLA Department of History since 1996.

Book preview

Mental Ills and Bodily Cures

MEDICINE AND SOCIETY

Andrew Scull, Editor

This series examines the development of medical knowledge and psychiatric

practice from historical and sociological perspectives. The books contribute

to a scholarly and critical reflection on the nature and role of medicine and

psychiatry in modern societies.

1. Robert Castel, The Regulation of Madness: Origins of Incarceration

in France. Translated by W. D. Halls

2. John R. Sutton, Stubborn Children: Controlling Delinquency

in the United States, 1640-1981

3. Andrew Scull, Social Order/Mental Disorder: Anglo-American Psychiatry in

Historical Perspective

4. Ian R. Dowbiggin, Inheriting Madness: Professionalization

and Psychiatric Knowledge in Nineteenth-Century France

5. Denise Jodele t, Madness and Social Representations. Translated

by Tim Pownall, edited by Gerard Duveen

6. James W. Trent, Jr., Inventing the Feeble Mind: A History of Mental

Retardation in the United States

7. Steven G. Epstein, Impure Science: AIDS, Activism, and the Politics

of Knowledge

8. Joel Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment

in the First Half of the Twentieth Century

Mental Ills and

Bodily Cures

Psychiatric Treatment in the First Half

of the Twentieth Century

Joel Braslow

UNIVERSITY OF CALIFORNIA PRESS

Berkeley Los Angeles London

University of California Press

Berkeley and Los Angeles, California

University of California Press

London, England

Copyright © 1997 by The Regents of the University of California

Library of Congress Cataloging-in-Publication Data

Braslow, Joel T, 1959—

Mental ills and bodily cures: psychiatric treatment in the first half of the twentieth century / Joel Braslow.

p. em. — (Medicine and society: 8)

Includes bibliographical references and index.

ISBN 0-520-20547-2 (cl: alk. paper)

1. Mental illness—Treatment—United States—History—20th century. 2. Mental illness—Physical therapy—United States—History—20th century. 3. Mind and body. I. Title. II. Series.

[DNLM: 1. Mental Disorders—therapy. 2. Therapeutics—history—United States. Wi ME6490 V. 8 1997 / WM 11 AAi B8c 1997] RC480.5.B725 1997

616.89'1—DC21

DNLM/DLC

for Library of Congress 96-39469

CIP

Printed in the United States of America

123456789

The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984®

For Christine

CONTENTS

CONTENTS

FIGURES

TABLES

ACKNOWLEDGMENTS

Introduction to the Psychiatric Body

Institutional Therapy: Context, Background, Structure

Discipline or Therapy: Patients, Doctors, and Somatic Remedies in the Early Twentieth Century

In the Name of Therapeutics: Sexual Sterilization as Psychic Cure

Neurosyphilis, Malaria, and a New Therapeutic Rationale

Where the Mind Ends and the Body Begins: The Practice of Electroconvulsive Therapy

Surgery as Discipline: Lobotomy at Stockton State Hospital

Discipline Gendered: Women and the Practice of Lobotomy

Conclusion

NOTES

REFERENCES

INDEX

FIGURES

1. Stockton Resident Patient Population, 1910—1955 / 21

2. Resident Patients per 100,000 of the General Population, 1910-1955 / 22

3. Statewide Sex Distribution of All Admissions, 1910-1950 / 24

4. Sterilization at Stockton State Hospital, 1935-1950 / 69

5. Articles on Malaria Fever Therapy Listed

in Index Medicus, 1917-1957 / 77

6. Disease Categories of Patients Treated with EST, 1944-1954, Compared to Disease Prevalence of Resident Patients

at Stockton State Hospital, 1949 / 103

7. Diagnosis at the Time of Lobotomy

at Stockton State Hospital, 1947-1954 / 141

8. Overcrowding at Stockton State Hospital, 1946-1955 / 155

TABLES

1. Selected Items Made by Patients in Occupational Therapy at Norwalk State Hospital, 1928-1930 / 30

2. Cumulative Sterilizations of Mental Patients in California

and the United States, 1907-1951 / 56

3. Classification Criteria for Positive and Negative Descriptions

of Neurosyphilitic Patients Made by Patton State Hospital Physicians / 8y

4. Characteristics of 129 Neurosyphilitic Patients Admitted between 1910 and 1950 / 88

5. Positive and Negative Descriptions Made by Physicians of 129 Neurosyphilitic Patients Admitted between 1910 and 1950 / 89

6. Stated Condition at Discharge as Determined by Physicians

of 129 Neurosyphilitic Patients Admitted between 1910 and 1950 / 90

7. Positive and Negative Descriptions Made by Physicians

of 79 Neurosyphilitic Patients Who Died Prior to Discharge / 91

8. Gender and Diagnostic Distribution of Patients Treated with EST / 118

9. Sex Distribution of Lobotomy Patients / 154

10. Multiple Lobotomies and Sex Distribution / 154

ACKNOWLEDGMENTS

In 1988, as I was nearing the end of my psychiatry residency, Dora Weiner allowed me to assist her in teaching a course on the history of psychiatry. Her encouragement led me to undertake this project, which in its early form was my doctoral dissertation. I am very grateful to those scholars who guided me early on. Regina Morantz-Sanchez alerted me to the importance of gender. Her insistence on clarity of argument and prose have, I hope, found their way into this book. My intellectual debts to Mario Biagi- oli and Martin Shapiro are enormous, and their contributions may be found throughout this work. There are two scholars who deserve my greatest thanks. My thesis adviser, Robert Frank, whose méthodologie sophistication and exhaustive knowledge of medical history have been indispensable, helped me to ask and try to answer why physicians, in the name of therapeutics, did what they did. Kenneth Wells has been, and continues to be, my closest mentor. Without his intellectual and emotional support this project would have been impossible.

There are many individuals who graciously read and commented on various parts and versions of the text. Though I was unable to attend to all their comments and suggestions, I am grateful to Arthur Kling, Lisa Rubenstein, Marvin Karno, Louis J. West (who also came up with part of the title), Vernon Rosario, and Robert Edgerton. Christian Zacher and Robert Bjork were especially helpful with issues of style. I especially want to thank Andrew Scull. He provided crucial encouragement when I first began this project and was invaluable in helping me transform this project from a dissertation into a book. I also thank Stanley Holwitz, Michelle Nordon, and Sheila Berg at the University of California Press for bringing this book to fruition.

My deepest thanks belong to my wife, Christine Schneider. As a psychiatrist, she has subjected many of the ideas contained herein to the concerns of a practicing clinician. We have had innumerable discussions on what it means to be a psychiatrist, and the insights contained herein are owed, in large part, to these dialogues. My two sons, Seth and Sam, though making this work harder to finish, also deserve heartfelt thanks for helping daddy work on his book.

I also want to thank the California Department of Mental Health for giving me access to patient medical records. William DeRise and Kathy Stye were especially generous with their time and advice on how to locate materials. At Patton State Hospital, William Summers, Sheila Fossum, and Nikki Batres provided invaluable assistance in finding patient records. At Stockton, Mary Anne Purlmutter was most helpful.

This work would not have been possible without the generous support of a postdoctoral fellowship from the UCLA/RAND Center for Health Policy, the UCLA Robert Wood Johnson Clinical Scholars Program, and the program’s director, Robert Brook. I also thank the UCLA Neuropsychiatrie Institute Research Center on Managed Care for supporting this project. This project was also supported in part by a VA Health Services and Research Grant and the Sepulveda VA Health Services and Research Field Program Center for the Study of Healthcare Provider Behavior.

Modified parts of this book have appeared earlier, as follows: Punishment or Therapy: Patients, Doctors and Somatic Remedies in the Early Twentieth Century, Psychiatric Clinics of North America 17 (September 1994): 493-513; The Effect of Therapeutic Innovation on Perception of Disease and the Doctor-Patient Relationship: A History of General Paralysis of the Insane and Malaria Fever Therapy, 1910-1950, American Journal of Psychiatry 152 (May 1995): 660-665, copyright 1995, the American Psychiatric Association, reprinted by permission; In the Name of Therapeutics: The Practice of Sterilization in a California State Hospital, Journal of the History of Medicine and Allied Sciences 51 (January 1996): 29-51. My thanks to the publishers for granting permission to reproduce copyrighted material. Chapter 4, in slightly different form, also appears as The Influence of a Biological Therapy on Doctors’ Narratives and Interrogations: The Case of General Paralysis of the Insane and Malaria Fever Therapy, 1910-1950, in Bulletin of the History of Medicine 70 (1996): 577-608. Finally, I wish to thank the California Institute of Technology for permission to quote from the E. S. Gosney Papers and Records of the Human Betterment Foundation, Box 12.8, Archives, California Institute of Technology, Pasadena, California.

Introduction to the Psychiatric Body

July 9,!943- Patient has had 12 electric shocks, resulting in 8 grand mal and 4 petit mal attacks. She has shown some improvement such as she is more concerned about her appearance than she was before. She is not as impudent and sarcastic as she has been on the ward. She claims that the reason she has not gotten along at home is because her husband is rather neglectful of her by leaving on weekends, she having to take care of the children and the house. At present she says she feels well but there are two things that are worrying her and she is afraid of. One is the electric shock treatments, she is morbidly in fear of them and worries a day or two before she gets them. The other is the operation that she is going to have performed for sterilization. If those two things could be eliminated she believes that she may make good if given a chance. For those reasons the examiner is discontinuing the electric shock treatments for the present to see what improvement the patient will make now.

— PHYSICIAN, MENDOCINO STATE HOSPITAL

Hounded by alien and menacing voices, Jane Lomax was first admitted to Mendocino State Hospital in the early 1930s.¹ Though she initially fought her fate as a psychiatric patient, Jane responded quickly to her doctors’ ministrations, which consisted primarily of numerous applications of mummylike wet sheet packs and hours of hot continuous baths, treatments collectively known as hydrotherapy. After a brief application of this rigorous regimen, Jane’s doctors discharged her as cured. She relapsed in early 1943, and her husband returned her to the hospital. With a nearly brand- new electroshock machine at the ready, Jane’s doctors instituted a course of shock treatments and, just in case she eventually might return home to her husband, recommended that she be sterilized. As the July 9 note suggests, her physician was not impervious to her pleas that the planned interventions on her body be halted. Despite having had the husband’s permission to sterilize her and to continue the shock treatments, the doctor acquiesced to her wishes, saving her, for the time being, from the scalpel and further convulsions.

Unfortunately, her condition worsened. By late 1947 a psychiatrist described her as silly, childish and stupid and changed her diagnosis from manic depression to dementia praecox, hebephrenic type. Dementia praecox, one of the most hopeless diagnoses that could be stamped on a patient, justified her new geographic location on a neglected back ward for the chronically disturbed. By this time her doctors had all but given up any hope of her recovery. Though they reinstituted electroshock, they had no illusions that this might result in a permanent cure. Instead, they used electroshock to quell her frequent attacks on patients and attendants. In fact, she eventually received well over one hundred treatments.

On January 18, 1950, Jane’s husband agreed with her doctors that cure might be found in a direct attack on her frontal lobes through a newly introduced and scientifically proven surgery, prefrontal lobotomy (indeed, just a few months earlier the Nobel Prize had been awarded to its inventor, Egas Moniz). Though admittedly radical, lobotomy offered the possibility of subduing her increasingly shock resistant behavior. However, she failed her screening interview for lobotomy. Answered questions poorly, the interrogating physician wrote. Appeared actively hallucinated. Enough response to indicate she had marked deterioration of an organic nature, lobotomy contraindicated.

She progressively withdrew from those around her, retreating into her own private and, no doubt, lonely world. In December 1956 her physician noted, The patient sits and grins, and gesticulates, making unintelligible replies. … Her daughter has requested one of the ataraxic drugs. Although there is not much hope of improvement, in view of her deterioration and her long hospitalization and no response to ECT [electroconvulsive therapy], we will try Thorazine. A short while later, Jane’s doctor decided that after nearly a quarter century of hospital life she should be released to a board and care home. Whether years of madness had simply worn her out or the new antipsychotic drugs had done their job, Jane’s violence had finally been vanquished. One of the doctor’s last notes in the medical record, written in the mid-1960s, updated her progress in the nursing home: The patient is reported clean, but does not work. … She is friendly, grins, grimaces, and gesticulates. Typical schizophrenic. … She grins delightedly when asked questions, such as does someone want to kill you?

Each intervention that Jane’s doctors employed or contemplated reaffirmed the intimate relationship they saw between her soma and her psyche. Whether they wrapped her in wet sheets, immersed her in warm tubs of water, sliced her fallopian tubes, or sent electrical current coursing through her, they deemed her body the main route to curing her troubled mind. The history of biological psychiatry was also inscribed on her body with these multiple interventions, for Jane underwent nearly every major somatic therapy created between the 1900s and the 1950s. The premier remedies of the first half of this century included hydrotherapy and sterilization beginning in the 1900s and 1910s, malaria fever therapy in the 1920s, shock therapies and lobotomy in the 1930s, and antipsychotic medications in the early 1950s. With varying degrees of enthusiasm, doctors continued to use all of these treatments through the 1950s. It is also worth noting that as one moves forward in time, these interventions spiral closer and closer to the interior of the brain. From merely applying water to the skin with hydrotherapy to the severing of frontal lobe axons with lobotomy to, finally, giving medications that putatively act at precise neurotransmitter sites, the brain increasingly took center stage as a source of disease and a site of cure. The aim of this book, then, will be to map the history of this psychiatric body and its cures over the first half of the twentieth century.

This history, while possessing intrinsic interest, becomes all the more important given the current dominance of biological psychiatry within the psychiatric profession and popular culture. We need turn only as far as television talk shows and best-seller lists to be convinced that somatic therapies have profoundly influenced the way in which American culture understands psychic distress and its cure. The latest psychopharmacological solution to gain notoriety has been what are known collectively as the serotonin selective reuptake inhibitors. These are relatively new antidepressant medications, the oldest and best known of which is fluoxetine (better known by its trade name, Prozac). Whether lauding or condemning this latest technology and its widespread use in America, works such as Listening to Prozac, Prozac Nation, and Talking Back to Prozac intentionally or unintentionally pay homage to the almost mystical power of this antidote to psychological suffering.² Peter Kramer, author of Listening to Prozac, writes,

Is Prozac a good thing? Asking the virtue of Prozac may seem like asking whether Freud’s discovery of the unconscious was a good thing. Once we are aware of the unconscious, once we have witnessed the effects of Prozac, it is impossible to imagine the modern world without them. Like psychoanalysis, Prozac exerts its influence not only in its interaction with individual patients, but through its effect on contemporary thought. In time, I suspect we will come to discover that modern psychopharmacology has become, like Freud in his day, a whole climate of opinion under which we conduct our different lives.³

Though one might quibble with Kramer’s assertion that fluoxetine has become the symbolic equivalent of the unconscious (one need only think of lobotomy, the last Nobel Prize-winning psychiatric remedy, to be less sanguine about fluoxetine’s longevity into the new millennium), he does capture our current fascination and desire to move away from the immaterial mind to the corporeal brain.

The psychiatric profession has aided and abetted this cultural embrace of the brain and biological interventions; for psychiatrists themselves, over the last few decades, have veered sharply away from psychoanalysis and psychological ways of understanding toward a somatic approach to psychiatric disorder and its treatment. Even a superficial perusal of the leading psychiatricjournals underscores the eclipse of talk therapies and the importance of biological psychiatry—in terms of both the theoretical understanding of disease and its treatment.⁴ Adding an exclamation mark to this growing trend, President George Bush and the United States Congress in 1989 declared that the 1990s would be the decade of the brain. Organized psychiatry has met this declaration with more than a modicum of enthusiasm.⁵ However, this turn has its critics, most of whom would not be classified as antipsychiatrists. For them, the legitimacy of psychiatry or psychological healing is not at issue but rather the hegemony of a biological vision of human behavior. Accordingly, they have argued that the scientific content of this ilk of psychiatric knowledge and practice is flawed at best and inconclusive regarding biological causation of nearly all psychiatric disorders. This way of viewing the mind and its disorders, they argue, is a form of reductionist determinism that is more of an ideological justification of the existing social order than scientific fact.⁶

I, too, am critical of an exclusive devotion to biological psychiatry and see this book as, in part, a critique of physical solutions to psychological distress, for in it we will see the particularly pernicious consequences of locating the cure of psychic and behavioral disorder in patients’ bodies. However, my aim is not to expose these practices as either unscientific or ineffectual. Science was and is historically and socially contingent, and to hold physicians of the 1900s to the 1950s up to a late twentieth-century ideal standard of science would be ahistorical and meaningless, except as an exercise in demonstrating the progress of current practice. Two useful concepts for understanding my point of view are efficacy and effectiveness. Derived from clinical epidemiology, effectiveness refers to how well a particular remedy performs in everyday clinical practice, while efficacy refers to how well a treatment does under controlled circumstances in clinical studies. Efficacy closely parallels what one would call a treatment’s scientific basis. For the most part, I will take a given remedy’s efficacy for granted. I make this odd statement (since few currently would be foolhardy enough to suggest that treatments such as insulin shock, lobotomy, and malaria fever therapy are efficacious) with a caveat or two. I do not mean that a particular remedy would be deemed efficacious today. By late twentieth-century standards, none of the treatments with the exception of electroshock therapy would hold up under scientific scrutiny. During their heydays, however, most of the therapeutic practices that are the subject of this book generally conformed to standards that constituted legitimate evidence for efficacy.⁷

Leaving efficacy aside, then, my aim will be to explore the ways in which doctors and, to a lesser extent, patients constructed and reacted to what they judged to be effective remedies. In fact, this is a central theme of the book and goes to the heart of therapeutic practices, whether psychiatric or medical. While the determination of efficacy generally goes on behind the ordinary practitioner’s back, he or she actively creates the treatment’s effectiveness. A naive realist might object by arguing that a patient’s biology and the physiological effects of the treatment account for what we think of as effectiveness. But what are we to make of the fact that doctors will use a remedy effectively for many years, and then, sometimes quite suddenly, that remedy becomes transformed, by a strange alchemy, into the therapeutic equivalent of fool’s gold? Whether dethroned by additional scientific evidence or a new treatment, the now-discarded remedy undergoes reinterpretation by its practitioners. What they once thought were biological effects they now disparagingly attribute to their (or, more commonly, their predecessors’) past ignorance and find that the old treatment no longer works and believe that it never really did. It is not that biology has suddenly changed. Rather, what has changed is the way doctors construct effectiveness. I am not arguing that therapeutic effects are entirely socially constructed. Instead, I am suggesting that whatever biological consequences a particular therapy has are mediated by and interpreted through the way doctors see disease and its cure, which are themselves determined by therapeutic practice. Looked at in this way, the biological effects of a treatment, though obviously important, assume a less important role in understanding the effectiveness of a particular remedy.

This act of constructing and perceiving an effective therapy requires that doctors create a kind of rough-and-ready therapeutic rationale through which they can interpret their patients’ signs and symptoms in the context of the proposed intervention.⁸ Acting as a conceptual filter, a therapeutic rationale organizes what physicians see as disease and its cure. In this way doctors structure signs and symptoms into treatable disease. Thus, for practitioners, disease and its treatment form an almost inseparable unit that mutually legitimates and reinforces the other’s existence. Assuming a treatment effectively eradicates these signs and symptoms, both the reality of disease and the effectiveness (and thus goodness) of the treatment are gloriously affirmed in the eyes of the doctor. With the somatic therapies of the first half of this century that this book explores, therapeutic rationales varied as different sites on the psychiatric patient’s body became the loci of various treatments.

My focus on therapeutic practices is part of a growing trend among historians. This interest was perhaps accelerated by Charles Rosenberg’s lament in 1977 that most historians have always found therapeutics an awkward piece of business and on the whole, they have responded by ignoring it.⁹ Rosenberg himself has made significant contributions to our understanding of early nineteenth-century medical therapeutics. For early nineteenth-century physicians and patients, various treatments mediated a shared belief between doctor and diseased regarding the nature of illness.¹⁰ More recently, John Harley Warner’s The Therapeutic Perspective h?cs provided a richly textured account of orthodox physicians and their therapies in nineteenth-century America.¹¹ His work relies heavily on medical records, which allow him to explore the local context of treatment practices. As his work illustrates, a doctor’s professional, social, and intellectual identity is central to what a doctor does to his or her patients.¹²

Whereas therapeutics has often figured centrally in accounts of nineteenth-century psychiatry, the history of twentieth-century somatic therapies, as Andrew Scull suggests, is in its infancy.¹³ There are two short studies of limited value that deal exclusively with psychiatric therapies, one by Wilfrid Jones and the other byj. F. Cade.¹⁴ Although he is primarily concerned with policy questions, Gerald Grob, in his numerous works on American psychiatry, does occasionally deal with biological therapies of the twentieth century, providing balanced and useful, albeit short, accounts of commonly deployed interventions.¹⁵ While beyond the chronological scope of this work, Judith Swazey provides an informative account of the history of chlorpromazine (Thorazine).¹⁶ Now that a new generation of antipsychotic drugs are being introduced which show promise of greater efficacy and fewer side effects than chlorpromazine and medications developed in its wake, perhaps we will see more critical histories of these older drugs.¹⁷

Though focusing on lobotomy, Elliot Valenstein’s Great and Desperate Cures is the most extensive published account of twentieth-century biological therapies in psychiatry.¹⁸ Understandably, given the terrain that his work covers, Valenstein’s account contains a large dose of moral outrage. However, this same laudable stance fundamentally flaws his account. On the one hand, he sees practices such as lobotomy as bizarre and obsolete; on the other, he does not fruitfully identify the means by which the bizarre was made therapeutic and efficacious for the many physicians who readily deployed these remedies. While he sees the rise of lobotomy not as an aberrant phenomenon but as a part of the mainstream of medicine, he presents a mainstream that seems simply too alien and grotesque in its application of science to have relevance as a modern cautionary tale. In the end, Valenstein claims that the necessary prophylactic to such unhealthy medicine is more, perhaps soberer, medicine: It is essential that we minimize the harm caused by premature claims of cures, by unbridled ambition, and by uncritically enthusiastic promotion. This end can be accomplished only by establishing procedures for testing innovative therapies before they are broadly used.¹⁹

In contrast, Jack Pressman’s soon to be published Ph.D. dissertation, Uncertain Promise: Psychosurgery and the Development of Scientific Psychiatry in America, 1935-1955, provides a history strikingly different from Valenstein’s.²⁰ Clearly the most exhaustive history of lobotomy, Uncertain Promise argues for the importance of psychosurgery in the development of controlled clinical trials and lobotomy’s symbolic function in the psychiatric profession’s attempt to end its isolation from scientific medicine. Focusing on a broad range of annual reports, Pressman tries to show how lobotomy helped state hospital superintendents deal with the pressing clinical problem of the chronic mentally ill patient.²¹ However, Pressman’s account transforms lobotomy from a procedure of bizarre excess to a crucial part of psychiatry’s scientific maturation: It was precisely through numerous lobotomy investigations and extensive conferences that psychiatrists learned important principles of experimental design, confronting problems that could not be foreseen but had to be experienced. In his desire to avoid characterizations [that] anachronisticallyjudge past efforts by current standards of scientific medicine, his account becomes, at times, simply a chronicle of psychiatric progress without critical regard for the consequences.²²

To uncover how doctors and, to a lesser extent, patients constructed their therapeutic world, this work relies heavily on patient records from California state hospitals. If one wished to study elite psychiatric culture, these archives would have little to recommend them. Most doctors at these institutions produced no scientific publications and practiced their craft in relative obscurity, although by the late 1930s increasing numbers of researchers from the University of California used the state hospitals as study sites. Records from these asylums, however, provide a remarkably clear window through which to observe how ordinary doctors and patients struggled, often with each other, to control and create meaning out of despair and madness. While my focus shifts between several institutional locales, depending on the therapeutic intervention in question, I have mined most extensively records at Patton State Hospital, located about sixty miles east of Los Angeles, and Stockton State Hospital, about fifty miles south of Sacramento.

Since the case records from these two institutions provide the flesh and bones of my account, a short description of these documents might be helpful. Throughout the first half of this century the structure of the medical records remained constant. They commonly contained the following: transcripts of court proceedings to determine insanity, which most often included testimony from family members and police officers; a typed admission history usually three to ten pages in length; typed physician progress notes whose entries varied in frequency (daily to several per decade) and length (a single sentence to several pages); family questionnaires asking for the supposed cause of the insanity; letters to and from the patient; and verbatim transcripts of patient interviews. Although all the contents of the case records help create a detailed picture of state hospital culture and practice, the transcripts of patient interviews offer perhaps the richest yield. These interviews were produced in what were called clinical case conferences. With a stenographer at the ready, physicians convened these conferences on a patient’s admission, when a new treatment was under consideration, when a particularly perplexing clinical problem needed ferreting out, and when the patient was considered for discharge. Several staff physicians and often the hospital superintendent participated in questioning the patient. The presenting doctor would then dismiss the patient so that the staff members could discuss the interview and any necessary interventions. The interviews and the ensuing discussions allow us a vivid, if brief, glimpse of psychiatric practice and discourse and allow us to reconstruct the intersection of therapies, perceptions, and the doctor-patient relationship.

Eventually heeding Erwin Ackerknecht’s plea to pay closer attention to what doctors actually did, historians increasingly have found medical records to be a vital source by which to go beyond the peer review literature and explore the ways in which medical knowledge was implemented and reinterpreted in actual practice.²³ Nancy Tomes’s work on Thomas Kirkbride and the Pennsylvania Hospital is a model study that relies heavily on patient records in its reconstruction of nineteenth-century asylum life from doctors’ and patients’ points of view.²⁴ Other notable studies of nineteenthcentury psychiatric and medical practices liberally using patient records include Anne Digby’s Madness, Morality, and Medicine, Ellen Dwyer’s Homes for the Mad, and Warner’s The Therapeutic Perspective.²⁰ Not surprising, given thorny issues of patient confidentiality, few have had the opportunity to mine the rich archives of twentieth-century hospitals. Joel Howell’s work on the introduction of a variety of medical technologies (such as X-ray machines and blood tests) into the New York and Pennsylvania hospitals, Cheryl Warsh’s study of the Homewood Retreat in Ontario, and Elizabeth Lunbeck’s examination of the Boston Psychopathic Hospital are notable exceptions.²⁶

It should be emphasized that the clinical narratives on which these histories (as well as my own) are based do not provide privileged access to what really happened. In the case of California state hospital records, they were penned (or dictated) by doctors and had a variety of legal and bureaucratic functions. Most important for our purposes, they also served as doctors’ collective diaries on medical life and were crucial in the construction of their clinical knowledge.²⁷ Thus they are best for revealing doctors’ subjective realities. However, any inferences we make about how patients felt or the nature of the interactions between doctors and patients must take into account the fact that first and foremost these records were created by and for physicians. Even the verbatim transcripts are not pristine true accounts, for the doctors’ very presence, not to mention their often interrogating, adversarial style, colored their patients’ responses.²⁸ Imbalances of power permeate these records in which authorial and real power over bodies and freedom was in the hands of