Ian Robert Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880-1940, Cornell University Press, Ithaca (NY), 1997, pp. xvii+245. £29.50. ISBN 0-8014-3356-8.

Dowbiggin positions this work as part of a 'new scholarly trend that has shifted attention away from the headline-grabbing leaders of the eugenics movement and towards the comparatively anonymous rank and file'. While as a result of the excellent work of previous historians we now know a great deal about eugenics and what this actually meant in the early twentieth-century, before being irretrievably tarnished by the association with Nazism, this has focussed mainly on the influence of propagandist organisations and their leaders. The means by which eugenic ideas were diffused through society as a whole (in which their pervasiveness is obvious) and how and if they were acted upon in policy-making are still very much open questions.

Keeping America Sane is a detailed and nuanced analysis of the influence of eugenic ideas on psychiatry in the United States and Canada over a sixty-year period, providing a rich comparative study between contiguous nations with much in common, but significant differences of political culture and tradition. Furthermore it amply demonstrates the shifts over time in sympathy towards, and implementation of policies based on, eugenics. These are shown to have had less to do with ideological commitment than with highly specific historical contingencies bearing upon the psychiatric profession as a whole and on individuals within it. By casting light on the complex careers of particular individuals Dowbiggin indicates how far from static and monolithic eugenic theories were. Individuals' adherence to eugenic tenets might change radically over time, and the amount of public promotion they gave them was as dependent on audience as on belief.

The centre of the book consists of meticulous studies of the careers of two influential individual psychiatrists, G. Alder Blumer in the USA and C. K. Clarke in Canada, and the ways in which the prevalent discourses of eugenics had an impact on them. Dowbiggin was fortunate in discovering the correspondence and papers of Blumer in the archives of the Butler Hospital at Providence, Rhode Island, where he was head psychiatrist. These revealed his eugenic leanings, but also constituted both 'one of the most important unpublished sources for the history of Anglo-American psychiatry' and 'an intriguing glimpse into the mental processes of an influential US psychiatrist'. Blumer is presented as a paradigmatic case of a psychiatrist of his period, when the reforming excitement of the era of moral therapy had grown tepid and public psychiatric institutions seemed to be increasingly becoming perceived as warehouses for the incurably insane rather than having an active curative role. The march of progress in other medical specialties seemed to be leaving psychiatry behind, before the interwar rise of new ideas of preventive psychiatry brought about a new pro-active model of the mental specialist emerging from the hospital into the community to engage with problems of mental health at a recuperable early stage. The alteration wrought in Blumer's own career, self-perception, and opinions on both the potential of psychiatry and eugenics, by a move from public institutions increasingly subject to bureaucratic control and cost-cutting, to the relatively privileged world of a well-reputed private asylum, is striking, drawing attention to the enormous disparities within the psychiatric profession as well as its rivalries with competing specialities such as neurology.

C. K. Clarke forms the Canadian counterpart to Blumer. He is located within 'the traditional Canadian reliance on government to take the initiative in public charity'. The state was expected 'to intervene in health and welfare': the effects could be far from benign, given the far stronger agenda within the Canadian psychiatric profession on eugenic policies such as sterilisation and emigration restriction forming an essential aspect of public health administration. Dowbiggin, however, gives due weight to the counterbalancing forces of large businesses greedy for cheap labour supplies, and organisations representing already resident immigrant communities, and their relationships with the bureaucracy and political interests. It was not just Eastern Europeans who were the target of Clarke's anti-immigration tirades: he also believed that Britain itself was 'dumping' its own undesirables on the Dominion.

Dowbiggin sites his subjects both in the context and culture of the particular institutions in which they served and within particular local political environments, to reveal the situations in which eugenics might have a strong appeal as providing an intellectual basis for something which beleaguered psychiatrists could do. He also demonstrates, however, that it was not necessarily or invariably trained medics who were advancing the most radical programmes of segregation, sterilisation and marriage regulation of the 'unfit', which had a strong appeal for a far wider constituency.

Lesley A. Hall

Wellcome Institute for the History of Medicine