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

Joel Braslow (Berkeley and Los Angeles: University of California Press, 1997. xiv plus 240pp. $40.00).

"With the decline of moral therapy in the second half of the nineteenth century and the rise of a more somatically based model of psychiatric disorders, the patient's body rather than his or her mind or environment became an increasingly important site of therapeutic intervention." (p. 34) In Mental Ills and Bodily Cures, Joel Braslow, a practicing psychiatrist and historian, interrogates the new "psychiatric body" and the major somatic therapies of the first half of the twentieth century. He constructs an engaging, sensitive, and intelligent narrative of mental hospital life by mining several rich collections of patient records from California state hospitals.

Following recent historiographical trends, Braslow argues that institutional imperatives, the power relationships between physicians and patients, the self-fashioning of mental hospital physicians (vis-a-vis lunatic asylums), and broader social and cultural forces shaped therapeutic practices; and that therapeutic practices structured various theoretical, conceptual and relational aspects of hospital life, such as the interaction between physicians and patients, the diagnosis, and even the physicians' understanding of the relationships between the body and the mind. The emphasis on therapeutic praxis, at the expense of medical and psychiatric theory, as the determining factor that shaped various aspects of mental hospital life is part of a newer wave of historiography in the history of science and medicine. This praxis-oriented approach emphasizes that theoretical and conceptual innovations often emerged from "low-level" practices, rather than accepting the traditional view of praxis as simply a substantiation of "high-level" theory (though Braslow does not make use of this broader literature in his study).(1) Institutional imperatives and practical solutions shape fundamental aspects of theory and of laboratory and clinical life.

The main core of the book examines in depth each of the major somatic therapies - hydrotherapy, sexual sterilization, malaria fever therapy, electroshock therapy, and lobotomy (clitoridectomy is also examined in the chapter on gender). The underlying "rationale" of each therapy is explored, for the author is concerned to demonstrate that these "seemingly incomprehensible and, at times, reprehensible acts" had a "meaning" for mental hospital physicians (and patients, p. 11). Institutional imperatives, such as overcrowding, led to solutions that focused on time-sparing interventions that controlled behaviors; and - importantly - the discipline of behaviors was perceived as therapeutic at its very core. Disordered behavior was a clinical sign of disease and the "therapeutic discipline" of patients "did not emerge from physicians' sadistic desire to control their patients," but rather, "flowed from their therapeutic rationale, which dictated that disordered behavior was disease." (p. 111) Hydrotherapy, for example, which, ultimately, immobilized the patient, was not perceived by physicians as a new form of restraint but as a cure through restraint, with an established scientific basis.

Not all patients were "quarrelsome, unreasonable, and assaultive;" (p. 51) some inhabited a life of despair. The author suggests a fascinating model in which a patient's behavior, the physician's therapeutic intervention, and the meaning of disease and its cure were all linked in a mutually sustaining harmony. When physicians focused on the control of behavior, they implemented a therapeutics of discipline which cured through restraint, developed a somatic conceptualization and localization of disease, and conceived their patients' disease and its cure in terms that were completely alien to their patients' perspectives. When the conduct of patients was not at issue, and the patient's subjectivity or a discrete and definable disease pathogen were the focus of intervention (the "therapeutics of despair" and malaria therapy for syphilitic paresis), physicians developed a psychic conceptualization and localization of disease (in despair), conceived their patients in positive terms (paresis), and constructed with their patients a mutually meaningful definition of disease and its cure. Though this scheme, as the author cautions, was not universally true (p. 123), it suggests an important historical model which had (and has) significant moral implications concerning the logic of psychiatry during the twentieth century.

In spite of the book's many strengths, it suffers from a number of problems. Braslow's focus on the "psychiatric body" does not engage the rich scholarly work on the body. This is an obvious lacuna. Braslow's particular concerns with the ways in which broader social and cultural ideologies were inscribed in the body - through the mediation of scientific knowledge and praxis - could have benefited from the historical, sociological, and anthropological analyses of the body, which specifically address and emphasize these very issues.(2) The author's theory of therapeutic change is also a less convincing aspect of the book. Braslow does not devote much space to the elucidation of therapeutic change or the reception of new therapies. He argues, for example, that malaria fever was the most frequently used therapy (in spite of alternatives, such as shortwaves, air-conditioned cabinets, electric blankets, etc.), because of its "ease of administration." (p. 78) Or that the "lobotomy program was killed by what doctors believed to be a better technology of therapeutic control" - Thorazine. (p. 169) Braslow does not explore the ideological, political or symbolic baggage that comments, such as "ease of administration" or a "better technology," conceal and contain. When mental hospital physicians introduced a new therapeutic technology they accepted much more than its functional and utilitarian aspects. A closer analysis of the reception of and transition between different therapies would have allowed Braslow to explore the implicit and negotiated meanings of these therapeutic interventions, rather than portray these therapeutic interventions as the causal factor that created these meanings (the author's discussion of this latter point is excellent). Lastly, though the book focuses on somatic therapies, patient records - cited at various points in the book - allude to non-somatic therapies (e.g., psychotherapy, analytic therapy, and group therapy; e.g., pp. 120, 134). We learn, for example, of a patient who was recommended for hydrotherapy and group therapy. (p. 120) This and other examples seem to indicate an unexplored tension in the logic of therapy, whereby patients were recommended for two therapies which, according to the author, implied two contrasting models of the meaning of disease, the doctor-patient relationship, and the locus of pathology. The relationships between somatic and non-somatic therapies (which the author explores for electroshock therapy) seems to provide a somewhat more precarious, tenuous, and unstable view of the therapeutic order than the one provided by the author in his broader narrative.

Whether one is convinced, like the author, that "locating the cure of psychic and behavioral disorders in patients' bodies" was responsible for the "pernicious consequences" described in the book (p. 4); or whether one believes that a pernicious principle underlies the Western episteme as a whole - irrespective of the somatic or psychological nature of the intervention - Braslow's book offers an insightful historical analysis of behaviorally-oriented medicine and an important model that suggests one possible explanation (and solution) for psychiatry's contemporary emphasis on behavior, its strict biological model of mental disorders, and its non-mutual construction of the meaning of disease and its cure.

Otniel E. Dror Getty Research Institute for the History of Art and the Humanities

ENDNOTES

1. For a recent and provocative analysis that emphasizes praxis, see Robert E. Kohler, Lords of the Fly: Drosophila Genetics and the Experimental Life (Chicago, 1994).

2. See, for example, Emily Martin, Flexible Bodies (Boston, 1994); Bryan S. Turner, Regulating Bodies: Essays in Medical Sociology (London and New York, 1992); and Thomas Laqueur, Making Sex: Body and Gender from the Greeks to Freud (Cambridge, Mass, 1990).