Mental Health Services Research, Vol. 1, No. 4, 1999

History and Evidence-Based Medicine: Lessons from the History of Somatic Treatments from the 1900s to the 1950s

Joel T. Braslow1

This paper examines the early history of biological treatments for severe mental illness. Focusing on the period of the 1900s to the 1950s, I assess the everyday use of somatic therapies and the science that justified these practices. My assessment is based upon patient records from state hospitals and the contemporaneous scientific literature. I analyze the following somatic interventions: hydrotherapy, sterilization, malaria fever therapy, shock therapies, and . Though these treatments were introduced before the method of randomized controlled trials, they were based upon legitimate contemporary science (two were Nobel Prize-winning interventions). Furthermore, the physicians who used these inter- ventions believed that they effectively treated their psychiatric patients. This history illustrates that what determines acceptable science and clinical practice was and, most likely will, continue to be dependent upon time and place. I conclude with how this history sheds light on present-day, evidence-based medicine. KEY WORDS: evidence-based medicine; history of ; somatic therapies; .

INTRODUCTION measured up to the new scientific standards. These facts have led us to view these pre-RCT therapies Over the last couple of decades, researchers, cli- and the doctors who used them as mired in a pre- nicians, and policy-makers have urged clinicians to scientific age, where personal conviction, local con- base their practices upon scientific evidence, the most text, and social and cultural values played as large a robust of this evidence being the randomized con- role as science in the care and treatment of patients. trolled trial (RCT). Introduced into clinical medical The recent proliferation of practice guidelines based science in the late the 1940s (Medical Research Coun- upon evidence from RCTs has reinforced the appar- cil, 1948), psychiatric researchers first began em- ent contrast between our therapeutic age and that of ploying the RCT in the 1950s (Elkes & Elkes, 1954; the first half of the century (American Psychiatric Elkes & Healy, 1998; Rees, 1956). The RCT quickly Association [APA], 1997; APA Steering Committee, gained status as the "gold standard" of therapeutic 1996; Lehman & Steinwachs, 1998; Veterans Health efficacy. For , the RCT dramatically al- Administration, 1997). However, despite our meth- tered their therapeutic landscape (Healy, 1997). With odological and therapeutic advances, the past has the exception of electroconvulsive therapy, nearly all much to teach us, particularly about how a given era's psychiatric treatments used in the first half of the scientific treatments can be transformed into what century have been discarded. Though not the primary physicians' believe to be effective medical practice, reason why physicians abandoned these therapies, even though we may later learn that a particular the evidence supporting these therapies no longer remedy that once "worked" in fact possessed little or no therapeutic value. Focusing on the period from the 1900s to the 1UCLA Departments of Psychiatry and History, and VISN 22 1950s, the aim of this essay will be to sketch briefly Mental Illness Research, Education and Clinical Center of the the science and actual use of treatments used before Department of Veterans Affairs, Los Angeles, California. the introduction of the RCT. I examine somatic and

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1522-3434/99/0400-0231$16.00/0 © 1999 Plenum Publishing Corporation 232 Braslow biological remedies for the severely mentally ill and canvas sheet that had a hole for the patient's head show how the science and practice of each interven- to go through. A series of valves and temperature tion reinforced each other. The treatments that fol- gauges allowed the attendant to regulate both tem- low largely have been abandoned and a few, such as perature and water flow. A single treatment could lobotomy, have been thoroughly discredited. Yet my last anywhere from hours to days. purpose is not to point to the misguided efforts of These treatments provided early twentieth-cen- biological psychiatry. One could certainly write a his- tury physicians with what they believed to be a genu- tory of similarly benighted efforts at psychological inely therapeutic and biological approach to the treat- healing. Further, to see this history as a series of ment of severely mentally ill patients. In particular, failed attempts at treating severe mental illness would they found these interventions especially effective be missing the point. Instead, this history illustrates means by which to therapeutically control psychotic that accepted science and therapeutics are dependent patients. While late nineteenth-century asylum doc- upon time and place. Indeed, this review of past bio- tors had a variety of drugs by which to sedate and logical therapies is important precisely because bio- calm severely agitated patients (Ackerknecht, 1979), logical therapies have proven to be so effective that they rarely considered these medications as having we often forget the evolving nature of science and true therapeutic value (Chapin, 1891-1892; Drapes, the practice that flows from that science. 1889; Mabon, 1888-1889; Macleod, 1900). Emphasiz- ing the nontherapeutic nature of pharmacological treatments, such as bromides, chloral hydrate, hyo- HYDROTHERAPY scine, paraldehyde, sulfonal, and narcotics, the well- known British , Henry Maudsley (1895, The first widely acknowledged effective somatic pp. 554-555) wrote: therapy of the twentieth century was hydrotherapy. Introduced into state hospitals throughout the United Mechanical restraint, except under surgical necessi- ties, was formerly abandoned, not because its use States in the late nineteenth and early twentieth cen- was sure to become abuse, but because it was deemed turies, this therapy consisted of a number of devices better for the patient to let him have the relief and and techniques that employed water. The two most self-respect of pretty free exercise than to keep him frequently used forms of hydrotherapy were the con- tied up like a mad dog . . . but it may be doubted tinuous bath and the wet sheet pack (Baruch, 1920; whether its coarse bond did as much harm as has been done by the finer means of chemical restraint Finnerty & Corbitt, 1960; Wright, 1940). The "pack" which have been used to paralyse the brain and required little in the way of sophisticated equipment. render the patient quiet. A sheet was dipped in water ranging from about 40 to 100°F and then the patient was snugly wrapped In contrast to drugs, physicians found hydrotherapy within this wet sheet. Very agitated patients were to be a genuinely scientific means by which to act given colder sheets and more frail patients were upon their psychiatric patients' biology in order to placed in warmer sheets. Patients generally remained effect mental cures. Indeed, researchers had discov- bundled for several hours at a time. Attendants often ered a variety of biological mechanisms through wrapped a blanket around the patient and the sheet. which hydrotherapy "worked." Some, for example, Finally, if the patient resisted the wet pack, the atten- asserted that the remedy relieved "cerebral conges- dant placed a third sheet over the patient, securely tion" through its influence on the peripheral vascular tying him or her to the bed. Patients went through system (Kellogg, 1887). Others argued that hydro- several stages while in the pack; first they were therapy helped eliminate "toxic impurities" that cooled, but over time the pack eventually heated. might cause insanity (Foster, 1899; Jagielski, 1896; At times, physicians ordered a rubber sheet to be Shepard, 1900). "It is extremely likely," a physician wrapped around the wet sheet to enhance the heat- wrote in explaining the physiology of hydrotherapy, ing effects. "that the excretory function of the skin and kidneys Continuous baths required more elaborate de- is stimulated" (Strecker, 1917, p. 1797). A body of vices than did wet packs. The baths most often con- research based on precise measurement of parame- sisted of a tub with an inlet for hot water and an outlet ters such as blood pressure, pulse, respiratory rate, to drain the water. Attendants placed the patient and differential blood count lent further support to in the hammock to which he or she was fastened. the science of hydrotherapy (Adler & Ragle, 1913; Attendants then covered the tub and patient with a Niles, 1899; Peck, 1909). History and Evidence-Based Medicine 233

Practitioners readily employed these physiologi- by severing the vas deferens, the interstitial cells of cal explanations in their everyday treatment of pa- the testicles would undergo hyperplasia. This in turn tients. Testifying in 1920 on behalf of a California would lead to the increased production of beneficial state hospital accused of misusing hydrotherapy, a hormones that "rejuvenated" the individual's mind psychiatrist at the University of California Hospital and body (Benjamin, 1925; Money, 1983; Wolbarst, in San Francisco declared that hydrotherapy "is the 1922). Psychiatrists logically adduced that vasectomy only scientific treatment for the acute excitement of might also benefit psychiatric patients, given that a the insane that has yet been discovered." Echoing variety of reports demonstrated testicular abnormali- the published literature, she went on to describe its ties in the insane (Editorial, 1915; Epitome, 1915; physiologic effects: "Packs act by increasing the elim- Gibbs, 1923a, b, 1924; Mott, 1922; Tiffany, 1921). As ination by the skin, helping to rid the system of toxins with their use of hydrotherapy, practitioners used this and poisonous matter in the constitution." Further- scientific evidence to support their clinical practice as more, hydrotherapy brings "blood to the surface and illustrated by the following conversation between a relieve[s] the congestion in the brain and spinal cord, state hospital physician and his patient transcribed which in most cases seems to cause the excitement" in 1928 (Stockton State Hospital [SSH] 32735, 1928, (In the Matter of the Investigation of Agnews State clinical conference, p. 1): Hospital, 1919, p. 531). While the scientific luster of Patient: I have these spells, I get a little melancholy, hydrotherapy faded over the following three or four and then things don't break quite right and I get decades, psychiatrists commonly prescribed it until quite nervous. they gradually replaced it in the 1940s and 1950s Doctor: Have you ever been sterilized? Patient: No. first with electroconvulsive therapy and later with Doctor: You had better let us operate on you while drugs. you are here? Patient: That will certainly be all right with me and with my wife also. STERILIZATION Doctor: We will do that then. Patient: Doctor, will that bring better composure to the nervous system? Sterilization was another major intervention in- Doctor: It is supposed to, it has in a number of cases, troduced in the early years of the twentieth century we do not guarantee it, but in a number of cases (Dowbiggin, 1997; Reilly, 1991). First introduced in it has had marked beneficial effects. It cannot hurt only a few states by 1910, by 1950, 26,000 American you and does not interfere with your sexual life in any way, we just cut a little duct and you absorb psychiatric patients had been sterilized, 11,000 of your own secretions. them in California (Robitscher, 1973). Though right- Patient: It has always been all right with me, and fully portrayed as a dark chapter in American psychi- my wife did not want to take the responsibility of atry, physicians use of this surgery also illustrates the signing it. I have spoken to my wife about it and close relationship between a therapeutic practice and have told her I wanted it to get through this time. Doctor: Well, it cannot hurt you and it might have its supporting scientific evidence. Granted, most ster- a marked beneficial result. ilization laws were passed in the first 25 years of this Patient: I will be very much obliged to you, sir.2 century largely at the urging of a small but influential group of eugenicists. In California, for example, phy- sicians could sterilize patients "afflicted with heredi- MALARIA FEVER THERAPY tary insanity or incurable chronic mania or dementia" (Laughlin, 1922). Yet physicians did not necessarily In the first quarter of this century, general paral- sterilize patients for eugenic reasons; some, in fact, ysis of the insane, a tertiary form of syphilis, posed opposed eugenics even though they readily employed 2In order to protect patient privacy, all hospital numbers and identi- the surgery. The reason for this apparent contradic- fying characteristics have been changed. I have retained the origi- tion was that physicians thought that the operation nal spelling and punctuation in all of my quotations from the had therapeutic value in itself, especially for their medical record. Records from Patton State Hospital are still re- male patients. For men, vasectomy was supposed to tained by the hospital, which is located in Patton, California. diminish anxiety and depression and increase vitality. Records from Stockton State Hospital were at the Stockton Devel- opmental Center until its closing in February 1996. With appro- Like hydrotherapy, physicians based their therapeu- priate permission from the California Department of Mental tic use of sterilization upon contemporary science. Health, one can obtain the actual patient record numbers from A body of evidence supported the belief that, the author. 234 Braslow one of the greatest challenges for psychiatrists. Not flected prevailing cultural values in which individuals only was the illness nearly invariably fatal, it also had afflicted with syphilis were seen as immoral transgres- a high prevalence. In Europe, for example, some sors, perhaps even deserving of their often hopeless institutions reported that up to 45% of their male condition. Physicians rarely gave these patients any patients suffered from this disease (Diefendorf, choice in their therapeutic regimen and, not unex- 1906). In America, physicians reported lower, al- pectedly, individuals afflicted with neurosyphilis were though substantial, rates of paresis. In the 1910s, ap- loath to admit themselves voluntarily into a state proximately 20% of male first admissions in New hospital for treatment. In a progress note written in York State mental hospitals had a diagnosis of pare- 1923, several years before the hospital in which he sis, a figure that did not decline until 1925. Women worked had begun using malaria fever therapy, a were less likely to be admitted with paresis and had California state hospital physician wrote the follow- an admission rate of approximately one third that of ing about his paretic patient: "An extremely vulgar male paretics. In the United States as a whole, about paretic who has led an immoral life. Had been treated 9% of all first admissions during the 1930s had the for syphilis. I think her judgment is better than her diagnosis of general paralysis (Grob, 1983; Va- behavior. This is the place for her" (Patton State lenstein, 1986). Hospital [PSH] case 25806,1923, continuous notes). In 1917, a Viennese neurologist, Julius Wagner After fever therapy was introduced, physicians von Jauregg, discovered that he could halt the pro- often described their patients more sympathetically gression of paresis by injecting patients with blood and even invited them to participate in therapeutic infected with benign tertian malaria. Once infected, decisions. Transcribed over a decade later at the same von Jauregg's patients experienced a series of fevers hospital, the following conversation between a doctor (up to 106° F) and chills, which he then terminated and his patient suggests that the malaria treatment after several weeks with quinine. Providing what ap- had altered the relationships between doctor and pa- peared to be the first successful remedy for paresis, tient (PSH case 29324,1937, clinical conference, p. 5): malaria fever therapy spread rapidly throughout the Patient: Good morning. world, becoming one of the first somatic treatments Doctor: Do you want malaria? for a mental illness widely acknowledged by the sci- Patient: Well yes, I want anything to make me better. entific community. Employing pre-RCT clinical sci- Thank you very much. entific standards, numerous researchers replicated Furthermore, when patients refused the treat- von Jauregg's findings using historical case controls, ment, physicians acquiesced to their patients' wishes. open trials, and clinical observation (Driver, Gam- Finally, unlike the pre-malaria era, patients volunta- mel, & Karnosh, 1926; Barnacle, Ebaugh, & Ewalt, rily admitted themselves specifically for treatment 1936; Rose & Solomon, 1947). Scientists put forth a with malaria fever. Taken together, these elements number of explanations for the efficacy of malaria suggest that therapies influence far more than disease fever therapy. Through animal experiments, some processes. Even the most biological of interventions found that the fever itself destroyed the syphilitic can change the doctor-patient relationship and the spirochetes (Delgado, 1922; Schamberg & Rule, very ways in which physicians' view their patients 1927), while others attempted to demonstrate that (Braslow, 1995). an enhanced immune response was responsible for the treatment's effectiveness (Bennett, 1938b; Del- gado, 1922; Solomon, 1923). In 1927 von Jauregg SHOCK THERAPIES received the Nobel Prize, the first ever awarded for a psychiatric intervention. Even as late as the early Introduced in the 1930s and known collectively 1960s and after the introduction of penicillin, physi- as "shock" therapies, these treatments consisted of cians continued to recommend the use of malaria three distinct, albeit overlapping, remedies: , fever therapy (Walshe, 1963). Metrazol, and electroconvlusive therapy (ECT). In- While by present-day standards we cannot be sulin differed the most from the other two treatments certain of the efficacy of malaria fever therapy, the in that it actually produced a state of physiologic treatment nonetheless dramatically altered the ways shock but no seizures, while Metrazol and electricity in which physicians dealt with their neurosyphilitic produced grand mal seizures or convulsions but no patients. Prior to the introduction of the remedy, physiologic shock. For this reason, the latter two were physicians' views of their neurosyphilitic patients re- also known as the convulsive therapies. While insulin History and Evidence-Based Medicine 235 and Metrazol have long since been consigned to the schizophrenic process" and that convulsions amelio- history of medicinal curiosities, ECT continues to be rated , Ladislas von Meduna in Budapest one of psychiatry's most effective interventions. developed a method to artificially induce convulsions. On November 3,1933, reported In early 1934 and after animal experimentation, he to the Society of Physicians his new therapy created convulsions first with intramuscular injec- for , termed insulin shock treatment tions of camphor, but later switched to Metrazol (Insulinshockbehandlung), in which he gave massive (pentylenetetrazol) (Meduna, 1938). This new treat- doses of insulin to induce a profound state of hypogly- ment gained wide and rapid acceptance, rivaling that cemic shock. Sakel had been using low doses of insu- of insulin. Compared to insulin, an individual Metra- lin in the late 1920s to quiet patients with delirium zol treatment was easier to administer, required less tremens as well as to improve their appetites. How- observation, took much less time, and produced ever, it was not until the early 1930s that he attempted fewer complications. As with insulin, most physicians to induce hypoglycemic comas in psychotic patients used Metrazol on patients diagnosed with schizo- (Sakel, 1937,1938; James, 1992). Sakel and most sub- phrenia. By the late 1930s, however, an increasing sequent practitioners of the therapy believed that number of researchers found that it had a greater these comas had especially beneficial effects on pa- efficacy on patients with depressive disorders than tients with schizophrenia. Nonetheless, practitioners on patients with psychotic disorders (Bennett, 1938a). and researchers never articulated a coherent, gener- Aware of the success of Metrazol convulsive ally accepted theoretical explanation as to why insu- therapy, the Italians and his co-worker lin shock "worked." Lucio Bini began work in 1936 on developing a Subject to a number of modifications, the most method to produce electrically induced convulsions commonly accepted method required daily injections in psychiatric patients. By 1938, they had perfected a of progressively higher doses of insulin until a coma- safe technique on dogs, and shocked their first human tose state was reliably produced. The patient then subject in April 1938 (Alverno, 1990; Endler, 1988; underwent daily injections at this "coma" dose. Harms, 1955; Impastato, 1960; Kalinowsky, 1980). These daily treatments generally lasted several hours Having fewer complications and easier to administer with termination of the coma by administration of a than either metrazol or insulin, ECT spread rapidly sugar solution via a nasogastric tube or an intrave- and eventually replaced both other shock therapies. nous solution. A complete course of insulin According to the previously mentioned 1941 U.S. entailed about 50-60 "coma" days. Not surprisingly, Public Health Service survey, 42% of 356 psychiatric given that patients were often brought to the brink institutions surveyed had electroshock machines just of death just before doctors resuscitated them, the 3 years after the first human electroshock trial. procedure was extremely labor-intensive, requiring The early use of ECT provides an excellent ex- the diligent attention of nurses and doctors to guard ample of how divisions between somatic and psycho- against a patient slipping too close toward an irrevers- logical interventions are often arbitrary. Of particular ible comatose state. Yet despite even the closest sur- interest is that state hospital physicians, though com- veillance, patients died at a rate of 1-2% from compli- monly portrayed as employing ECT as a means of cations such as hypoglycemic encephalopathy, heart patient control, often used the treatment as a means failure, aspiration pneumonia, and cerebral hemor- of enhancing a patient's accessibility toward psycho- rhage (Kinsey, 1941; U.S. Public Health Service, logical interventions. State hospital doctors fre- 1941). quently recommended both and elec- In spite of these difficulties, the treatment spread troshock simultaneously on many of their patients, rapidly. In a 1941 U.S. Public Health Service survey, believing that the two modalities acted synergistically for example, 71% of 305 public and private institu- (Gordon, 1948; Millet & Mosse, 1944; Selinsky, 1943). tions reported that they used In a typical passage, a California state hospital physi- (U.S. Public Health Service, 1941). Its widespread cian wrote in 1952: "Transfer for psychotherapy (EST application, however was short-lived and was quickly [electroshock therapy] also suggested)" (SSH case replaced by the much easier to administer ECT (Ben- 68621, 1952, continuous notes, p. 1). While patients nett, 1966). at times resisted ECT, this was not invariably the ECT had its origins in the work of Ladislas von case, especially when physicians also attended to their Meduna. Believing that "a certain biochemical antag- patients' psychological needs. "I don't know doctor," onism exists between the convulsive state and the a grateful patient told his ward physician in 1950, "I 236 Braslow had the electric shocks and that's the greatest thing believed that the efficacy of lobotomy resided in sev- ever happened in my life. I am telling you, that's the ering the fibers between the thalamus and the frontal greatest thing that ever happened to me" (SSH case lobes. He argued that the thalamus imparted the 63564,1950, clinical conference, p. 1). pathological emotional content to ideas and that a surgeon had to destroy these fibers in order for lobot- omy to succeed (Freeman & Watts, 1947). LOBOTOMY Unlike the shock therapies, the diffusion of lo- botomy into physicians' practices took place slowly. Of all therapeutic interventions introduced prior Though introduced into the United States in 1936 by to the 1950s, lobotomy is perhaps the most infamous, Freeman and James Watts (1937), lobotomy would although interestingly the practice faced its harshest not reach its golden age for at least another decade. criticism long after physicians stopped using it (Press- This comparatively slow diffusion was, in part, due to man, 1998; Valenstein, 1986). Ironically, the rationale its apparent lack of efficacy on patients with chronic for lobotomy rested on relatively stable scientific schizophrenia (Freeman & Watts, 1936). For exam- ground. Its most important justification came from ple, in his original report, Moniz found that the sur- John Fulton's physiology laboratory at Yale. Fulton, gery worked best on those with agitated depressions beginning with his appointment as chairman of the and worst on those with psychosis. However, encour- physiology department in 1929, devoted much of his aged by positive reports of lobotomy on schizophre- scientific energies to understanding frontal lobe func- nia in the early 1940s (Strecker, Palmer, & Grant, tion. In 1935 Fulton and his younger colleague, Car- 1942), state hospital physicians slowly began trials of lisle Jacobson, delivered a paper at the Second Inter- the treatment, although the total number of loboto- national Neurological Congress. Also attending the mies performed remained relatively low. For exam- conference was Egas Moniz, a Portuguese neurolo- ple, between 1940 and 1944, physicians reportedly gist and the inventor of cerebral angiography. Moniz had performed 684 . After the war, how- learned of how they had destroyed the frontal lobes ever, the fortunes of lobotomy turned sharply for the of two chimpanzees, Lucy and Becky, a procedure better. By 1949, for example, spurred on by Free- that resulted in dramatically altered behavior. Moniz man's tireless efforts to expand the surgery to as later used Fulton's and Jacobson's findings as part of many state hospitals as possible, physicians had oper- his justification for proceeding with his brain surger- ated on 5,000 patients in a single year. In that same ies, performing his first lobotomy in 1936. year, Moniz was awarded the Nobel Prize for his Moniz' surgery entailed drilling two holes into work on lobotomy. Fulton's research and personal the top of the scull and then injecting alcohol into effort further reinforced the acceptance of lobotomy the frontal lobe white matter of the brain. Later, (Fulton, 1951,1956; Pressman, 1988,1998). By 1951, Moniz replaced the less predictable alcohol injections a total of nearly 20,000 lobotomies had been per- with a device called a leucotome, a rod-shaped instru- formed in the United States (Kramer, 1954). As ment with a steel loop that crushed the white matter quickly as it rose, the fortunes of the surgery turned (the loop was eventually replaced by a band that cut for the worse. After the introduction of the antipsy- instead of crushed) (Moniz, 1937, 1956). Over the chotic drug in 1954, doctors quickly following two decades, surgeons devised numerous abandoned the surgery in favor of this new drug, and modifications to Moniz's original surgery, although by the 1960s doctors rarely performed the surgery they all had the basic aim of severing frontal white (Barahal, 1958; Robin, 1958). matter fibers. Though it would be easy to dismiss the prac- While few would dispute that lobotomy acted titioners of lobotomy as, at best, misguided, this inter- directly on the brain, the exact mechanism by which pretation is perhaps too simplistic, especially when it worked was never agreed upon. Moniz proposed evaluated in the light of everyday clinical dilemmas that psychiatric pathology was the consequence of faced by physicians of the 1940s and early 1950s. neuronal pathways becoming "fixed" within the Far from suggesting that lobotomists were unusually white matter. He believed that by severing the frontal sadistic or deluded, examination of the everyday ex- fibers these pathological associations became dis- periences of these physicians illustrates the ways in rupted, creating less fixed and more normal patterns which science and local context and needs shape phy- (Black, 1982; Damasio, 1975). Walter Freeman, the sicians' assessment of whether a treatment works. major proponent of lobotomy in the United States, For state hospital physicians working in over- History and Evidence-Based Medicine 237 crowded and understaffed institutions, lobotomy pro- tion of the effectiveness of a treatment is particularly vided a scientifically based means by which to treat well illustrated by how Stockton physicians interpre- their most psychotic and uncontrollable patients. It ted a common, though potentially troubling, outcome is worth emphasizing that though physicians often of lobotomy in which a lobotomized individual be- used lobotomy as a "last resort," after all other thera- came unmotivated, apathetic, and indifferent. The pies had failed, they nonetheless believed in its status following conversation between a doctor and his re- as one of their most scientific of treatments. Writing cently lobotomized patient exemplifies this outcome to a prospective surgical candidate's family, a state (SSH case 54919, clinical case conference, no date): hospital superintendent explained the surgery and its rationale: Doctor: Hello, Joan. Patient: Hello. All forms of medical and psychiatric treatment up Doctor: Why are you wearing your hat? to this time have not been of more than temporary Patient: I don't know. benefit. Unless a more drastic therapy is carried out, Doctor: Joan, did you have an operation? there will be little hope of any improvement . . . Patient: Not that I know of. The treatment suggested is a delicate brain operation Doctor: Do you feel differently now? performed by a qualified neurosurgeon, which in- Patient: No. volves cutting certain nerve pathways controlling the basic emotions. This is known technically as psycho- Whether this neurological sequela was seen as surgery or prefrontal leukotomy. an untoward side effect or evidence of the treatment's As this letter makes clear, while lobotomy was admit- effectiveness depended largely upon context. tedly a "drastic" remedy, physicians did not employ In state hospitals, where controlling behavior it simply out of desperation or a need to do something measured therapeutic success, physicians' were less for their otherwise intractable and most difficult pa- likely to see this well-known outcome as necessarily tients. Doctors who recommended the surgery saw an unwanted consequence of the surgery (Aldrich, it as an unimpeachably scientific procedure. 1950; Cohen, Novick, & Ettleson, 1942; Ewald, Free- In state hospitals, physicians used lobotomy al- man, & Watts, 1947; Freeman & Watts, 1937). Sum- most exclusively as a means of therapeutically con- marizing a recently lobotomized patient's progress trolling extremely psychotic patients. In a typical at a clinical case conference in 1954, the patient's progress note recommending lobotomy, a ward phy- ward physician observed (SSH case 61399,1954, clini- sician wrote (SSH case 70456,1953, continuous notes, cal case conference), "Lobotomy through the eye was done and apparently it has had beneficial effects p. 2): . . . It is quite definite that the operation helped him. She is a senile woman who shows her years, and at His comments almost sound like a testimonial, as the rate she is going she will probably wear herself though he has been coached by somebody to make [out] before long. She is gradually deteriorating these statements about his improvement at the hospi- physically and something should be done about it tal. In any case, he is dull, somewhat apathetic, and now. Lobotomy is recommended in this case, primar- ily as a means of terminating the disturbed behavior, he answers questions in single words." Not only did hoping that it may affect favorably the long term apathy not negate a successful therapeutic outcome, course of the illness before she becomes critically ill. but, at times, was seen as a precondition for the treat- ment's effectiveness. According to one practitioner In this case, as in many others, the lobotomy success- at the same California state hospital, "Maybe that fully eliminated the patient's disturbed behavior. In [apathy] is what cures them" (SSH case 51465,1949, so doing, it reaffirmed her physician's belief in the clinical conference, p. 3). effectiveness of the treatment. Local context, in this While scientific pronouncements (and scientific instance, state hospital overcrowding, defined what evidence) certainly shape physicians' decisions to use physicians counted as the most significant aspects of a particular treatment and to perceive whether it disease, namely unmanageable psychotic behavior. works, they are not the sole determinants, as illus- Not surprisingly, then, interventions that quelled trated by the fate of lobotomy. In the mid 1950s, these symptoms, such as lobotomy, were seen as ef- physicians abruptly abandoned lobotomy in favor of fective. chlorpromazine. The meteoric rise in the popularity The way in which local context, combined with of chlorpromazine (by 1955, over two million pre- scientific evidence, reinforces physicians' determina- scriptions in the United States had been written) and 238 Braslow the equally rapid decline in lobotomy had little to paradigms are perhaps the early stages of the creation do with scientific evidence (Feyhan, 1955; Freeman, of a new mode of making evidence (Wells, 1999; 1958). It was not until the late 1950s that a number National Advisory Council's Clinical of large-scale studies demonstrated the questionable Treatment and Services Research Workgroup, 1998). efficacy of lobotomy and not until the early 1960s This history also raises difficult ethical questions. that large-scale randomized controlled trials showed On the one hand, looking back from our contempo- the efficacy of chlorpromazine ( rary vantage point, one could rightly view such treat- Service Center, 1964; Casey, Lasky, Klett, & Hoi- ments as lobotomy as brutal and inhumane. It is a lister, 1960). At the same time, physicians did not history that reminds us that science and good inten- stop using lobotomy because they decided it was inef- tions in the care of the severely mentally ill can, at fective. Instead, they found chlorpromazine a more times, have disastrous consequences for those whom effective intervention within the state hospital physicians seek to help. On the other hand, we should context. not judge these physicians too harshly. Each interven- tion partook in legitimate contemporary science with, perhaps, the exception of sterilization. Further, acting CONCLUSION to heal their patients, practitioners found these inter- ventions effective within their social and cultural Though nearly all of the psychiatric treatments practice context. As the context of both care and (with the exception of ECT) introduced before the science has changed, the ways in which physicians in 1950s have been abandoned, the aim of this overview everyday clinical practice judge the effectiveness of has not been to chronicle the failures of biological an intervention also has changed. And our moral psychiatry. Whether biologically or psychologically evaluation of how we intervene upon those afflicted oriented, science and therapeutic practices are with severe mental illness has shifted as well, and bounded by time, place, and culture and, as such, are will, no doubt, continue to evolve. subject to reevaluation over time. The concept of the schizophrenogenic mother and the psychoanalytic treatment of patients with psychotic disorders are REFERENCES examples of an era when psychosocial reductionism partook in mainstream psychiatric science and, if Ackerknecht, E. (1979). The history of drug treatment of mental diseases. Transactions and Studies of the College of Physicians taken out of their contexts, could be viewed as exem- of Philadelphia, 1, 161-170. plars of the folly of psychological approaches to psy- Adler, H. M., & Ragle, E. H. (1913). Note on the influence of chiatric illness. Similarly, many of the treatments dis- hydrotherapy on the red blood cell count in the insane. 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