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 lobotomy. 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 psychiatry; somatic therapies; biological psychiatry. 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 psychiatrists, 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 231 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 psychiatrist, 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