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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 interventions 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
and the doctors who used them as mired in a prescientific age, where personal conviction, local context, and social and cultural values played as large a
role as science in the care and treatment of patients.
The recent proliferation of practice guidelines based
upon evidence from RCTs has reinforced the apparent contrast between our therapeutic age and that of
the first half of the century (American Psychiatric
Association [APA], 1997; APA Steering Committee,
1996; Lehman & Steinwachs, 1998; Veterans Health
Administration, 1997). However, despite our methodological and therapeutic advances, the past has
much to teach us, particularly about how a given era's
scientific treatments can be transformed into what
physicians' believe to be effective medical practice,
even though we may later learn that a particular
remedy that once "worked" in fact possessed little
or no therapeutic value.
Focusing on the period from the 1900s to the
1950s, the aim of this essay will be to sketch briefly
the science and actual use of treatments used before
the introduction of the RCT. I examine somatic and
Over the last couple of decades, researchers, clinicians, and policy-makers have urged clinicians to
base their practices upon scientific evidence, the most
robust of this evidence being the randomized controlled trial (RCT). Introduced into clinical medical
science in the late the 1940s (Medical Research Council, 1948), psychiatric researchers first began employing the RCT in the 1950s (Elkes & Elkes, 1954;
Elkes & Healy, 1998; Rees, 1956). The RCT quickly
gained status as the "gold standard" of therapeutic
efficacy. For psychiatrists, the RCT dramatically altered their therapeutic landscape (Healy, 1997). With
the exception of electroconvulsive therapy, nearly all
psychiatric treatments used in the first half of the
century have been discarded. Though not the primary
reason why physicians abandoned these therapies,
the evidence supporting these therapies no longer
1
UCLA Departments of Psychiatry and History, and VISN 22
Mental Illness Research, Education and Clinical Center of the
Department of Veterans Affairs, Los Angeles, California.
231
1522-3434/99/0400-0231$16.00/0 © 1999 Plenum Publishing Corporation
232
biological remedies for the severely mentally ill and
show how the science and practice of each intervention reinforced each other. The treatments that follow largely have been abandoned and a few, such as
lobotomy, have been thoroughly discredited. Yet my
purpose is not to point to the misguided efforts of
biological psychiatry. One could certainly write a history of similarly benighted efforts at psychological
healing. Further, to see this history as a series of
failed attempts at treating severe mental illness would
be missing the point. Instead, this history illustrates
that accepted science and therapeutics are dependent
upon time and place. Indeed, this review of past biological therapies is important precisely because biological therapies have proven to be so effective that
we often forget the evolving nature of science and
the practice that flows from that science.
HYDROTHERAPY
The first widely acknowledged effective somatic
therapy of the twentieth century was hydrotherapy.
Introduced into state hospitals throughout the United
States in the late nineteenth and early twentieth centuries, this therapy consisted of a number of devices
and techniques that employed water. The two most
frequently used forms of hydrotherapy were the continuous bath and the wet sheet pack (Baruch, 1920;
Finnerty & Corbitt, 1960; Wright, 1940). The "pack"
required little in the way of sophisticated equipment.
A sheet was dipped in water ranging from about 40
to 100°F and then the patient was snugly wrapped
within this wet sheet. Very agitated patients were
given colder sheets and more frail patients were
placed in warmer sheets. Patients generally remained
bundled for several hours at a time. Attendants often
wrapped a blanket around the patient and the sheet.
Finally, if the patient resisted the wet pack, the attendant placed a third sheet over the patient, securely
tying him or her to the bed. Patients went through
several stages while in the pack; first they were
cooled, but over time the pack eventually heated.
At times, physicians ordered a rubber sheet to be
wrapped around the wet sheet to enhance the heating effects.
Continuous baths required more elaborate devices than did wet packs. The baths most often consisted of a tub with an inlet for hot water and an outlet
to drain the water. Attendants placed the patient
in the hammock to which he or she was fastened.
Attendants then covered the tub and patient with a
Braslow
canvas sheet that had a hole for the patient's head
to go through. A series of valves and temperature
gauges allowed the attendant to regulate both temperature and water flow. A single treatment could
last anywhere from hours to days.
These treatments provided early twentieth-century physicians with what they believed to be a genuinely therapeutic and biological approach to the treatment of severely mentally ill patients. In particular,
they found these interventions especially effective
means by which to therapeutically control psychotic
patients. While late nineteenth-century asylum doctors had a variety of drugs by which to sedate and
calm severely agitated patients (Ackerknecht, 1979),
they rarely considered these medications as having
true therapeutic value (Chapin, 1891-1892; Drapes,
1889; Mabon, 1888-1889; Macleod, 1900). Emphasizing the nontherapeutic nature of pharmacological
treatments, such as bromides, chloral hydrate, hyoscine, paraldehyde, sulfonal, and narcotics, the wellknown British psychiatrist, Henry Maudsley (1895,
pp. 554-555) wrote:
Mechanical restraint, except under surgical necessities, was formerly abandoned, not because its use
was sure to become abuse, but because it was deemed
better for the patient to let him have the relief and
self-respect of pretty free exercise than to keep him
tied up like a mad dog . . . but it may be doubted
whether its coarse bond did as much harm as has
been done by the finer means of chemical restraint
which have been used to paralyse the brain and
render the patient quiet.
In contrast to drugs, physicians found hydrotherapy
to be a genuinely scientific means by which to act
upon their psychiatric patients' biology in order to
effect mental cures. Indeed, researchers had discovered a variety of biological mechanisms through
which hydrotherapy "worked." Some, for example,
asserted that the remedy relieved "cerebral congestion" through its influence on the peripheral vascular
system (Kellogg, 1887). Others argued that hydrotherapy helped eliminate "toxic impurities" that
might cause insanity (Foster, 1899; Jagielski, 1896;
Shepard, 1900). "It is extremely likely," a physician
wrote in explaining the physiology of hydrotherapy,
"that the excretory function of the skin and kidneys
is stimulated" (Strecker, 1917, p. 1797). A body of
research based on precise measurement of parameters such as blood pressure, pulse, respiratory rate,
and differential blood count lent further support to
the science of hydrotherapy (Adler & Ragle, 1913;
Niles, 1899; Peck, 1909).
History and Evidence-Based Medicine
Practitioners readily employed these physiological explanations in their everyday treatment of patients. Testifying in 1920 on behalf of a California
state hospital accused of misusing hydrotherapy, a
psychiatrist at the University of California Hospital
in San Francisco declared that hydrotherapy "is the
only scientific treatment for the acute excitement of
the insane that has yet been discovered." Echoing
the published literature, she went on to describe its
physiologic effects: "Packs act by increasing the elimination by the skin, helping to rid the system of toxins
and poisonous matter in the constitution." Furthermore, hydrotherapy brings "blood to the surface and
relieve[s] the congestion in the brain and spinal cord,
which in most cases seems to cause the excitement"
(In the Matter of the Investigation of Agnews State
Hospital, 1919, p. 531). While the scientific luster of
hydrotherapy faded over the following three or four
decades, psychiatrists commonly prescribed it until
they gradually replaced it in the 1940s and 1950s
first with electroconvulsive therapy and later with
antipsychotic drugs.
233
by severing the vas deferens, the interstitial cells of
the testicles would undergo hyperplasia. This in turn
would lead to the increased production of beneficial
hormones that "rejuvenated" the individual's mind
and body (Benjamin, 1925; Money, 1983; Wolbarst,
1922). Psychiatrists logically adduced that vasectomy
might also benefit psychiatric patients, given that a
variety of reports demonstrated testicular abnormalities in the insane (Editorial, 1915; Epitome, 1915;
Gibbs, 1923a, b, 1924; Mott, 1922; Tiffany, 1921). As
with their use of hydrotherapy, practitioners used this
scientific evidence to support their clinical practice as
illustrated by the following conversation between a
state hospital physician and his patient transcribed
in 1928 (Stockton State Hospital [SSH] 32735, 1928,
clinical conference, p. 1):
Patient: I have these spells, I get a little melancholy,
and then things don't break quite right and I get
quite nervous.
Doctor: Have you ever been sterilized?
Patient: No.
Doctor: You had better let us operate on you while
you are here?
Patient: That will certainly be all right with me and
with my wife also.
Doctor: We will do that then.
Patient: Doctor, will that bring better composure to
the nervous system?
Doctor: It is supposed to, it has in a number of cases,
we do not guarantee it, but in a number of cases
it has had marked beneficial effects. It cannot hurt
you and does not interfere with your sexual life
in any way, we just cut a little duct and you absorb
your own secretions.
Patient: It has always been all right with me, and
my wife did not want to take the responsibility of
signing it. I have spoken to my wife about it and
have told her I wanted it to get through this time.
Doctor: Well, it cannot hurt you and it might have
a marked beneficial result.
Patient: I will be very much obliged to you, sir.2
STERILIZATION
Sterilization was another major intervention introduced in the early years of the twentieth century
(Dowbiggin, 1997; Reilly, 1991). First introduced in
only a few states by 1910, by 1950, 26,000 American
psychiatric patients had been sterilized, 11,000 of
them in California (Robitscher, 1973). Though rightfully portrayed as a dark chapter in American psychiatry, physicians use of this surgery also illustrates the
close relationship between a therapeutic practice and
its supporting scientific evidence. Granted, most sterilization laws were passed in the first 25 years of this
century largely at the urging of a small but influential
group of eugenicists. In California, for example, physicians could sterilize patients "afflicted with hereditary insanity or incurable chronic mania or dementia"
(Laughlin, 1922). Yet physicians did not necessarily
sterilize patients for eugenic reasons; some, in fact,
opposed eugenics even though they readily employed
the surgery. The reason for this apparent contradiction was that physicians thought that the operation
had therapeutic value in itself, especially for their
male patients. For men, vasectomy was supposed to
diminish anxiety and depression and increase vitality.
Like hydrotherapy, physicians based their therapeutic use of sterilization upon contemporary science.
A body of evidence supported the belief that,
MALARIA FEVER THERAPY
In the first quarter of this century, general paralysis of the insane, a tertiary form of syphilis, posed
2
In order to protect patient privacy, all hospital numbers and identifying characteristics have been changed. I have retained the original spelling and punctuation in all of my quotations from the
medical record. Records from Patton State Hospital are still retained by the hospital, which is located in Patton, California.
Records from Stockton State Hospital were at the Stockton Developmental Center until its closing in February 1996. With appropriate permission from the California Department of Mental
Health, one can obtain the actual patient record numbers from
the author.
234
one of the greatest challenges for psychiatrists. Not
only was the illness nearly invariably fatal, it also had
a high prevalence. In Europe, for example, some
institutions reported that up to 45% of their male
patients suffered from this disease (Diefendorf,
1906). In America, physicians reported lower, although substantial, rates of paresis. In the 1910s, approximately 20% of male first admissions in New
York State mental hospitals had a diagnosis of paresis, a figure that did not decline until 1925. Women
were less likely to be admitted with paresis and had
an admission rate of approximately one third that of
male paretics. In the United States as a whole, about
9% of all first admissions during the 1930s had the
diagnosis of general paralysis (Grob, 1983; Valenstein, 1986).
In 1917, a Viennese neurologist, Julius Wagner
von Jauregg, discovered that he could halt the progression of paresis by injecting patients with blood
infected with benign tertian malaria. Once infected,
von Jauregg's patients experienced a series of fevers
(up to 106° F) and chills, which he then terminated
after several weeks with quinine. Providing what appeared to be the first successful remedy for paresis,
malaria fever therapy spread rapidly throughout the
world, becoming one of the first somatic treatments
for a mental illness widely acknowledged by the scientific community. Employing pre-RCT clinical scientific standards, numerous researchers replicated
von Jauregg's findings using historical case controls,
open trials, and clinical observation (Driver, Gammel, & Karnosh, 1926; Barnacle, Ebaugh, & Ewalt,
1936; Rose & Solomon, 1947). Scientists put forth a
number of explanations for the efficacy of malaria
fever therapy. Through animal experiments, some
found that the fever itself destroyed the syphilitic
spirochetes (Delgado, 1922; Schamberg & Rule,
1927), while others attempted to demonstrate that
an enhanced immune response was responsible for
the treatment's effectiveness (Bennett, 1938b; Delgado, 1922; Solomon, 1923). In 1927 von Jauregg
received the Nobel Prize, the first ever awarded for
a psychiatric intervention. Even as late as the early
1960s and after the introduction of penicillin, physicians continued to recommend the use of malaria
fever therapy (Walshe, 1963).
While by present-day standards we cannot be
certain of the efficacy of malaria fever therapy, the
treatment nonetheless dramatically altered the ways
in which physicians dealt with their neurosyphilitic
patients. Prior to the introduction of the remedy,
physicians' views of their neurosyphilitic patients re-
Braslow
flected prevailing cultural values in which individuals
afflicted with syphilis were seen as immoral transgressors, perhaps even deserving of their often hopeless
condition. Physicians rarely gave these patients any
choice in their therapeutic regimen and, not unexpectedly, individuals afflicted with neurosyphilis were
loath to admit themselves voluntarily into a state
hospital for treatment. In a progress note written in
1923, several years before the hospital in which he
worked had begun using malaria fever therapy, a
California state hospital physician wrote the following about his paretic patient: "An extremely vulgar
paretic who has led an immoral life. Had been treated
for syphilis. I think her judgment is better than her
behavior. This is the place for her" (Patton State
Hospital [PSH] case 25806,1923, continuous notes).
After fever therapy was introduced, physicians
often described their patients more sympathetically
and even invited them to participate in therapeutic
decisions. Transcribed over a decade later at the same
hospital, the following conversation between a doctor
and his patient suggests that the malaria treatment
had altered the relationships between doctor and patient (PSH case 29324,1937, clinical conference, p. 5):
Patient: Good morning.
Doctor: Do you want malaria?
Patient: Well yes, I want anything to make me better.
Thank you very much.
Furthermore, when patients refused the treatment, physicians acquiesced to their patients' wishes.
Finally, unlike the pre-malaria era, patients voluntarily admitted themselves specifically for treatment
with malaria fever. Taken together, these elements
suggest that therapies influence far more than disease
processes. Even the most biological of interventions
can change the doctor-patient relationship and the
very ways in which physicians' view their patients
(Braslow, 1995).
SHOCK THERAPIES
Introduced in the 1930s and known collectively
as "shock" therapies, these treatments consisted of
three distinct, albeit overlapping, remedies: insulin,
Metrazol, and electroconvlusive therapy (ECT). Insulin differed the most from the other two treatments
in that it actually produced a state of physiologic
shock but no seizures, while Metrazol and electricity
produced grand mal seizures or convulsions but no
physiologic shock. For this reason, the latter two were
also known as the convulsive therapies. While insulin
History and Evidence-Based Medicine
and Metrazol have long since been consigned to the
history of medicinal curiosities, ECT continues to be
one of psychiatry's most effective interventions.
On November 3,1933, Manfred Sakel reported
to the Vienna Society of Physicians his new therapy
for schizophrenia, termed insulin shock treatment
(Insulinshockbehandlung), in which he gave massive
doses of insulin to induce a profound state of hypoglycemic shock. Sakel had been using low doses of insulin in the late 1920s to quiet patients with delirium
tremens as well as to improve their appetites. However, it was not until the early 1930s that he attempted
to induce hypoglycemic comas in psychotic patients
(Sakel, 1937,1938; James, 1992). Sakel and most subsequent practitioners of the therapy believed that
these comas had especially beneficial effects on patients with schizophrenia. Nonetheless, practitioners
and researchers never articulated a coherent, generally accepted theoretical explanation as to why insulin shock "worked."
Subject to a number of modifications, the most
commonly accepted method required daily injections
of progressively higher doses of insulin until a comatose state was reliably produced. The patient then
underwent daily injections at this "coma" dose.
These daily treatments generally lasted several hours
with termination of the coma by administration of a
sugar solution via a nasogastric tube or an intravenous glucose solution. A complete course of insulin
entailed about 50-60 "coma" days. Not surprisingly,
given that patients were often brought to the brink
of death just before doctors resuscitated them, the
procedure was extremely labor-intensive, requiring
the diligent attention of nurses and doctors to guard
against a patient slipping too close toward an irreversible comatose state. Yet despite even the closest surveillance, patients died at a rate of 1-2% from complications such as hypoglycemic encephalopathy, heart
failure, aspiration pneumonia, and cerebral hemorrhage (Kinsey, 1941; U.S. Public Health Service,
1941).
In spite of these difficulties, the treatment spread
rapidly. In a 1941 U.S. Public Health Service survey,
for example, 71% of 305 public and private institutions reported that they used insulin shock therapy
(U.S. Public Health Service, 1941). Its widespread
application, however was short-lived and was quickly
replaced by the much easier to administer ECT (Bennett, 1966).
ECT had its origins in the work of Ladislas von
Meduna. Believing that "a certain biochemical antagonism exists between the convulsive state and the
235
schizophrenic process" and that convulsions ameliorated psychosis, Ladislas von Meduna in Budapest
developed a method to artificially induce convulsions.
In early 1934 and after animal experimentation, he
created convulsions first with intramuscular injections of camphor, but later switched to Metrazol
(pentylenetetrazol) (Meduna, 1938). This new treatment gained wide and rapid acceptance, rivaling that
of insulin. Compared to insulin, an individual Metrazol treatment was easier to administer, required less
observation, took much less time, and produced
fewer complications. As with insulin, most physicians
used Metrazol on patients diagnosed with schizophrenia. By the late 1930s, however, an increasing
number of researchers found that it had a greater
efficacy on patients with depressive disorders than
on patients with psychotic disorders (Bennett, 1938a).
Aware of the success of Metrazol convulsive
therapy, the Italians Ugo Cerletti and his co-worker
Lucio Bini began work in 1936 on developing a
method to produce electrically induced convulsions
in psychiatric patients. By 1938, they had perfected a
safe technique on dogs, and shocked their first human
subject in April 1938 (Alverno, 1990; Endler, 1988;
Harms, 1955; Impastato, 1960; Kalinowsky, 1980).
Having fewer complications and easier to administer
than either metrazol or insulin, ECT spread rapidly
and eventually replaced both other shock therapies.
According to the previously mentioned 1941 U.S.
Public Health Service survey, 42% of 356 psychiatric
institutions surveyed had electroshock machines just
3 years after the first human electroshock trial.
The early use of ECT provides an excellent example of how divisions between somatic and psychological interventions are often arbitrary. Of particular
interest is that state hospital physicians, though commonly portrayed as employing ECT as a means of
patient control, often used the treatment as a means
of enhancing a patient's accessibility toward psychological interventions. State hospital doctors frequently recommended both psychotherapy and electroshock simultaneously on many of their patients,
believing that the two modalities acted synergistically
(Gordon, 1948; Millet & Mosse, 1944; Selinsky, 1943).
In a typical passage, a California state hospital physician wrote in 1952: "Transfer for psychotherapy (EST
[electroshock therapy] also suggested)" (SSH case
68621, 1952, continuous notes, p. 1). While patients
at times resisted ECT, this was not invariably the
case, especially when physicians also attended to their
patients' psychological needs. "I don't know doctor,"
a grateful patient told his ward physician in 1950, "I
236
had the electric shocks and that's the greatest thing
ever happened in my life. I am telling you, that's the
greatest thing that ever happened to me" (SSH case
63564,1950, clinical conference, p. 1).
LOBOTOMY
Of all therapeutic interventions introduced prior
to the 1950s, lobotomy is perhaps the most infamous,
although interestingly the practice faced its harshest
criticism long after physicians stopped using it (Pressman, 1998; Valenstein, 1986). Ironically, the rationale
for lobotomy rested on relatively stable scientific
ground. Its most important justification came from
John Fulton's physiology laboratory at Yale. Fulton,
beginning with his appointment as chairman of the
physiology department in 1929, devoted much of his
scientific energies to understanding frontal lobe function. In 1935 Fulton and his younger colleague, Carlisle Jacobson, delivered a paper at the Second International Neurological Congress. Also attending the
conference was Egas Moniz, a Portuguese neurologist and the inventor of cerebral angiography. Moniz
learned of how they had destroyed the frontal lobes
of two chimpanzees, Lucy and Becky, a procedure
that resulted in dramatically altered behavior. Moniz
later used Fulton's and Jacobson's findings as part of
his justification for proceeding with his brain surgeries, performing his first lobotomy in 1936.
Moniz' surgery entailed drilling two holes into
the top of the scull and then injecting alcohol into
the frontal lobe white matter of the brain. Later,
Moniz replaced the less predictable alcohol injections
with a device called a leucotome, a rod-shaped instrument with a steel loop that crushed the white matter
(the loop was eventually replaced by a band that cut
instead of crushed) (Moniz, 1937, 1956). Over the
following two decades, surgeons devised numerous
modifications to Moniz's original surgery, although
they all had the basic aim of severing frontal white
matter fibers.
While few would dispute that lobotomy acted
directly on the brain, the exact mechanism by which
it worked was never agreed upon. Moniz proposed
that psychiatric pathology was the consequence of
neuronal pathways becoming "fixed" within the
white matter. He believed that by severing the frontal
fibers these pathological associations became disrupted, creating less fixed and more normal patterns
(Black, 1982; Damasio, 1975). Walter Freeman, the
major proponent of lobotomy in the United States,
Braslow
believed that the efficacy of lobotomy resided in severing the fibers between the thalamus and the frontal
lobes. He argued that the thalamus imparted the
pathological emotional content to ideas and that a
surgeon had to destroy these fibers in order for lobotomy to succeed (Freeman & Watts, 1947).
Unlike the shock therapies, the diffusion of lobotomy into physicians' practices took place slowly.
Though introduced into the United States in 1936 by
Freeman and James Watts (1937), lobotomy would
not reach its golden age for at least another decade.
This comparatively slow diffusion was, in part, due to
its apparent lack of efficacy on patients with chronic
schizophrenia (Freeman & Watts, 1936). For example, in his original report, Moniz found that the surgery worked best on those with agitated depressions
and worst on those with psychosis. However, encouraged by positive reports of lobotomy on schizophrenia in the early 1940s (Strecker, Palmer, & Grant,
1942), state hospital physicians slowly began trials of
the treatment, although the total number of lobotomies performed remained relatively low. For example, between 1940 and 1944, physicians reportedly
had performed 684 lobotomies. After the war, however, the fortunes of lobotomy turned sharply for the
better. By 1949, for example, spurred on by Freeman's tireless efforts to expand the surgery to as
many state hospitals as possible, physicians had operated on 5,000 patients in a single year. In that same
year, Moniz was awarded the Nobel Prize for his
work on lobotomy. Fulton's research and personal
effort further reinforced the acceptance of lobotomy
(Fulton, 1951,1956; Pressman, 1988,1998). By 1951,
a total of nearly 20,000 lobotomies had been performed in the United States (Kramer, 1954). As
quickly as it rose, the fortunes of the surgery turned
for the worse. After the introduction of the antipsychotic drug chlorpromazine in 1954, doctors quickly
abandoned the surgery in favor of this new drug, and
by the 1960s doctors rarely performed the surgery
(Barahal, 1958; Robin, 1958).
Though it would be easy to dismiss the practitioners of lobotomy as, at best, misguided, this interpretation is perhaps too simplistic, especially when
evaluated in the light of everyday clinical dilemmas
faced by physicians of the 1940s and early 1950s.
Far from suggesting that lobotomists were unusually
sadistic or deluded, examination of the everyday experiences of these physicians illustrates the ways in
which science and local context and needs shape physicians' assessment of whether a treatment works.
For state hospital physicians working in over-
237
History and Evidence-Based Medicine
crowded and understaffed institutions, lobotomy provided a scientifically based means by which to treat
their most psychotic and uncontrollable patients. It
is worth emphasizing that though physicians often
used lobotomy as a "last resort," after all other therapies had failed, they nonetheless believed in its status
as one of their most scientific of treatments. Writing
to a prospective surgical candidate's family, a state
hospital superintendent explained the surgery and
its rationale:
All forms of medical and psychiatric treatment up
to this time have not been of more than temporary
benefit. Unless a more drastic therapy is carried out,
there will be little hope of any improvement . . .
The treatment suggested is a delicate brain operation
performed by a qualified neurosurgeon, which involves cutting certain nerve pathways controlling the
basic emotions. This is known technically as psychosurgery or prefrontal leukotomy.
As this letter makes clear, while lobotomy was admittedly a "drastic" remedy, physicians did not employ
it simply out of desperation or a need to do something
for their otherwise intractable and most difficult patients. Doctors who recommended the surgery saw
it as an unimpeachably scientific procedure.
In state hospitals, physicians used lobotomy almost exclusively as a means of therapeutically controlling extremely psychotic patients. In a typical
progress note recommending lobotomy, a ward physician wrote (SSH case 70456,1953, continuous notes,
p. 2):
She is a senile woman who shows her years, and at
the rate she is going she will probably wear herself
[out] before long. She is gradually deteriorating
physically and something should be done about it
now. Lobotomy is recommended in this case, primarily as a means of terminating the disturbed behavior,
hoping that it may affect favorably the long term
course of the illness before she becomes critically ill.
In this case, as in many others, the lobotomy successfully eliminated the patient's disturbed behavior. In
so doing, it reaffirmed her physician's belief in the
effectiveness of the treatment. Local context, in this
instance, state hospital overcrowding, defined what
physicians counted as the most significant aspects of
disease, namely unmanageable psychotic behavior.
Not surprisingly, then, interventions that quelled
these symptoms, such as lobotomy, were seen as effective.
The way in which local context, combined with
scientific evidence, reinforces physicians' determina-
tion of the effectiveness of a treatment is particularly
well illustrated by how Stockton physicians interpreted a common, though potentially troubling, outcome
of lobotomy in which a lobotomized individual became unmotivated, apathetic, and indifferent. The
following conversation between a doctor and his recently lobotomized patient exemplifies this outcome
(SSH case 54919, clinical case conference, no date):
Doctor: Hello, Joan.
Patient: Hello.
Doctor: Why are you wearing your hat?
Patient: I don't know.
Doctor: Joan, did you have an operation?
Patient: Not that I know of.
Doctor: Do you feel differently now?
Patient: No.
Whether this neurological sequela was seen as
an untoward side effect or evidence of the treatment's
effectiveness depended largely upon context.
In state hospitals, where controlling behavior
measured therapeutic success, physicians' were less
likely to see this well-known outcome as necessarily
an unwanted consequence of the surgery (Aldrich,
1950; Cohen, Novick, & Ettleson, 1942; Ewald, Freeman, & Watts, 1947; Freeman & Watts, 1937). Summarizing a recently lobotomized patient's progress
at a clinical case conference in 1954, the patient's
ward physician observed (SSH case 61399,1954, clinical case conference), "Lobotomy through the eye
was done and apparently it has had beneficial effects
. . . It is quite definite that the operation helped him.
His comments almost sound like a testimonial, as
though he has been coached by somebody to make
these statements about his improvement at the hospital. In any case, he is dull, somewhat apathetic, and
he answers questions in single words." Not only did
apathy not negate a successful therapeutic outcome,
but, at times, was seen as a precondition for the treatment's effectiveness. According to one practitioner
at the same California state hospital, "Maybe that
[apathy] is what cures them" (SSH case 51465,1949,
clinical conference, p. 3).
While scientific pronouncements (and scientific
evidence) certainly shape physicians' decisions to use
a particular treatment and to perceive whether it
works, they are not the sole determinants, as illustrated by the fate of lobotomy. In the mid 1950s,
physicians abruptly abandoned lobotomy in favor of
chlorpromazine. The meteoric rise in the popularity
of chlorpromazine (by 1955, over two million prescriptions in the United States had been written) and
Braslow
238
the equally rapid decline in lobotomy had little to
do with scientific evidence (Feyhan, 1955; Freeman,
1958). It was not until the late 1950s that a number
of large-scale studies demonstrated the questionable
efficacy of lobotomy and not until the early 1960s
that large-scale randomized controlled trials showed
the efficacy of chlorpromazine (Psychopharmacology
Service Center, 1964; Casey, Lasky, Klett, & Hoilister, 1960). At the same time, physicians did not
stop using lobotomy because they decided it was ineffective. Instead, they found chlorpromazine a more
effective intervention within the state hospital
context.
CONCLUSION
Though nearly all of the psychiatric treatments
(with the exception of ECT) introduced before the
1950s have been abandoned, the aim of this overview
has not been to chronicle the failures of biological
psychiatry. Whether biologically or psychologically
oriented, science and therapeutic practices are
bounded by time, place, and culture and, as such, are
subject to reevaluation over time. The concept of the
schizophrenogenic mother and the psychoanalytic
treatment of patients with psychotic disorders are
examples of an era when psychosocial reductionism
partook in mainstream psychiatric science and, if
taken out of their contexts, could be viewed as exemplars of the folly of psychological approaches to psychiatric illness. Similarly, many of the treatments discussed in this essay could be interpreted as biological
reductionism run amok. However, instead of a story
about the excesses of biological psychiatry, this history shows how dependent a successful, scientifically
based therapy can be upon time and place.
What does this teach us about our present-day
efforts at evidence-based medicine? First, this history
should encourage a sense of humility despite our
scientific and therapeutic advances. Every generation
believes in what they deem as "evidence" and, as
this history illustrates, what counts as evidence is
not fixed, but evolves over time. Second, this history
should encourage us to ask critical questions about
our contemporary methods of producing evidence
and treating patients, since, if history is any guide,
these methods will no doubt be subject to revision.
While no one would seriously consider abandoning
the RCT, researchers have begun to question its generalizability and utility for informing policy decisions.
Recent efforts to combine efficacy and effectiveness
paradigms are perhaps the early stages of the creation
of a new mode of making evidence (Wells, 1999;
National Advisory Mental Health Council's Clinical
Treatment and Services Research Workgroup, 1998).
This history also raises difficult ethical questions.
On the one hand, looking back from our contemporary vantage point, one could rightly view such treatments as lobotomy as brutal and inhumane. It is a
history that reminds us that science and good intentions in the care of the severely mentally ill can, at
times, have disastrous consequences for those whom
physicians seek to help. On the other hand, we should
not judge these physicians too harshly. Each intervention partook in legitimate contemporary science with,
perhaps, the exception of sterilization. Further, acting
to heal their patients, practitioners found these interventions effective within their social and cultural
practice context. As the context of both care and
science has changed, the ways in which physicians in
everyday clinical practice judge the effectiveness of
an intervention also has changed. And our moral
evaluation of how we intervene upon those afflicted
with severe mental illness has shifted as well, and
will, no doubt, continue to evolve.
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