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A History of Somatic Therapies - Spring 2000
Table of Contents
- Introduction
- Hydrotherapy
- Maleria Fever Therapy
- Shock Therapies
- Lobotomy
- Conclusion
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Profile of Joel T. Braslow, M.D., Ph.D.
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Director's Letter
Introduction
Nearly fifty years old, the randomized clinical trial (RCT) has become our "gold standard" for scientifically determining whether a treatment works. It has become so much a part of our clinical science that we tend to imagine that physicians of the past lived in a pre-scientific Dark Age. The fact that psychiatrists have discarded most of the treatments used during the first half of the 20th century has reinforced this idea that pre-RCT therapies were based solely on personal conviction, local context, and the social and cultural values of the physicians employing them. Yet, a closer look at psychiatrists and their treatments of this era reveals that there was much more to their science and clinical practice than we might at first suspect. For example, even though these treatments were pre-RCT, they were based upon legitimate contemporary science (two, in fact, were Nobel Prize winning interventions). Further, physicians and, not infrequently, patients believed these treatments to be effective not only because of the science that "proved" their efficacy but because their clinical, everyday experiences also "proved" to them that the treatments worked.
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HYDROTHERAPY
The first widely acknowledged effective somatic therapy of the twentieth century was hydrotherapy. This treatment consisted of several devices and techniques that made use of water. The two most popular means of administering hydrotherapy were the continuous bath and the wet sheet pack. Following a doctor's order for a "pack" (since it was a "medical" intervention, a doctor's order was always required), an attendant would dip a sheet in water ranging from 40 to 100 degrees Fahrenheit, then snugly wrap it around the patient. Patients remained in this cocoon-like state for several hours. At first, the individual might experience cooling as water evaporated off the dripping, water-soaked cloth but, as his or her body began to generate heat, the pack would warm. Often, an attendant would swaddle the packaged patient in an outer blanket, tying the more resistant patient securely to a bed.
Continuous baths also required a doctor's prescription, but were more elaborate than the pack, necessitating specially designed facilities with large rooms containing numerous tubs. A large control console festooned with dials, knobs, and gauges allowed the attendant to manipulate temperature and water flow as specified by the psychiatrist. Often a daily ritual, a patient would be placed in a tub, fastened to a hammock suspended above the bottom of the tub, and finally covered with a canvas sheet with a hole for his or her head to poke through.
Hydrotherapy was viewed as a scientifically "proven" therapy, acting directly upon the biology of mental illness, for example, by relieving "cerebral congestion" via its influence on the peripheral vascular system or by eliminating "toxic impurities." Research based on precise measurement of blood pressure, pulse, respiratory rate, and differential blood count supported these biological explanations. These findings, in turn, reinforced physicians everyday perceptions in the therapeutic effectiveness of hydrotherapy. For instance, while doctors most commonly used this treatment to calm their disturbed and out-of-control patients, they did not view it as simply another form of physical or chemical restraint, both of which physicians believed to have possessed scant therapeutic value. Reflecting the prevailing consensus, a psychiatrist in 1920 declared that hydrotherapy "is the only scientific treatment for the acute excitement of the insane that has yet been discovered."
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MALARIA FEVER THERAPY
Widely acknowledged as a major scientific and clinical breakthrough, malaria fever therapy was another treatment introduced in the first quarter of the 20th century. In contrast to most psychiatric interventions of this era, fever therapy was given almost exclusively to patients suffering from a late stage of neurosyphilis, called general paralysis of the insane (or, more simply, paresis). Though rare today largely because of the advent of antibiotics, this disease posed one of the greatest clinical challenges for early twentieth-century physicians. The illness produced not only vexing neurologic and psychiatric symptoms, but invariably killed its victims, of which there were many (up to 20 percent of state hospital admissions were so afflicted). Not surprisingly, given how intertwined sex, sin and disease were, physicians viewed their neurosyphilitic patients as, perhaps, pitiful but, nonetheless, sinful transgressors. For example, describing a neurosyphilitic patient a few years before his hospital had malaria fever therapy, a physician wrote:
"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".
In 1917, prominent Viennese neurologist, Julius Wagner von Jauregg, discovered 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 degrees Fahrenheit) and chills, which he terminated with quinine after several weeks. Appearing to be the first successful remedy for paresis, malaria fever therapy spread rapidly throughout the world and became 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. 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 for paresis.
While by present-day standards we cannot be certain of the efficacy of malaria fever therapy, we know that the treatment dramatically improved the relationship between neurosyphilitic patients and their doctors. After fever therapy was introduced, physicians described their patients more sympathetically and even invited them to participate in therapeutic decisions (unheard of before they began using the treatment). When patients refused the treatment, physicians acquiesced to their patients' wishes (also an extremely unusual event before the introduction of the remedy). Finally, unlike in the pre-malaria era, patients voluntarily admitted themselves and often requested treatment with malaria fever. Taken together, these elements illustrate that therapies influence far more than disease processes, shaping not only the doctor-patient relationship but the very ways in which physicians view their patients.
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SHOCK THERAPIES
Introduced in the 1930s and known collectively as "shock" therapies, these treatments were actually three distinct, albeit overlapping, remedies: insulin, Metrazol, and electroconvusive therapy (ECT). While insulin and Metrazol have long since been abandoned, ECT continues to be widely used.
In 1933, Manfred Sakel introduced insulin shock treatment (Insulinshockbehandlung) for psychotic patients. Massive doses of insulin were administered to patients to induce a state of hypoglycemic shock resulting in coma and near-death states before doctors resuscitated them with sugar solutions. Even with close surveillance, patients died at a rate of 1 to 2 percent from complications. Nevertheless, the treatment spread rapidly, reflecting the dire need for remedies for chronic psychotic disorders. Widespread application of insulin shock therapy was short-lived, however, and was quickly replaced by the much easier to administer ECT.
ECT had its origins in the work of Ladislas von Meduna of Budapest. He believed that "a certain biochemical antagonism exists between the convulsive state and the schizophrenic process" and that convulsions could ameliorate psychosis. In early 1934 and after animal experimentation, he artificially induced seizures first with intramuscular injections of camphor and later with Metrazol (pentylenetetrazol). This new treatment gained wide acceptance, quickly 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, but by the late 1930s, researchers discovered that it worked better on patients with depressive disorders.
In 1936, aware of the success of Metrazol convulsive therapy, Italians Ugo Cerletti and Lucio Bini began developing a method to electrically induce convulsions in psychiatric patients. After perfecting a safe technique on dogs, they shocked their first human subject in 1938. Having fewer complications and even easier to administer than either Metrazol or insulin, ECT spread rapidly, replacing both insulin and Metrazol shock therapies. Just three years after the first human trial, over forty percent of U.S. psychiatric hospitals had purchased or built their own electroshock machines.
The popular media and psychiatric critics, particularly in the 1960s and 1970s, often portrayed physicians' use of ECT in lurid ways, etching it into the popular consciousness as a barbaric symbol of psychiatric control. In fact, doctors' early use of ECT illustrates that psychiatric treatment, even in the worst hospital situations, often resists simple generalizations. For example, though physicians did prescribe ECT in order to control patients' behaviors, they just as often employed it to enhance their psychotic patients' autonomy and self-esteem. Furthermore, physicians often saw ECT as a prelude to an equally important remedy, namely psychotherapy. For even in the chaotic and sometimes brutal world of the state hospital, the biological and psychological remained intimately inter-connected and treatment practices reflected this belief. Patients themselves provide us with the best testimony for how far actual practices may have deviated from our popular conceptions of ECT.
"I don't know doctor," a grateful patient told his ward physician in 1950, "I had the electric shocks and that's the greatest thing that ever happened in my life. I am telling you, that's the greatest thing that ever happened to me".
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LOBOTOMY
Lobotomy is the most controversial (and infamous) of the therapeutic interventions introduced before 1950. The rationale for using this procedure on humans had its origins in John Fulton's physiology laboratory at Yale, where it was discovered that destroying the frontal lobes of chimpanzees resulted in dramatically altered behavior. After learning of these results, neurologist Egas Moniz proceeded to develop the surgical technique for lobotomy in humans, performing the first human lobotomy in 1936. Moniz's technique entailed drilling two holes into the top of the scull and injecting alcohol into the frontal lobe white matter of the brain. Later, he replaced the alcohol injections with a device called a leucotome, a rod-shaped instrument with a steel band that severed the white matter fibers. In 1949, Moniz was awarded the Nobel Prize for his efforts; an accolade that serves to remind us of the contemporary scientific legitimacy that the surgery and Moniz enjoyed.
At first, lobotomy appeared to be most effective on patients with agitated depressions and less effective on patients with chronic schizophrenia. This, as well as the strain on available resources and personnel due to World War II, slowed the use of the operation. After the war , aided by new reports of positive results on patients with schizophrenia, the procedure's popularity soared. By 1951, nearly 20,000 lobotomies had been performed in the United States. The surgery's fortune took a dramatic turn for the worse in 1954, the year chlorpromazine was introduced. By the 1960s, the surgery had only a few faithful believers left.
In hindsight, we might view the practitioners of lobotomy as, at best, misguided and, perhaps, even sadistic or deluded. However, when we examine the use of lobotomy in light of their every day experiences a different picture emerges. Working in overcrowded and understaffed state hospitals, physicians viewed lobotomy as one of the few scientifically based treatments for their most psychotic and uncontrollable patients. Indeed, the actual use of lobotomy illustrates how context powerfully shapes what doctors see as a good therapeutic outcome, although in retrospect we might judge the outcome quite differently. For in state hospitals of the 1940s and 1950s, physicians measured the worth of their therapies for particularly psychotic and incorrigible individuals by how well it quelled disordered behavior. It was in this respect that doctors saw lobotomy as an acceptable and, at times, necessary treatment. Let me illustrate with a couple of brief vignettes from a California State hospital. The first is of a 40 year-old woman, who had undergone two previous radical lobotomies but continued to display "extremely perverse behavior." In recommending a third lobotomy, her ward physician wrote:
"A transorbital variety of prefrontal leukotomy has not yet been tried and it is recommended...[T]here is a hope that personnel may be released for more useful work elsewhere if not required to continually supervise and restrain this patient."
Furthermore, physicians determined a successful or unsuccessful outcome by how well a lobotomized patient adapted to the ward routine as this next example illustrates:
"Six months [after lobotomy] she was still...restless, assaultive toward others and herself...,kicking and fighting anyone who came near...antagonistic, she screams and throws anything she can get a hold of...The question is, would a second radical prefrontal be of any help?"
The staff's continued inability to control this woman's violence constituted her physician's primary measure of the treatment's effectiveness. Significantly, the first lobotomy's failure did not shake the doctor's belief in the surgery as a means of behavioral control. Shortly after this note was written, the patient underwent a second lobotomy, underscoring the central importance that context played in determining when and how to care and treat a patient.
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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 periodically subject to reevaluation. These physicians were not unusually naïve nor unsympathetic towards their patients, but were, instead, caught within a particular historical, scientific, and clinical milieu that differs dramatically from our own.
What does this teach us about our present-day clinical science and practice? First, this history should encourage a sense of humility despite our scientific and therapeutic advances. Every generation believes in their scientific evidence. This history illustrates that clinical science evolves in ways that are not always predictable as witnessed by the awarding of two Nobel Prizes for interventions that later proved to have had little or no therapeutic value. Second, this history should encourage us to ask critical questions about contemporary science and therapies, since, if history is any guide, these too will be subject to revision. Asking historically informed questions of how we understand and care for chronic mental illness provides us with the opportunity to learn from , rahter than repeat, many of the errors of our predecessors.
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