Though treatment methods at The Retreat did indeed go on to have a positive and lasting influence on asylum practice the world over, for reasons not entirely clear, by the mid-to-late 19th century “moral treatment” as a systematic approach had begun to fade into obscurity.
One likely possibility is that advances in medicine, and in particular the development of biological psychiatry, compelled the field to once again begin searching for the biological origins of mental illness and thus medicines and surgical procedures designed to address them.
As a result of this change in direction the late 19th and the first half of the 20th century are littered with “treatments” barbaric enough to make the likes of blistering and rotational therapy appear almost tame by comparison.
Beginning in 1888, the Swiss psychiatrist, Gottlieb Burckhardt, believing that mental illness was caused by brain lesions, attempted, despite little surgical experience, to ameliorate the symptoms of six of his patients by cutting out sections of their cerebral cortex. Complications as a result of the procedure included epilepsy, muscle weakness, sensory aphasia, one death and one suicide.
In 1912 the Estonian neurosurgeon, Ludvig Puusepp, criticized Burckhardt’s attempt as “groundless” and “dangerous”, adding that he was “unable to explain how their author, holder of a degree in medicine, could bring himself to carry them out.”. Two years earlier this same Ludvig Puusepp had himself performed experimental brain surgery on three of his own “manic-depressive” patients.
In the 1910’s, American psychiatrist Henry Cotton began performing surgical procedures based on the idea that untreated bodily infection was the cause of mental illness. Cotton would begin by pulling the teeth of his patients. If symptoms persisted the tonsils were removed. When this didn’t work he would shift his attention to anything from the stomach, gallbladder, spleen, intestines, and even the reproductive organs.
Cotton claimed success rates of 85%, and with it worldwide fame and medical accolades. Later investigations would reveal that in actual fact his procedures resulted in death rates of about 45% due to postoperative infection.
In 1933 the Austrian-American psychiatrist Manfred Sakel introduced the world to Insulin Shock Therapy. During this procedure patients with “schizophrenia” were injected with high doses of insulin in order to induce seizures and a coma which were thought to jolt patients out of their mental illness.
A typical treatment course involved daily injections 6 days a week for 2 months, with each coma lasting around 1-4 hours. Sakel claimed success rates of more than 80%. In all likelihood any successes attributed to this treatment were most likely the result of selection bias, administering treatment to patients with a good prognosis who would have likely experienced some level of improvement regardless.
Common complications included prolonged comas, brain damage and a mortality rate of between 1% and 10%. Despite this, by 1941, 72% of all asylums in the U.S. were using insulin shock therapy. The practice didn’t fall out of use until the late 1950’s.
In 1934, Hungarian psychiatrist Ladislas von Meduna began experimenting with seizure therapy by injecting camphor, and later Metrazol, into patients diagnosed with “schizophrenia”. The seizures were so severe that patients commonly suffered bone fractures and muscle tears as a result. An X-ray study at the New York State Psychiatric Institute in 1939 discovered that 43% of Metrazol seizure therapy patients had fractured their vertebrae as a result.
The principles on which both insulin and Metrazol shock therapies were based would lead to the development of Electroconvulsive therapy, a practice which is still in use today despite a meager 25% long-term success rate.
Julius Wagner-Jauregg, the first psychiatrist to win the Nobel Prize (1927) for his discovery that patients with paralytic dementia could be cured by infecting them with malaria-infected blood (this actually did work!), also believed that excessive masturbation was the cause of “schizophrenia” in some of his patients, and so castrated them.
Finally, at the 1935 International Neurological Congress in London, Yale physiologists John Fulton and Carlyle Jacobsen presented a study on the surgical removal of the frontal lobes in two chimpanzees, Becky and Lucy, which resulted in the quelling of their temper tantrums and “experimental neuroses”.
Portuguese neurologist, Egas Moniz, who was in attendance at the conference, approached Fulton to inquire as to whether this same procedure could be used to treat mental illness in human subjects.
Whatever Fulton’s response, Moniz got straight to work that same year, testing out the procedure on 20 patients with a range of diagnoses including schizophrenia, panic disorder, and depression.
Early versions of this procedure involved drilling a hole into the skull and then injecting ethanol into the prefrontal cortex in order to destroy the connecting fibers.
The American physician Walter Freeman later developed a streamlined version of the procedure intended to be carried out by psychiatrists without the need for a surgeon. His approach involved the insertion of an orbitoclast (a long thin surgical pick) beneath the eyelid which would then be struck with a hammer to pierce through the thin layer of bone behind the eye socket and travel up into the brain. The pick would then be raked in various directions in order to separate the frontal lobes from the thalamus.
Complications would include fever, vomiting, incontinence, diarrhea, sinus and vision problems, decreased motor function, dulled emotions, lethargy, disorientation, bizarre compulsions, hyperphagia, and seizures. Patients also often needed to relearn how to eat and use the toilet, and the mortality rate was about 15%.
It was Freeman who performed this same disastrous procedure on 23-year-old Rosemary Kennedy, the sister of President John F. Kennedy, which left her incontinent, unable to speak, and with the mental age of a 2-year-old.
The level of compassion that Freeman had for his patients (nay, victims), not to mention the quality of his work, can be gleaned from his description of a young female patient who, as a result of one of his procedures, was turned into a “smiling, lazy and satisfactory patient with the personality of an oyster.”.
In 1949, Moniz was awarded the Nobel Prize for developing this surgical procedure which later became known as the lobotomy.
Though the procedure began to fall out of favor in the mid-1950’s due to the introduction of psychiatric medication, by 1972 over 40,000 lobotomies had been performed on patients in the U.S., and more than 17,000 in the UK.