Respectful Insolence

I’ve pointed out before that pover the last couple of years I’ve become a bit of a fan of old time radio, having discovered Radio Classics on Sirius XM Radio. I don’t remember how I discovered it, but I rapidly became hooked on shows like Suspense, Yours Truly, Johnny Dollar, The Whistler, Gunsmoke, Dragnet, The Six Shooter, and The Adventures of Sam Spade (the Howard Duff episodes, of course). Then, of course, there’s The Story of Dr. Kildare. This particular radio show stared Lew Ayres as Dr. Kildare and Lionel Barrymore as the irascible Dr. Leonard Gillespie (the latter of whom was actually hilarious, by the way).

I sometimes listen to Dr. Kildare not so much for the stories themselves, but because of what a time capsule the show represents when it comes to how medicine is practiced. Most of the radio episodes I listen to tend to be from the early 1950s. As I’ve pointed out before, medicine 60+ years ago was a lot more paternalistic than it is now (although there is still some residual paternalism in medicine, truth be told). It’s also an era of medicine I’ve mentioned before with respect to advertisements featuring doctors smoking their favorite cigarettes under the tag line, “What cigarette do you smoke, Doctor?” In any case, I was driving home last night when I happened to notice an episode of Dr. Kildare starting up. Since my commute is usually on the order of a half hour, it’s the perfect length to listen to an episode of a typical radio show, and this one caught my attention, and I couldn’t resist listening. Little did I know just how much this show would tell me that medicine has changed in 60 years.

I’m talking about an episode that originally aired February 1, 1950 entitled “Angela and Steven Kester.” The episode begins with Dr. Kildare showing up in his office on a typical morning to cover a long shift on duty. He’s greeted with a phone call from an old friend of his named Angela Kester. Angela used to be a famous concert pianist, but in this phone call she frantically begs Dr. Kildare to come right away to her apartment because she’s convinced that her husband is planning to kill her. Dr. Kildare protests that he’s on duty and can’t easily leave the hospital, but she’s so upset and sounds so desperate that he tells her he’ll be right over and then tells his nurse where he’ll be if anyone needs him. On his way out the door Dr. Kildare runs into a man named Steven Kester who has come to visit him. He’s informed that he is Angela Kester’s husband. Kester tells him that he’s very worried about his wife. According to him, she appears to be exhibiting obsessive behaviors, playing the same piece over and over again, sometimes practicing 16 hours a day. Apparently, five years ago at a concert at Carnegie Hall, she suffered some sort of breakdown and hasn’t been able to perform in front of an audience since then. Kildare informs Kester that his wife had just called him and told him that she thought Kester was trying to kill her. Kester, not surprisingly, is horrified, and the two of them head over to the Kesters’ apartment, where they encounter Mrs. Kester feverishly playing and yelling that her hands are being controlled by the music.

Later, we learn that Mrs. Kester’s father had been a “second rate” pianist who had wanted her to succeed where he failed. Recognizing Amanda’s talent at a young age, he pressured her to take lessons, sacrificed for her, and in general spent lots of money on lessons for her and pushing her beyond what any father should push his daughter (or son). The stereotypical overbearing father, he also took pains to make sure that Amanda was constantly reminded of just how much he had sacrificed for her, placing enormous pressure on her to succeed where he had failed. We also learn that she had undergone insulin shock therapy (also known as insulin coma therapy), a treatment in which large doses of insulin were administered to induce a hypoglycemic coma, a treatment that fell out of favor a few years after this particular episode aired because, well, not only did it not work but it was very dangerous, given that hypoglycemia can easily kill. Indeed, in 1953, British psychiatrist Harold Bourne published a paper entitled The insulin myth in the Lancet. In this paper, he argued that there was no scientifically plausible basis for concluding that insulin coma therapy did anything specific for schizophrenia and that the apparently positive results were a result of selection bias. What ultimately did in insulin shock therapy, however, was a randomized clinical trial in 1957 of insulin coma therapy versus inducing unconsciousness with barbiturates. No difference in outcome was observed, which led the authors to conlude that insulin was not a specific therapeutic agent. We then learn that Amanda Kester had undergone many cycles of electroconvulsive therapy, with little or no improvement. Much discussion occurs about how Amanda couldn’t tolerate another course of ECT or insulin shock therapy.

Around this point, Amanda tries to commit suicide by shooting herself in the chest, but fortunately for her all she did was to give herself a pneumothorax. Dr. Kildare operates and easily saves her life. (These days, we would have probably just put a chest tube in and observed to see if there was any bleeding before deciding whether to operate.) Amanda’s suicide attempt, however, leads Dr. Gillespie and Dr. Kildare each independently to delve into the medical literature looking for answers (one of the better aspects of this particular episode, as disturbing as the solution they both ultimately found was). The solution they come up with? They both decide that a prefrontal lobotomy is Amanda’s only chance to be “cured” of her condition. Consistent with the view of mental illness of the time, Amanda’s condition was discussed in apocalyptic terms, too, in that the decision to be made was presented as a choice between a procedure as drastic as a prefrontal lobotomy, which, according to Gillespie and Kildare, might make her better, might make her worse, might completely cure her, or might even kill her, versus gradually getting worse to the point where she would spend the rest of her life as a “hopeless lunatic” (the exact words used by Dr. Gillespie).

One of the more annoying aspects of fictional doctors is that specialties don’t seem to matter. I used to annoy the hell out of my wife when we used to watch episodes of E.R. and I’d point out that in a real hospital doctors wouldn’t do what was being portrayed. For instance, you wouldn’t have emergency room doctors doing endoscopy in the E.R. (they’re not trained to do that), nor would we have an apparent general surgeon like Dr. Corday doing spinal surgery, as one episode featured her doing. Even 50 years earlier, there was the same problem. Dr. Kildare was a surgeon, but in this episode we see him diagnosing Amanda with paranoid schizophrenia (which in all fairness was probably an accurate diagnosis and would still be even now), obsessive-compulsive disorder, and neuroses. Yes, Dr. Kildare was definitely the complete doctor. Not only could he do surgery, but he could be a psychiatrist, and, yes, a neurosurgeon too. Amazing, isn’t it? In any case, not surprisingly, given the framing of the choice in such terms, the decision is made to go ahead with the operation, even though Dr. Kildare is not a neurosurgeon and appears not even to have performed this particular operation before. None of this stops Steven Kester from agreeing to the operation on behalf of his wife, and the operation proceeds. Dr. Kildare whips out the leucotome (a special instrument designed to use in performing prefrontal lobotomies) and does the operation, drilling a hole in Mrs. Kester’s skull and using the leucotome to cut the connections between the prefrontal cortex and the the underlying structures. Naturally, Dr. Kildare’s surgical skill is copiously praised when he finishes the operation. After a few days of suspense, during which everyone wondered whether the lobotomy had been successful, Mr. Kester demands to see his wife, who is initially afraid of him, but then, after she recognizes him, declares that her “hands are free,” meaning that she didn’t feel the compulsion to play anymore. She is declared “cured.”

From the perspective of 2012, this episode is disturbing in any number of ways. First, there is the demonization of mental illness that shows through even a seemingly sympathetic script. Words like “lunatic” and “lunacy” were thrown about not by lay people but by Drs. Gillespie and Kildare themselves, to describe Mrs. Kester’s mental illness, which is portrayed as hopeless before the radical surgical intervention is proposed. In some ways, the desperation is understandable. 62 years ago, there was little that could be done in such cases, and it is not entirely surprising that a sense of desperation led to the conclusion that desperate conditions call for desperate measures, such as insulin shock therapy (a dangerous therapy that didn’t work), ECT (which could work and is still occasionally used in the case of severe depression refractory to medication but was hugely overused), and, of course, prefrontal lobotomy. In fact, for a couple of decades, roughly between 1935 and 1955, prefrontal lobotomy was a hugely popular operation, as described in a PBS documentary on the topic, an excerpt of which is here (note that the lobotomy portrayed in this excerpt was a different technique than what was used in the Dr. Kildare episode):

Note the rather cavalier attitude towards sterile technique or even the use of sterile gloves (or, rather, the lack of use of sterile gloves).

Interestingly, this particular episode of Dr. Kildare aired right at the height of the lobotomy craze (and, quite honestly, that’s what it is best described as, as is evident from Mo Costandi‘s description of the rise and fall of the lobotomy from back when he was still part of the ScienceBlogs collective). As the PBS FAQ points out, around 50,000 people in the U.S. were lobotomized, the vast majority of them between 1949 and 1952. It’s no coincidence that this episode of the Dr. Kildare radio show aired in 1950. No doubt the writers were doing what writers of medical series frequently do now: Feature a controversial new medical or surgical treatment as the focus of drama. In that, it’s rather amazing how little has changed in 62 years when it comes to medical fiction.

Listening to this episode as I drove home from work both fascinated and appalled me at the same time, reminding me how much things have changed in medicine in the 62 years since it first aired. Like most TV and radio shows, Dr. Kildare is a time capsule both of the popular perception of how medicine was practiced at the time and of how medicine actually was practiced at the time. We had the young gun surgeon willing, highly skilled and compassionate, willing to take risks and push the boundaries paired with the old curmudgeon of a doctor who serves as his mentor and, despite his crankiness, is often revealed to have a heart of mushy gold. The show featured real medicine of the time, and, much like medical TV shows today, had medical advisors to guide the writers regarding current practice of the times.

More importantly, sometimes it helps me to be reminded how medicine changes. In 1950, the prefrontal lobotomy, although admittedly controversial, was still state of the art (although ironically, the Soviet Union banned this procedure long before it fell out of favor in the U.S., concluding that it was “contrary to the principles of humanity” and that it turned “an insane person into an idiot.”). Its fall began with the introduction of effective antipsychotic medications in the 1950s, but, even so, it took nearly two decades to fall out of favor completely in the U.S. It’s a humbling thought and makes me wonder what we are doing today that will appear just as appalling to a doctor in the year 2074. Unfortunately, unless I live to be over 110, I’ll never know. Or maybe it’s fortunate.

Comments

  1. #1 machintelligence
    June 1, 2012

    I hat to pick nits, but isn’t the line: I’d rather have a free bottle in front of me than a prefrontal lobotomy?

  2. #2 Orac
    June 1, 2012

    Yes, it is nitpicky. I changed it.

    Now that I’ve done that, do you have anything substantive to say about the post?

  3. #3 Dianne
    June 1, 2012

    If you live to be over 100 and continue to practice, please keep up with your CMEs.

    I kept expecting the episode to end with the usual surprise twist: Steven really is trying to kill his wife! He’s jealous of her success and has been trying to undermine her for years, succeeding in ending her career but unable to stop her from playing better than he does. He is content, in the end, with the lobotomy which has stopped her from playing and thanks Dr. Kildare for saving him from having to commit a crime that he could be caught for.

  4. #4 machintelligence
    June 1, 2012

    Not being a neurosurgeon, my understanding of the operation is pretty sketchy, but I have read that if done properly, it does not make an idiot, but induces apathy. For someone who is hypercompulsive, this might be seen as an improvement. Similarly, electroshock therapy for depression seems barbaric, but I have a friend who was helped by it when less violent methods had failed. Sometimes even primitive interventions can be helpful.

  5. #5 Dianne
    June 1, 2012

    I’ve heard of lobotomy being used in an absolute last ditch effort to treat intolerable pain that has been resistant to every other form of control. It doesn’t do anything for the pain, but relieves suffering in that the patient no longer cares about his/her pain. Never heard of it being used in real life, just in theory.

    ECT is still used in depression at times. It has a reputation for working faster than antidepressants so, ironically, is sometimes the treatment of choice for people like major corporate execs who want a rapid resolution to their depression as well as for people who have failed or can’t tolerate antidepressants. I’ve seen it used all of once. Successfully, for what that’s worth. It’s done with anesthesia and monitoring, not the “hook an electrode on either side and zap” thing that you see in movies.

  6. #6 Jojo
    June 1, 2012

    I frequently run in the park next to my house. The run takes me past the grounds of the state mental hospital. It’s a beautiful, old campus that still treats patients to this day. I cringe knowing some of the horrible tings that were done there in the past. After a suicide attempt, my grandfather was taken there. He underwent ECT there before they made the many improvements in the therapy that they use today. He went on to many more years of functional life frequently interrupted by depressive periods.

    I ended up with the same illness as him, but thanks to the improvements in medicine, I simply take a pill a day, and I’m fine. The only horrible thing that ever happens to me at that location is that I have to run up a killer hill to get to the beautiful part of the run that skirts the state hospital property.

  7. #7 Todd W.
    http://harpocratesspeaks.com
    June 1, 2012

    @machintelligence

    Unless, of course, Orac had been going for the original phrase “I’d rather have a bottle in front of me than a frontal lobotomy.”

    At any rate, it’s always interesting to see how popular media perceive the practice of medicine. This story reminded me of the portrayal of Stephen Maturin in the Master & Commander series by Patrick O’Brian. Maturin is a shipboard physician who, in one instance, performs trepanation on one of the crew.

    The portrayal of mental illness is also both intriguing and horrifying. I’m impressed with how far we’ve come in changing attitudes toward mental illness, but we still have a long way to go.

  8. #8 Roger Kulp
    June 1, 2012

    It’s a humbling thought and makes me wonder what we are doing today that will appear just as appalling to a doctor in the year 2074. Unfortunately, unless I live to be over 110, I’ll never know.

    Oh I don’t know,chelation,lupron,MMA is a pretty good start on such a list byitself.And that’s autism.Think of all the cancer quackery out there.Between the two,there would be enough for a semester long class at any medical school.

    I wasn’t aware Dr.Kildare was on radio in 1949,or for that matter in movies in 1937.I know it’s going to get caught by the mods/spam filter,but here’s two fun little YouTube clips
    http://www.youtube.com/watch?v=hPCR65t8lbk
    One of Dickie Goodman’s more twisted records.
    http://www.youtube.com/watch?v=n0OTeYLggtc
    Green Day – Teenage Lobotomy

  9. #9 Orac
    June 1, 2012

    I was referring not to treatments that are already know to be useless now, of course, but to treatments we routinely do that are currently considered mainstream standard-of-care but in the next 60 years will come to be viewed the same way we view lobotomies now. Remember, from around 1940 to 1955 prefrontal lobotomy was considered part of the standard of care for various mental illnesses and disorders. It was not considered quackery then.

  10. #10 Denice Walter
    June 1, 2012

    I really like the period discussion of causation of the character’s mental illness: inappropriate parental pressure and aspirations**. Often folklore would have it that events which transpired in adolescence “caused” the schizophrenic episode… a teacher rebuked the teenager or a girl rejected him- probably putting the cart before the horse.

    This resembles the popular vaccines-autism myth: because the symptoms become apparent at a particular time doesn’t mean that the condition *started* at that time.
    Schizophrenia.com shows the genetic and pre- and peri-natal causation as shown by research.

    ** notice also the pre-feminism slant: wanting to become accomplished leads to ruin and lobotomy and it wasn’t even her own idea!

  11. #11 Liz Ditz
    http://lizditz.typepad.com
    June 1, 2012

    Howard Dully was lobotomized at age 12, at the urging of his stepmother.

    Howard Dully’s Story: My Lobotomy

    “If you saw me you’d never know I’d had a lobotomy,” Dully says. “The only thing you’d notice is that I’m very tall and weigh about 350 pounds. But I’ve always felt different — wondered if something’s missing from my soul. I have no memory of the operation, and never had the courage to ask my family about it. So two years ago I set out on a journey to learn everything I could about my lobotomy.”

  12. #12 trrll
    June 1, 2012

    My father was a neurosurgeon a bit after the era of this show (I remember watching Dr. Kildare on TV with him during his residency). He told me a story about lobotomy that I always figured was likely apocryphal:

    There was a man, otherwise a good husband and father, who had a drinking problem: every so often, he would go on a bender, get into fights and smash up bars. Afterwards, he was always consumed with guilt. Somehow, he got it into his head that what he needed to cure this condition was a frontal lobotomy. He went doctor-shopping, trying to find a neurosurgeon who would give him a lobotomy, and finally found one who agreed to do the procedure. And it worked! Oh, he still got drunk and smashed up bars–but he no longer felt guilty about it.

  13. #13 Chris
    With sane mind, perhaps..
    June 1, 2012

    Jojo:

    I ended up with the same illness as him, but thanks to the improvements in medicine, I simply take a pill a day, and I’m fine.

    That is what I thought the “bottle” in the title referred to. I don’t think I have heard of the actual phrase. And truly, if it is the meds that help you function you do not want the bottle to be full. You want to have taken at least one dose.

  14. #14 Marry Me, Mindy
    http://www.lyricsondemand.com/s/stankastbonelyrics/existentialblueslyrics.html
    June 1, 2012

    According to T-Bone Stankas, the “bottle” is a bottle of Yukon Jack.

  15. #15 DLC
    June 1, 2012

    (meta : anybody else having problems posting? or getting their RSS feed to work? )
    There’s one of the old Dr Kildare movies from the 30s that stands out in my mind. In this episode, Dr Gillespie tells a young couple who come to see him in his office that the key to saving their marriage is for the wife to become pregnant, immediately. Meanwhile, Dr Kildare, the Brave Young Maverick, saves an insane man using the controversial , not yet approved , OMG it might kill the patient! Insulin Shock Therapy. Yes. . . insulin shock therapy. These movies were made in the mid to late 30s, and starred Ayers and Barrymore. Apparently they were popular going quite a ways back.

  16. #16 Narad
    June 1, 2012

    According to T-Bone Stankas, the “bottle” is a bottle of Yukon Jack.

    The black sheep of Canadian liquors just doesn’t get the credit it deserves nowadays.

  17. #17 Scote
    June 1, 2012

    Todd W. wrote: “This story reminded me of the portrayal of Stephen Maturin in the Master & Commander series by Patrick O’Brian. Maturin is a shipboard physician who, in one instance, performs trepanation on one of the crew.”

    Which reminds me of the incident where Maturin performs open chest surgery on himself to remove a bullet lodged next to his aorta, or some such. Being adventure fiction I can grant Maturin near miraculous paint tolerance, but the ability to breathe with an open chest cavity? Not so much…

    As to radio shows, they can be a lot of fun, but some with some of them the expository dialogue where the characters try to describe what they are seeing and doing as if it is natural to do so can be ridiculous. Episode 1 of the Superman radio show has some of the most over the top expository dialogue ever. Worth checking out for that if nothing else. Also, the classic Superman phrase, “Up, up and away!!” is an example of expository dialogue. (Superman talks to himself in the show to describe what is happening–worryingly schizophrenic if you ask me… :-0 )

  18. #18 Daniel J. Andrews
    June 1, 2012

    Maybe chemotherapy and radiation will be looked at with horror by the next century? I rather hope so because it’ll mean they’ve found better methods to treat cancers.

  19. #19 Pareidolius
    June 1, 2012

    I remember a woman who lived in the same rest home that my grandfather was in back in the early 70s who had undergone a lobotomy. My aunt always spoke of her in hushed tones and poor-dears. I thought she was quite nice if a bit on the loud side. She was always quick to smile and launch into a story about living in Africa when she was a child. I always wondered why she was there.

    I was referring not to treatments that are already know to be useless now, of course, but to treatments we routinely do that are currently considered mainstream standard-of-care but in the next 60 years will come to be viewed the same way we view lobotomies now.

    That is one huge, red cape you just waved in front of the alties. As you well know, they just love to compare vaccines, chemotherapy and radiotherapy to lobotomies as examples of SBM’s barbarism. And yet, so far . . . crickets. I totally agree that there may very well be targeted, most likey genetic remedies for cancers and viruses in the future. These will probably afford greater survival rates and fewer side effects and be well tolerated. This will no doubt cause our descendants to reflect on the early 21st century MDs as “savages and butchers” and will make future Dr. McCoy’s weep with empathy and employ the ol’ “stone knives and bearskins” analogies.

    We do know what it won’t be: woo.

  20. #20 Queen Khentkawes
    June 1, 2012

    And then there is the most famous patient of all, Rosemary Kennedy.

    I’ve read that the reason she had the slight mental impairment was because the nurse tried to delay her birth until the doctor got there and she was deprived of oxygen. (Don’t know if that part is true.) Anyway, the family did their best to include her in everything. She even made her debut at the Court of St. James when the old man was our ambassador there. But when the hormones started kicking in, her behavior became unpredictable. She was 23. The old man decided a lobotomy would calm her down. It did that, all right. It also completely ravaged her in every way, and she had to be institutionalized for the rest of her life. She died in 2005 at the age of 86.

  21. #21 Denice Walter
    June 1, 2012

    @ Jojo:

    I’m glad to hear that you’re doing well.
    Because I frequent those despicably vile quagmires of rapidly decaying reason ( otherwise-known as Natural News**, the Progressive Radio Network and Mercola), I know how alt med advocates enjoy heaping scorn upon psychiatric meds – especially SSRIs- however, meds are responsible for emptying out hospitals all over the industrialised world.

    Truth-be-told- lord help me- the drugs aren’t perfect and they have side-effects but they have enabled many people to live better, more independent lives.

    This is a personal issue for me- because of my studies, past work and the many people I know who battle depression- including family members ( we seem to have been rather fortunate in not suffering the most serious consequences of depression- and I know many relations in far-flung locales and tales of the ancestors- we have a sort of resiliance- inherited, learned or both- I have no idea. We also like to write about our moroseness and dysthymia)

    Alt med prevaricators do society a disservice by scaring people off of meds while promoting spurious treatments like herbs, supplements, EFT, NLP, Scientology, meditation, energy psychology, orthomolecular bs and other inefficacies. They waste time, money, effort… and lives.

    ** Adams has a new advocate against mental health, Mike Bundrant, who writes today- badly, I should note- about SSRIs. Those who own the aforementioned websites are on a crusade agianst reason .

  22. #22 bad poet
    June 1, 2012

    @Denice Walter, 5:10 pm

    From personal experience, it takes a lot of trial and error with one’s psychiatrist to find the correct combination
    (or combinations) of drugs to determine which to use.
    Adams et al are doing a major misservice to those (like me) who can be productive members of society.

  23. #23 peebs
    June 1, 2012

    With reference to the Master and Commander movie and trepanation, I trained in the Medical Branch of the Royal Navy way back in the 70’s and served as what you chaps would call a Corpsman for near on 30 years.
    A frigate or destroyer would typically carry 280+ ships company and just me in the Sick Bay.
    I was taught how to trapanne by our top surgeons.
    They always finished the lecture by saying
    “He’s probably going to die but give it a go anyway”.
    I hasten to add I never had cause to get out that one piece of kit which truly scared me!

    As an aside there was one notifiable infectious disease we were all terrified of, Tuberculosis.
    That could go through a ship like shit through a goose and the paperwork and follow up X Rays for all the ships company were a nightmare.
    Up until the early 80’s every member of the British Armed Forces had a compulsory CXR.
    Could anyone explain why these were stopped?
    I’m thinking it may have been a Heaf test followed (if necessary) by a BCG.
    No doubt thingy will tell me I’m wrong and it’s because we wash our lungs and stuff.

    Having thought about it I’m convinced it was.down to the King’s Touch.

    Apologies for rambling and veering off thread, it’s been a long day.

  24. #24 Denice Walter
    June 1, 2012

    @ bad poet:
    I hope you’ve found the right med(s). While none of this is easy, it beats living with untreated symptoms. I know that people can become very discouraged but chances are that there are appropriate meds. So that’s another reason to mistrust woo-meisters.
    Best wishes to you!

    @ peebs:
    Altho’ it may have been off thread, it certainly was
    friggin’ awe-inspiring!
    ‘I know how to trepanne. Top that.’
    I can’t.

  25. #25 Alan Kellogg
    Some locale between Venus and Mars
    June 1, 2012

    I do believe the saying goes, “I’d rather have a bottle in front of me than a frontal lobotomy.” Where the “free” comes from I haven’t the foggiest notion.

  26. #26 Alia
    June 2, 2012

    Surgery is still used with some success in treatment of mental disorders, namely in case of drug and therapy-resistant OCD. But it’s limited to those cases where the symptoms are very developed and make the patient’s life almost unbearable.

  27. #27 Krebiozen
    June 2, 2012

    First post at the new-look blog. I find the history of medicine fascinating. It’s really only been the past 80 years or so that medicine has started to become truly evidence and science-based, and even 20 years ago long-established practices were regularly being exposed as ineffective and/or dangerous. I have posted this link before, that looks at RCTs that changed medical practise. I suspect there are still some currently used interventions that will eventually prove to be useless or worse.

    I’m reminded of the 80s when vagotomy was still a common treatment for gastric and duodenal ulcers. A branch of the vagus nerve was cut to stop stomach acid secretion. I used to titrate the acidity of gastric aspirate to see if the surgeon had cut the right nerve, while the patient was on the table IIRC. Of course since it was discovered that the main cause of such ulcers is helicobacter, this kind of surgery has become much less common.

    This aspect of medicine is one that CAM proponents often pick up on, claiming that because medicine has changed before, it will change again, meaning that all conventional medical practices are useless. Of course this doesn’t follow at all, being a sort of distorted tu quoque fallacy. When science-based medicine finds out it has been doing something useless it does eventually stop, whereas most CAM practices seem to go on forever, no matter how much evidence against their efficacy mounts. Gonzalez is still treating cancer, and even laetrile still has its supporters.

    There is also a difference between using a treatment that isn’t very effective because it is the best we currently have, and using a treatment instead of the best available treatment. I’m sure one day we will look back at the current craze for CAM in the same way we look back at the Victorian obsession with seances and spirit photography. Discussions about whether homeopathy works will look like discussions about the nature of ectoplasm.

    Apologies for any HTML errors in the above. My friend preview seems to have disappeared.

  28. #28 Orac
    June 2, 2012

    In case your comment goes to moderation, please read this:

    http://scienceblogs.com/insolence/2012/06/02/time-to-throw-the-switch-open-thread/

    And patience, my readers. Thanks.

  29. #29 peebs
    June 2, 2012

    Denice,

    I’m humbled to be called awe inspiring (if that makes sense) in such illustrious company!

    The mention of vagotomies drags me back to my dim and distant past as I was a guinea pig for the first of the H2 receptor antagonists.

    The RN had major problems with peptic ulcers, usually amongst our chefs who spent their working day tasting but not eating.

    The surgical protocol, if memory serves, was Highly Selective Vagotomy, if that didn’t work partial gastrectomy or, if duodenal, anastamosis. Finally a total gastrectomy if those failed.

    The introduction of the drug they tried out on me, Cimetadine, stopped these (major) operations almost overnight (okay, slight exaggeration but you know what I mean).

  30. #30 Krebiozen
    June 3, 2012

    Peebs,

    The introduction of the drug they tried out on me, Cimetadine, stopped these (major) operations almost overnight (okay, slight exaggeration but you know what I mean).

    I had always assumed it was the discovery of H. pylori’s role that put an end to vagotomies, but what you say makes more sense. Cimetidine was licensed in the UK in 1976, Barry Marshall and Robin Warren made their H. pylori discovery in 1982. They were still doing vagotomies in the UK in the early 80s, but I guess it takes a while for medical practice to change.

    Your mention of cimetidine led me to come across a reference to its use to treat herpes zoster (shingles) and other herpes infections. I know the Life Extension Foundation is perhaps not the most reliable source, but their references seem sound. Since cimetidine is cheap and widely available it may be worth trying for shingles and herpes generally.

  31. #31 Jay Gordon, MD, FAAP
    June 3, 2012

    This is a wonderfully entertaining post.

    Jay

  32. #32 Agashem
    Actually on the road to Toronto
    June 3, 2012

    Jay Gordon,
    Slumming?

  33. #33 peebs
    June 3, 2012

    Krebiozan
    1976 fits perfectly into my recollection and timeline.

    I took the Queen’s Shilling in ’76 and would have been under training in 77/8.

    I remember being paid the absolute (to me) fortune of £10 per day. To put that into some perspective, my take home pay at the time was about £2 per day.

    You raise another interesting point with the Cimetadine/Herpes reference.

    I’ll never cease to be fascinated by the serendipity in pharmacology. The two classics obviously being the actual discovery of penicillin itself and the interesting side effect noted by the first patients taking Viagra.
    Apparently Thalidomide is proving effective against leprosy.

  34. #34 dedicated lurker
    June 4, 2012

    Thalidomide is also used in cases of multiple myeloma (which I know because my stepfather took it for such). And cyclosporine was originally being researched for some other medical condition that I cannot remember instead of immunosuppresion.

  35. #35 JGC
    June 4, 2012

    The clue’s in the name cyclosporine–it was originally identified in screens for antifungal agents.

  36. #36 Mark Wilson
    New Boston NH USA
    June 4, 2012

    If you haven’t found this site already, check it out for a great selection of old radio shows:
    http://www.otr.net/

  37. #37 Politicalguineapig
    June 4, 2012

    ORAC: my comment went through moderation, and then it disappeared. Could you please retrieve it when you have a moment?

  38. #38 David N. Brown
    June 4, 2012

    I made a comment this morning, and it disappeared in an error report, tho the effect that I posted “too fast”… ???

    What I wante to point out is that Walter Freeman was by all accounts the most prominent promoter of the lobotomy, and depending on figures can be “credited” with not less than 5% and possibly close to 10% of all lobotomies performed in the US. I think the disproportionate impact of this single individual calls into some question whether the procedure should be considered a part of “mainstream” medicine even for the mid-20th century.

    David N. Brown
    Mesa, Arizona

  39. #39 Mrs Woo
    June 4, 2012

    The very physical illness I have was at one point shrugged off to “women’s hysteria” (as people are getting increasingly more open to discussing the illness and investigating it, the population of men diagnosed with it vs. women grows every year). When I google “psychosomatic” with the illness, I find a published paper by a psychiatrist about some poor woman who had the illness. After having her bladder removed and still having pain (at that point they didn’t understand the nerve pathways as they do now, and apparently weren’t convinced you could have ghost pain from a cystectomy) she was sent to a psychiatrist who pretty much said that her carrying on about the illness, how sick it made her, etc., rather than being symptoms of any organic disorder, was actually an unconscious attempt to manipulate and control male (therefore all those in authority) figures around her, and that, since even radical surgery had failed, there was little hope left except further psychological counseling and study…

    It, too, is its own little time capsule of “how far we have come.”

  40. #40 herr doktor bimler
    June 5, 2012

    whether the procedure should be considered a part of “mainstream” medicine even for the mid-20th century.

    But the thing about Freeman’s fact-free evangelising for the operation, and his tours of the States with his silver-plated ice-picks looking for captive populations to lobotomise, is that it *worked* — he did convince enough other people to perform the other 90% or 95% of operations.

  41. #41 Krebiozen
    June 5, 2012

    Dedicated lurker,
    It’s funny you should mention cyclosporine as a lot of the research on it was done at the hospital where I did those gastric aspirate titrations I mentioned above. Professor Sir Roy Calne was doing pioneering work on liver transplants at the time. I once had the opportunity to watch him operate; I’ve never seen so much blood in my life. Since liver transplantation was a new and risky procedure they only did it on very sick patients, who of course had practically no clotting factors, since they are made in the liver, and they bled a lot. I used to see the Prof. in the hospital bar, knocking back a pint of Abbott Ale to steady his hand before going to the operating theatre. Those were the days (the idea of a hospital having a bar seems outrageous now, much less people habitually drinking alcohol at lunchtime, as many of us did). The Prof. went on to become part of the editorial board of Medical Hypotheses, oddly enough.

  42. #42 elburto
    June 5, 2012

    Peebs- IIRC Prozac was the end result of researchers trying to formulate a new antihistamine.

    WRT common practices that will seem bizarre to future generations – my vote is for routine infant circumcision.

    It’s not done here in the UK, or continental Europe, or Scandinavia. We find it bizarre and anachronistic.

    Cornflakes are great, but that’s as far as our Kellogg-worship goes.

  43. #43 Antaeus Feldspar
    June 5, 2012

    But the thing about Freeman’s fact-free evangelising for the operation

    That’s exactly the reason why it’s so hard to judge Freeman in the correct context: his support of the operation wasn’t completely divorced from the facts; rather, it was built on a deceptive subset of them.

    It’s important to remember that the average lobotomy patient was nothing like the image that now comes to mind when the word “lobotomised” gets used: they weren’t drooling, will-less zombies, people you’d look at for five minutes and say “Holy hell, what terrible thing has been done to these people?!” If you talked to these people for five minutes, you might actually never suspect that any such operation had taken place. It’s probably true that none of them would seem of above-average intelligence, but Lake Wobegon effect notwithstanding, half the population is already of below-average intelligence. And these patients were able to talk, to think, to form opinions – and frequently the opinion they formed was that they would be forever grateful to Freeman and his “miracle operation” that had ended a hell of suffering for them.

    Make no mistake: the lobotomy was a horrible, horrible mistake; and Freeman was no saint evangelizing lobotomies with no motive except selfless philanthropy. But modern portrayals assume that he looked at moaning zombies, chuckled, rubbed his hands and cackled “This is perfect!” It’s more accurate to see him as blinded by confirmation bias, far from an uncommon failing.

  44. #44 herr doktor bimler
    June 5, 2012

    It’s more accurate to see him as blinded by confirmation bias
    Fair point.

  45. #45 Jenora Feuer
    Supposed to be working...
    June 5, 2012

    Regarding the comments about SSRIs above… one thing I remember that has been touted about them is that they have no real ‘street value’. Unlike opiates, SSRIs don’t really produce a high at all; the only thing SSRIs do is break the ‘feedback loop’ that keeps depressions going, and allow your brain chemistry to stabilize at a safer level. No immediate effect.

  46. #46 Politicalguineapig
    June 5, 2012

    Jenora: Not only do they have no immediate effect, on some people, they don’t work at all. I took imepermene, then paxil, then zoloft, all without noticing any change at all.

    Frankly, I’m terrified of psychiatrists. They may have stopped doing lobotomies, but that doesn’t mean their fingers don’t still itch for the ice picks. And a lot of them are slaves to Freud, who was just a really messed up man with a morphine addiction.
    I’m also wary of doctors and psychologists. Back in the bad old days, they could commit anyone, whether they were actually mentally ill or not. This is why I never tell a doctor the truth.

  47. #47 herr doktor bimler
    June 6, 2012

    But modern portrayals assume that he looked at moaning zombies, chuckled, rubbed his hands and cackled “This is perfect!”

    IIRC, Freeman did claim that the more extensive the damage the better the cure (in response to criticism that his trans-orbital leucotomies were unnecessarily destructive). And that having a forebrain was basically wasted on most people, serving only to depress them. Some of his patients he lobotomised twice, or even three times, basically because he could. So I’m not too worried if his legacy is an unfair caricature.

  48. #48 Adam Sutherland
    Aspen, Colorado
    June 7, 2012

    That’s what Ive also thought on the “bottle” issue. If the medical assistant that help you function does not want the bottle to be full, atleast one does would have been enough.

    Adam,
    http://naturalremediesnews.org/

  49. #49 Antaeus Feldspar
    June 7, 2012

    But modern portrayals assume that he looked at moaning zombies, chuckled, rubbed his hands and cackled “This is perfect!”

    … I’m not too worried if his legacy is an unfair caricature.

    I think you misunderstand what my concern is. It’s not with Freeman’s reputation, because frankly Freeman seems to have been a real jerkhole. Even if the lobotomy had indeed been the miracle operation he claimed it to be, he was without question a gloryhound who used his patients for both fame and fortune, and skated pretty damn close to the edge of even the somewhat looser ethics codes of his day. So no, rehabilitating Freeman’s image isn’t my concern.

    My concern is about how the other people of the time – like those who produced the Dr. Kildare episode that’s the subject of this post, for instance – are judged. They presented the lobotomy as a miracle operation; it’s hard to put aside everything we know about the lobotomy and understand that to them, it really did look like a miracle operation. Part of that was, of course, because Freeman was a shameless evangelist for the operation and painted a far rosier picture of it than the facts merited – but part of it is that our picture of what they “must have seen” is helplessly tainted by hindsight. Knowing what lobotomy victims lose, and how horrifying the loss is, we find it hard to remember that those lost faculties weren’t obvious to initial examination. We know what to look for; they didn’t. They were mistaken, horribly mistaken. But we shouldn’t be too sure that we would not have been mistaken as well, if we’d been in their shoes.

  50. #50 dedicated lurker
    June 7, 2012

    Jenora: Not only do they have no immediate effect, on some people, they don’t work at all. I took imepermene, then paxil, then zoloft, all without noticing any change at all.

    Imipramamine (Tofranil) is actually a tricyclic antidepressant.

    I was put on Paxil almost twelve years ago for anxiety. The symptoms had been there so long that I didn’t realize how much they afffected my life until they were gone. (Anxiety disorders run in my family, but they seem to affect all of us differently – my sister’s main symptom is constant needless worry and mine is psychosomatic pain, usually in the stomach but also in the hands and feet.) I was suddenly able to eat breakfast again! Before the stomach aches were so bad in the morning I didn’t dare to eat anything because I’d be sick. Miracle drug, no. Still happy to have it.

  51. #51 Krubozumo Nyankoye
    June 7, 2012

    Just more or less making a comment to get up to date with the previous commenter switch you through. This was an interesting aside from your usual insolence. There is even a parallel in my field, a 1960s genre movie that I believe was titled – Crack in the World and must have been the result of some Hollywood screenwriter’s conflation of poorly reported findings concerning plate tectonics.

    Dr. Kildare, the TV show, I am of the post radio era. I always conflated, Kildare, Killdeer, Killjoy and Killroy.
    m__0-0__m

    Very much enjoy and appreciate this blog though I don’t have anything really to contribute.

    The way I have always heard the phrase was I’d rather have a bottle in front of me than a frontal lobotomy. I think because most lay people are not familiar with the term pre-frontal lobotomy.

    Anyway, I hope this comment will get me back in the loop.

    You do yeoman’s work Orac.

  52. #52 Krubozumo Nyankoye
    June 7, 2012

    Duhuhhh, – threw. Yes it would be nice to have preview but I should have proof read.

  53. #53 Politicalguineapig
    June 7, 2012

    Dedicated lurker: That wasn’t Jenora, that was me responding to Jenora. Thanks for the correction, I never knew how to spell it. All I know is that it might as well have been a placebo.
    As for paxil, I’m glad it worked for you. I still think doctors are overzealous in diagnosing and ‘treating’ depression.

  54. #54 David N. Brown
    June 8, 2012

    @Bimmler:
    “(Freeman) did convince enough other people to perform the other 90% or 95% of operations.”
    Unfortunately, I have yet to see any information on the “disciples” Freeman presumably picked up. But it seems doubtful whether many of them equalled even Freeman’s modest credentials and reputation. It is also of considerable interest that Freeman’s documented critics included a former partner, James Watts.

    ” Some of his patients he lobotomised twice, or even three times, basically because he could.”
    Wow, I hadn’t even noticed that detail, but it is mentioned in sources I had already consulted. According to wikipedia, the final patient who died after an operation was a “repeat”. Discussion of Freeman’s motives really ought to be treated as speculative, but your interpretation certainly makes sense. On consideration, I think there’s possible parallels to Mengele, and discussion of the latter’s activities and motivations has focused on the role of power for it’s own sake.

    David N. Brown
    Mesa, Arizona

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