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. Braslow 1 This paper examines the early history of biological treatments for severe mental illness. Focusing on the period of the 1900s to the 1950s, I assess the everyday use of somatic therapies and the science that justified these practices. My assessment is based upon patient records from state hospitals and the contemporaneous scientific literature. I analyze the following somatic interventions: hydrotherapy, sterilization, malaria fever therapy, shock therapies, and lobotomy. Though these treatments were introduced before the method of randomized controlled trials, they were based upon legitimate contemporary science (two were Nobel Prize-winning interventions). Furthermore, the physicians who used these inter- ventions believed that they effectively treated their psychiatric patients. This history illustrates that what determines acceptable science and clinical practice was and, most likely will, continue to be dependent upon time and place. I conclude with how this history sheds light on present-day, evidence-based medicine. KEY WORDS: evidence-based medicine; history of psychiatry; somatic therapies; biological psychiatry. INTRODUCTION Over the last couple of decades, researchers, cli- nicians, and policy-makers have urged clinicians to base their practices upon scientific evidence, the most robust of this evidence being the randomized con- trolled trial (RCT). Introduced into clinical medical science in the late the 1940s (Medical Research Coun- cil, 1948), psychiatric researchers first began em- ploying 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 al- tered 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. 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 pre- scientific age, where personal conviction, local con- text, 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 appar- ent 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 meth- odological 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 231 1522-3434/99/0400-0231$16.00/0 © 1999 Plenum Publishing Corporation