I’d rather have a free bottle in front of me than a prefrontal lobotomy

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.