Performing a cure for schizophrenia: Insulin coma therapy on the wards

Journal of the History of Medicine and Allied Sciences

Volumn 62, Issue 2, 2007, Pages 213-243

  Doroshow, Deborah Blythe ^a  

^a HARVARD MEDICAL SCHOOL   (United States)

Author keywords

ICT; Insulin coma therapy; Psychiatry; Somatic therapy; Therapeutic efficacy

Indexed keywords

INSULIN;

HISTORY; HUMAN; HYPOGLYCEMIC COMA; MENTAL HOSPITAL; PSYCHIATRIC TREATMENT; PSYCHIATRY; REVIEW; SCHIZOPHRENIA; TREATMENT OUTCOME;

HISTORY, 20TH CENTURY; HOSPITALS, PSYCHIATRIC; HUMANS; INSULIN; INSULIN COMA; PSYCHIATRIC SOMATIC THERAPIES; PSYCHIATRY; SCHIZOPHRENIA; TREATMENT OUTCOME;

EID: 33947138748     PISSN: 00225045     EISSN: 14684373     Source Type: Journal    
DOI: 10.1093/jhmas/jrl044     Document Type: Review

References (102)

1. J. D. Ratcliff, "Minds that Come Back," Collier's, 12 February 1938, 38.
2. Elliot S. Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (New York: Basic Books, 1986), 56.
3. In fact, most critics of ICT called it "unscientific," using this broad term to call attention to the fact that the treatment was empirical; no one knew how it worked (although individual practitioners had their own theories, there was no unifying therapeutic rationale) and it was not based on an understanding of the etiology of schizophrenia (Gerald Grob, From Asylum to Community: Mental Health Policy in Modern America [Princeton, NJ: Princeton University Press, 1991], 127).
4. See H. R. Rollin, "Treatment in Psychiatry. From Nihilism to Cautious Optimism," Practitioner, 1980, 224:1344, 645-49;
5. Valenstein, Great and Desperate Cures.
6. This category is well represented by general histories of psychiatry (see Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac [New York: John Wiley and Sons, 1997]), as well as more focussed histories of somatic therapy (see Valenstein, Great and Desperate Cures). Because ICT employed a specific pharmaceutical agent that had already achieved acceptance in mainstream medicine and even fame as a panacea, its performance provided a unique opportunity for psychiatrists to assert their legitimacy as physicians. The unique pharmaceutical origin of ICT makes its story unique, a narrative apart from those of other somatic therapies from the same era, such as metrazol or electroconvulsive therapy.
7. For a more complete discussion, see Deborah Doroshow, "The Injection of Insulin into Psychiatry" (Undergraduate Thesis, Harvard University, 2004).
8. G. Tourney, "A History of Therapeutic Fashions in Psychiatry, 1800-1966," Am. J. Psychiatry, 1967, 124, 784-96;
9. Kingsley Jones, "Insulin Coma Therapy in Schizophrenia," J. R. Soc. Med., 2000, 93, 147-49.
10. ECT was deemed the symbol of torturous psychiatric disciplinary techniques by the anti-psychiatry historians and especially by the anti-psychiatrists themselves, notably Thomas Szasz and R. D. Laing. It was also criticized in a broader historical context through such cultural depictions as Ken Kesey's novel One Flew over the Cuckoo's Nest (New York: Viking Press, 1962), later a play and award-winning movie, and Anthony Burgess' novel A Clockwork Orange (London: Heinemann, 1962), also made into a popular film. Historians Zigmond Lebensohn and Petr Skrabanek have more recently deemed ICT an ECT precursor, labeling it the first "shock therapy" (in fact, convulsions were rarely a desired effect) and concluding that it was a crude, cumbersome, and cruel predecessor (Zigmond M. Lebensohn, "The History of Electroconvulsive Therapy in the United States and Its Place in American Psychiatry: A Personal Memoir," Comp. Psychiatry, 1999, 40, 173-81,
11. and Petr Skrabanek, "Convulsive Therapy: A Critical Appraisal of its Origins and Value," Ir. Med. J., 1986, 79, 157-65.
12. Carol Tamminga included herself in this recent movement when she reminded the readers of the American Journal of Psychiatry's 1994 historical supplement that while the study of ICT did lack a strong mechanistic understanding, the same could be said of much of biological psychiatric research today (Carol Tamminga, Introduction to "Developments in Somatic Treatment," Am. J. Psychiatry, 1994, 151:6 Suppl., 216-19).
13. Psychiatrist David Healy, in The Creation of Psychopharmacology (Cambridge: Harvard University Press, 2002), tried to make the case that ICT may actually have been an effective treatment for schizophrenia, based on current knowledge about the possibility that insulin is a modified neurotransmitter. However, Healy's insistence on evaluating ICT by late twentieth-century standards precludes any exploration of why ICT might have been esteemed during its period of enthusiastic use, leaving the treatment vulnerable to further historical castigation for failing to meet modern standards of medical proof.
14. Andrew Scull, "Somatic Treatments and the Historiography of Psychiatry," Hist. Psychiatry, 1994, 5, 1-12. Scull points out that "historians have tended to pass over these innovations in embarrassed silence or to dismiss episodes of this sort as aberrations", 9.
15. Jack D. Pressman, Last Resort: Psychosurgery and the Limits of Medicine (New York: Cambridge University Press, 1998). Pressman's work is a deliberate attempt to avoid an anachronistic analysis of psychosurgery; see his introduction for an explanation of his rationale.
16. In recruiting retired psychiatrists to discuss their memories of ICT, I found that many of them were quite embarrassed to discuss their involvement with the treatment. One psychiatrist suggested I contact the World Psychiatric Association rather than speak with him about his personal experiences. "As for my own experience with this treatment," he said, "I had to participate in its administration many years ago and thinking about it [I] feel happy that young colleagues today do not have to do so any longer" (Norman Sartorius, personal communication, 27 July 2003).
17. Max Fink, Robert Shaw, George E. Gross, and Frederick S. Coleman, "Comparative Study of Chlorpromazine and Insulin Coma in Therapy of Psychosis," J. Am. Med. Assoc., 1958, 166, 1846.
18. The term "local world" is derived from the work of anthropologist Margaret Lock, who uses the phrase "local biology" to describe what is at stake, both scientifically and socially, in a local world comprised of actors with specific moral stakes. Lock, Encounters with Aging: Mythologies of Menopause in Japan and North America (Berkeley: University of California Press, 1993). Harvard medical anthropologist Arthur Kleinman further distinguishes between the local and the global by deeming the local world a "moral" one, and the global an "ethical" one, more concerned with the theoretical.
19. Kleinman, "Experience and its Moral Modes," in The Tanner Lectures of Human Values: Volume 20, ed. Grethe B. Peterson (Salt Lake City: University of Utah Press, 1999).
20. Robert Darnton, The Great Cat Massacre and Other Episodes in French Cultural History (New York: Basic Books, 1984);
21. see Chapter 2, "Workers Revolt: The Great Cat Massacre of the Rue Saint-Séverin."
22. Edmund Pellegrino, "The Sociocultural Impact of Twentieth-Century Therapeutics," in The Therapeutic Revolution, ed. Morris Vogel and Charles Rosenberg (Philadelphia: University of Pennsylvania Press, 1979), 256-57.
23. Whether ICT would be proven effective today, if examined in a randomized controlled trial, is unknown. I do not wish to suggest either that it would have been proven ineffective but was effective in a more global way or that it might have actually received its due were such a trial to be performed now.
24. The intensive care unit as a specialized hospital space did not become established in the United States until after World War II, during the middle of ICT's period of usage (Christine Wenc, personal communication, 27 February 2004; Wenc is a graduate student in the Department of the History of Science at Harvard University, preparing to write her dissertation on the history of the ICU). Nevertheless, close monitoring for patients in critical condition has always been a part of medical practice.
25. Isabel G. H. Wilson, A Study of Hypoglycaemic Shock Treatment in Schizophrenia (London: H.M. Stationery Office, 1936), 57.
26. Joel Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore, MD: The Johns Hopkins University Press, 1995).
27. Alessandro Portelli, "What Makes Oral History Different," in The Oral History Reader, ed. Robert Perks and Alistair Thomson (London: Routledge, 1998).
28. Despite the increasingly popular use of patient records to re-create the patient experience (see Braslow, Mental Ills and Bodily Cures), an aspect of the history of medicine that is now receiving much-deserved attention, my focus will remain on the mental health practitioner's experience in order to clarify the meaning of ICT within psychiatry as a profession.
29. Hillside is now a subsidiary facility of the Long Island Jewish Medical Center, an academic teaching facility of Albert Einstein College of Medicine.
30. To ensure maximum historical accuracy, I have sampled patient records so as to assure randomness. The available records extended from 1928 to the present; to account for developments in ICT administration, I sampled records from the beginning (1938-39; microfilm reels 10-11), middle (1945-46; reels 24-25), and end (1954-55; reels 84-86) of the insulin era at Hillside. Nine records were sampled from each of the two latter eras and were chosen by virtue of their placement at the beginning of the microfilm(s) containing records from that era. In the first era, only four patients received insulin; their charts were all reviewed. Although the records ultimately chosen may not provide as rich a picture of ICT as, for example, a carefully selected patient sample, it provides a more accurate snapshot of the treatment's role at Hillside. In accordance with HIPAA regulations as well as common privacy practices, no identifying information about patients has been used. Because almost all the patients whose records I reviewed were Jewish, I have attempted to choose appropriate, realistic aliases for each of them. Hereafter, these records will be cited as "Hillside case series."
31. Jay T. Shurley and Earl D. Bond, Veterans Administration Technical Bulletin: Insulin Shock Therapy in Schizophrenia (Washington, DC: Veterans Administration, 1946), 15.
32. Lenore Boling, interview with author, 12 December 2003, Cambridge, MA.
33. Lucie Jessner and V. Gerard Ryan, Shock Treatment in Psychiatry: A Manual (London: W. Heineman, 1943), 12-13.
34. Max Fink, interview with author, 30 June 2003, St. James, NY.
35. Marilyn Freedman, interview with author, 12 December 2003, Cambridge, MA.
36. Joyce McConnell, "Two Years' Experience of Female Schizophrenics Treated by Insulin Coma Therapy," J. Ment. Sci., 1945, 91, 506.
37. Shurley and Bond, Insulin Shock Therapy in Schizophrenia, 4.
38. William Sargant and Eliot Slater, An Introduction to Physical Methods of Treatment in Psychiatry, 5th ed. (London: Churchill Livingstone, 1972), 262.
39. Sargant and Slater, An Introduction to Physical Methods of Treatment in Psychiatry, 262; Boling, interview with author.
40. Boling, interview with author. Boston Psychopathic Hospital was a public hospital in Boston, managed by state funds; thus, it is an excellent representative of the environment in which ICTwas administered, which was dominated by public hospitals.
41. George Awad, interview with author, 31 October 2003, Boston, MA.
42. Gerald Sarwer-Foner, interview with author, 20 July 2003, Cambridge, MA.
43. Marilyn Freedman, interview with author, 12 December 2003, Cambridge, MA.
44. This fact is notable in itself because diagnostic therapeutic specificity, the constrained use of a treatment for only one diagnosis, was at that point relatively unknown to psychiatry. The only earlier instance of therapeutic specificity is the use of malaria fever therapy for neurosyphilis. By the late 1930s, however, insulin coma therapy had become a standard therapy for schizophrenia - and only schizophrenia. ICT differed in this way from contemporary treatments like ECT, which was being used for a wide range of diagnoses including manic depressive disorder, obsessive compulsive neurosis, and schizophrenia. Of twelve interviewed psychiatrists, eight noted that in their experience, ICT was administered only or mostly to schizophrenic patients. The other interviewees were not able to remember or state with certainty the diagnoses of ICT patients. Every Hillside patient whose chart I examined was discharged from the hospital with a diagnosis of schizophrenia, with the exception of David Levin, diagnosed with the closely related diagnosis of Schizoid personality. This brand of therapeutic specificity is also evident in the charts of three 1940s insulin patients who entered Hillside with diagnoses of Obsessive Compulsive Neurosis, Manic Depressive Psychosis, and Psychoneurosis, and were all discharged with diagnoses of schizophrenia. It is as if their diagnoses changed once they were administered insulin coma, because ICT was understood to be a treatment for schizophrenia only (Hillside case series, 1945-46).
45. For example, one Hillside patient, Esther Sherman, received both ICT and ECT, after having gained insight into her delusional thinking during a previous course of ECT at another hospital. The psychiatrist's brief note about Sherman's previous success with ECT suggests that examining her earlier treatment may have provided a logical means of deciding what to do next (Hillside case series, 1954-55).
46. Max Müller, "The Insulin Therapy of Schizophrenia," in The Treatment of Schizophrenia, 12.
47. Because of this, insulin enthusiasts such as William Mayer-Gross in England suggested that "every early schizophrenic should be given the chance of insulin treatment" (Mayer-Gross, "Insulin Coma Therapy of Schizophrenia: Some Critical Remarks on Dr. Sakel's Report," in "Comments on the Opening Papers on Indications For Shock Treatment, to be Presented at the International Congress of Psychiatry in Paris, September 1950," J. Ment. Sci., 1951, 97, 132-47).
48. Other psychiatrists attempted to provide detailed checklists with which physicians could determine the prognosis of an ICT patient. In their 1952 somatic treatment manual, Kalinowsky and Hoch suggested considering heredity, age, sex, duration of illness, number of previous attacks, type of schizophrenia, the presence or absence of precipitating causes, and the patient's personality (Kalinowsky and Hoch, Shock Treatments, Psychosurgery and Other Somatic Treatments in Psychiatry, 76).
49. Joseph Wortis, "The History of Insulin Shock Treatment," in Insulin Treatment in Psychiatry: Proceedings of the International Conference on the Insulin Treatment in Psychiatry Held at the New York Academy of Medicine October 24 to 25, 1958 (New York: Philosophical Library, 1958), 32.
50. In fact, psychiatrists were so selective about their ICT treatment population that opponents, especially in the 1950s, accused them of cherry-picking the healthiest patients. Some even argued that these patients would have recovered spontaneously, questioning whether the treatment had any value at all.
51. Arthur Cain, interview with author, 6 November 2003, Cambridge, MA.
52. Sargant and Slater, An Introduction to Physical Methods of Treatment in Psychiatry, 8.
53. Lothar B. Kalinowsky and Paul H. Hoch, Shock Treatments, Psychosurgery and Other Somatic Treatments in Psychiatry, 2nd ed. (New York: Grune & Stratton, 1952), 8.
54. Sarwer-Foner, interview with author.
55. Bernard Glueck, "Society Proceedings: Section of Neurology and Psychiatry, New York Academy of Medicine, and the New York Neurological Society," J. Nerv. Ment. Dis., 1937, 85, 565.
56. Jonathan Cole, interview with author, 19 September 2003, Belmont, MA.
57. Boling, interview with author; Cain, interview with author.
58. Cole, interview with author.
59. The record of Bernard Morris's treatment demonstrates this pattern. When Morris achieved coma for the first time (Day 24) with 250 units of insulin, his doses were not kept constant but were increased to a maximum of 360 units. On Day 40, Morris received ten fewer units of insulin than he had the day before. This three-day diminishing pattern reversed on Day 43, when his doses were increased until the end of the treatment course (Hillside case series).
60. Shurley and Bond, Insulin Shock Therapy in Schizophrenia, 4.
61. Hillside case series, 1954-55.
62. Boling, interview with author.
63. See Joel Howell, Technology in the Hospital; urinalyses were long used in a nondirective, comprehensive fashion before they became diagnostic tools.
64. Fink, personal communication, 17 December 2003.
65. Harry M. Marks, The Progress of Experiment (New York: Cambridge University Press, 1997), Introduction.
66. Shurley and Bond, Insulin Shock Therapy in Schizophrenia, 4.
67. Sargant and Slater's British ICT manual differentiated between fits occurring early in coma, which often ended with the patient's spontaneous awakening, and those occurring late in coma, for which "immediate intravenous interruption is necessary" (Edinburgh: E&S Livingstone, 1944), 33.
68. Their list of "helper" drugs to ward off convulsions includes luminal, dilantin, and belladenal (Shock Treatments, Psychosurgery And Other Somatic Treatments in Psychiatry, 42). For prolonged comas, different treatments were specified for different kinds of unresponsive patients. For patients who simply did not respond to attempts at termination, Kalinowsky and Hoch suggested blood transfusions and extra potassium; for those who failed to wake up completely, coramine or caffeine; and for those who failed to fully digest the sugar in their nasal tubes, acidol pepsin tablets, strong intravenous termination, or shorter comas (Ibid., 47-49).
69. Daniel Weiss, "Insulin Coma Therapy in a Veterans Administration Hospital," in Insulin Treatment in Psychiatry: Proceedings of the International Conference on the Insulin Treatment in Psychiatry Held at the New York Academy of Medicine October 24 to 25, 1958 (New York: Philosophical Library, 1958).
70. Thomas Detre, interview with author, 2 July 2003, Cambridge, MA.
71. Boling, interview with author.
72. Daniel Weiss, "Insulin Coma Therapy in a Veterans Administration Hospital," 308;
73. Kalinowsky and Hoch, Shock Treatments, Psychosurgery and Other Somatic Treatments in Psychiatry, 26.
74. Cole, interview with author.
75. E. Larkin, "Psychological Aspects of Insulin Shock Therapy: A Psychosomatic Study," J. Ment. Sci., 1945, 91, 669.
76. Freedman, interview with author.
77. O. H. Arnold, "Results and Efficacy of Insulin Shock Therapy" in Insulin Treatment in Psychiatry, 210;
78. Sargant and Slater also address patient synchronization (An Introduction to Physical Methods of Treatment in Psychiatry, 260).
79. Sarwer-Foner, interview with author; Sargant and Slater, An Introduction to Physical Methods of Treatment in Psychiatry, 260.
80. Cole, interview with author.
81. Boling, interview with author.
82. Cole, interview with author.
83. Cain, interview with author.
84. It was quite common for psychiatrists to remark on the curative effect of the ICT environment. See Alexander Gralnick, "A Three-Year Survey of Electroshock Therapy: Report on 276 Cases; Comparative Value of Insulin-Coma Therapy," Am. J. Psychiatry, 1946, 2, 591,
85. and "Discussion" following R. K. Freudenberg, "Ten Years' Experience of Insulin Therapy in Schizophrenia," J. Ment. Sci., 1947, 18, 22.
86. Records of Saul Heller, Hillside case series.
87. David Corcoran and Alexander Gralnick, Metrazol, Electric, and Insulin Treatment of the Functional Psychoses (New York State Department of Mental Hygiene, Central Islip State Hospital, 1934);
88. James D. Page, Treatment in Mental Disorders (Rochester, NY: University of Rochester Press, 1939).
89. Boling, interview with author.
90. Elliot S. Valenstein, Great and Desperate Cures.
91. Cole, interview with author.
92. Max Fink, "A Beautiful Mind and Insulin Coma: Social Constraints on Psychiatric Diagnosis and Treatment," Harv. Rev. Psychiatry, 2003, 11, 286.
93. Two patients, Esther Sherman and Rose Sternberg, are described as more involved in ward activities and socializing. Two others, Edward Kaufman and Rebecca Eisen, are described as having gained insight into their conditions. Even Betty Kaminsky, a chronic patient with a relatively poor prognosis, is described as "less tense and less frightened" after her course of ICT. While these conclusions are certainly positive and show improvement, many other patients do not appear to have experienced any changes at all. Art Steinfeldt, according to his physicians, found that his somatic symptoms of itching and discomfort actually increased, as did feelings of depersonalization (Hillside case series).
94. Freedman, interview with author.
95. Sarwer-Foner, interview with author.
96. Fink, "A Beautiful Mind and Insulin Coma," 287.
97. Shurley and Bond, Insulin Shock Therapy in Schizophrenia, 10.
98. Earl D. Bond and Thurston D. Rivers, "Insulin Shock Therapy after Seven Years," Am. J. Psychiatry, 1944, 101, 63.
99. Boling, interview with author.
100. Mark Walter, interview with author, 12 December 2003, Cambridge, MA.
101. Bourne, interview with author, 6 November 2003.
102. Sarwer-Foner, interview with the author.