Gracefully Insane

by Alex Beam

  He conveys the idea that he is active in some business (without telephone) and has sort of dropped much of it to take care of his wife. She denies his working since marriage and says that they mostly live on her income, except for a small part that he has. He would lead one to believe that he is the model husband with over solicitous care and tenderness, but he is very insecure in his relationship with his wife, due to the financial arrangement.

  Priscilla Jenkins was discharged after two weeks. Her McLean doctor, Douglas Sharpe, wrote that she “had shown marked physical improvement since her hospitalization. She has gained weight, slept without medication, and has not complained of any somatic problems since her two epileptic convulsions on February 5, 1949, which were probably due to drug withdrawal.... All the various complaints she presented on admission have disappeared. She frankly stated that she presented these problems in order to gain attention and sympathy.” The prognosis, Sharpe reported, was “guarded.”

  Priscilla Jenkins died at age fifty of lung cancer.

  5

  The Search for the Cure

  I remember one of my supervisors, the famous Abraham Myerson, when we asked about treating depression, saying: “Look, we give them Dexedrine for depression, and then they get elated. Then you give them phenobarbital to calm them down. They ricochet between mania and depression.” And that’s really what it was, with electric shock, wet sheet packs, and hot tubs all thrown in.

  Dr. Edward Daniels

  Addressing the American Psychiatric Association in 1933, President James May bemoaned the state of the profession. Few medical schools employed professors in the field of psychiatry. Mental illness, May said, was “a medical playground” in which neurologists, neurosurgeons, and psychiatrists competed with gynecologists and ophthalmologists in speculations on the causes of psychoses. From about 1930 until the introduction in 1954 of Thorazine, the first usable antipsychotic drug, the curative landscape resembled not a playground so much as the Wild West. Every few years, a new sheriff would ride into town, promoting a new wonder cure that eventually yielded to the next, short-lived fashion.

  In the 1930s, for instance, a Trenton psychiatrist named Henry Cotton pulled patients’ teeth and removed their large intestines to cure mental illness, which he believed to be caused by “autointoxication.” (Stanley McCormick’s psychiatrist, the well-regarded Adolf Meyer of Johns Hopkins, hailed Cotton’s work as a “remarkable achievement of the pioneer spirit.”) For a while, fever was thought to be restorative for mental patients, especially for the stiff-gaited victims of general paresis, the physical and mental paralysis that accompanied the advanced stage of syphilis. Some hospitals—McLean was not one of them—kept malarial mosquitoes or diseased rats on hand to bite treatment subjects and induce fever. Others injected blood from fever victims into the paretics, who crowded the mental hospitals until the discovery of penicillin. For the ostensible purpose of boosting patients’ white blood cell count, some doctors injected horse blood into their subjects’ lumbar cavities, mixing the blood with spinal fluid. Then sleep therapy, or “prolonged narcosis,” came on the scene. In theory, a week-long, drug-induced nap would help restore a patient’s exhausted nervous system.

  In 1941, two McLean doctors, John Talbott and the bumptious Kenneth Tillotson, reported encouraging results from a therapy they called hypothermia. Like Dr. Willard’s drowning regimen of a century and a half before—and like the various shock therapies coming into use during the twentieth century—the hypothermia cure reduced the body to a near-death state by lowering the patient’s body temperature. It was not hibernation, the doctors emphasized, and was decidedly not refrigeration. “We object to the word refrigeration,” they wrote, “because it implies that the object treated is refrigerated and that the temperature is reduced considerably lower than is compatible with life.” Their modus operandi and their conclusions seem comic to us now, all the more so because they cited an 1805 cold-water dunking of an English convulsive as an important precursor for their experiment. But Talbott and Tillotson produced two important results: Four of the ten patients whose body temperatures they lowered by twenty degrees or more for periods of up to sixty-eight hours (!) showed marked improvements. The mental state of one sixteen-year-old boy cleared to the point where he could leave the hospital and go home. And one patient, a forty-six-year-old male paranoid schizophrenic whom they kept cold and semiconscious for fifty hours, died when his lowered blood pressure never came back again. The doctors injected him with adrenaline and caffeine, to no avail. “It is hoped that this would not have occurred,” Talbott and Tillotson wrote. But it did.

  The procedure sounds, well, chilling. After sedating the schizophrenic patients with a barbiturate (Nembutal) and a muscle relaxant (Evipal), the doctors wrapped them in special blankets manufactured by the Therm-O-Rite Products Company of Buffalo, New York, through which they circulated a refrigerant. A stomach tube pumped glucose into the patient to keep him or her alive, and a thermocoupled rectal thermometer transmitted bodytemperature readings every other minute. The patients were garden-variety catatonic, paranoid, and hebephrenic (the “laughing disease”) schizophrenics. One young woman, a twenty-five-year-old medical student, had already received Dauernarkose (continuous sleep), insulin shock, metrazol, and typhoid vaccine therapies before coming to McLean. She had an unusual reaction to the cold: Her mental acuity cleared when her body temperature was more than ten degrees below normal, and she then reverted to her disturbed condition as the thermometer approached 98.6. She had three hypothermia treatments and was classified as a success, although she remained at the hospital. Overall, the doctors claimed success in four cases, temporary improvements in four others, and no discernible effects in the remaining two. The younger patients with shorter histories of mental illness responded better than the older patients; it was the oldest patient who died. Talbott and Tillotson derived a “modicum of hope” from their work: “The results would seem to be at least equally as promising as insulin and metrazol in the treatment of schizophrenia,” they wrote. They felt compelled to add that “hypothermia does not cause morphologic damage,” meaning bodily harm. That is true, unless one includes death by cardiac arrest.

  A kinder, gentler form of therapy was the various water treatments that had been administered to mental patients since the end of the eighteenth century. (A young psychiatrist once asked Paul Howard, who joined the McLean staff before World War II, why patients comported themselves better after hydrotherapy treatment. “Don’t you always feel more relaxed after a nice, warm bath?” was Howard’s commonsensical reply.) The 1922 McLean nurses’ manual lists no fewer than seventeen different hydrotherapy regimens, from the foot bath to the shampoo. Most are categorized as “tonic baths” and administered in the “hydriatic suite” in the basement of the women’s gymnasium. Here are a few of the treatments and a partial list of the illnesses they were supposed to assuage:

  Hot Air Bath Alcoholism, manic depression, dementia praecox (senility)

  Electric Light Bath Same

  Vapor Bath Same

  Salt Glow (an eight- to twelve-minute rubdown with salt crystals) Huntington’s chorea, involution melancholia, multiple sclerosis

  Fomentation (application of moist heat using a thirty-inch-square piece of white woolen flannel) Same, plus cerebral syphilis, paralysis agitans, etc.

  Revulsive Sitz Bath (“As patient arises from the bath, a pail of cold water, 80 deg., is splashed upon the hips.”) Neuralgia

  Pail Douche (“Have water at three temperatures in pails holding several gallons. Dash the contents of each pail over the patient in quick succession.”) Good tonic treatment

  Wet Mitt Friction (loofah or white mohair) “Invaluable in inaugurating hydrotherapy in the psycho neuroses”

  Neptune Girdle (apparently a variant of the cold wet sheet pack, placed around a woman’s waist) “Employed extensively in the treat ment of the psychoneuroses”

  One of the most common hydrotherapies was wrapping
the patients in cold (forty-eight to fifty-six degrees Fahrenheit), wet sheets. These so-called packs were used to pacify agitated patients up through the 1970s. In 1922, the packs’ effect was divided into action (“sensation of chilliness ... cooling of the skin ... shivering”) and thermic reaction (“chilliness disappears ... skin become warm ... muscular relaxation occurs”). Hypothermia was of course a risk: “If there is any unusual paleness of the face, blueness of the lips or shivering, the patient ... should be warmed by the application of hot water bags to his sides and feet. He should also be give a hot stimulating drink. (A teaspoonful of whiskey in hot water is considered good because whiskey dilates the blood vessels in the skin.)”

  Another ubiquitous remedy was the “continuous bath.” According to the nurses’ manual, the prolonged bath could be “administered for hours, days, weeks or months.” “In some hospitals [and this is a tip-off that we are not speaking about McLean], it is customary to keep the patients in the tubs 18 hours daily and some very disturbed patients are kept in the baths without removal for periods of 2 or 3 weeks.”

  Director Franklin Wood’s desk notebook of course codified every last concern about the continuous baths, from the proper temperature (ninety-four degrees Fahrenheit) to the possible dangers: “I. Heat prostration; 2. Chilling; 3. Scalding; 4. Drowning; 5. Convulsions.” The following instruction would indicate that some patients did spend day-long cycles in the baths: “If a patient is very noisy, restless, or flushed, or if the pulse rate is 88 or more rapid, supply an ice collar. Sponge the face of each patient with cold water once or twice during the bath. Omit during sleep.”

  The real action, however, was in the shock therapies—insulin coma, metrazol, and electric—which were widely used at McLean and elsewhere at midcentury. “All the theories attempting to explain how these treatments worked proved to be wrong,” writes Elliot Valenstein in his delightfully readable psychiatric history, Great and Desperate Cures, “and, as they were stated, so vague as to be impossible to take seriously.”

  Insulin coma was discovered by accident by the colorful Viennese physician Manfred Joshua Sakel, who claimed to be a direct descendant of the twelfth-century rabbi, physician, and philosopher Moses Maimonides. Sakel unintentionally gave a diabetic mental patient an overdose of insulin, lowering her blood sugar to the point where she fell into a coma. When she emerged from unconsciousness, she felt considerably better. In clinical trials, Sakel reported an astonishing 88 percent success rate, and he even treated the famous Russian dancer Vaslav Nijinsky. Success, of course, is always relative in psychiatry; Nijinsky did not figure in the lucky 88 percent and was not able to resume a normal life after Sakel’s treatment.

  Insulin coma caught on quickly in the United States, as did metrazol shock, which had precisely the opposite effect on patients. After examining the cadavers of epileptics and schizophrenics, a Hungarian researcher named Joseph Ladislas von Meduna had concluded that epilepsy and schizophrenia were mutually antagonistic. Thus, theoretically, an induced epileptic seizure would “cure” a psychotic patient. Meduna found that a synthetic chemical called metrazol would send patients into the desired convulsions. (Other doctors similarly enamored with the epilepsyschizophrenia connection tried injecting epileptics’ blood, drawn immediately after a seizure, into mental patients. These conjectures have little basis in scientific fact.)9 Meduna, like Sakel, Freud, and many ambitious European doctors before him, eventually made a U.S. landfall, and popularized his treatment around the country.

  Metrazol shock naturally led to electroshock therapy, which also caused patients to go into convulsions. “Medical electricity” was nothing new. Scribonius Largus, who lived in the first century A.D., treated the Roman emperor’s headaches with electric eels. In the eighteenth century, a French physician used electroconvulsive therapy on a patient with psychogenic blindness. In his early neurology practice, Freud experimented with low-grade electric shock, “only to find [it] grossly ineffective and lacking any sound foundation,” according to one history of psychiatry. “Freud realized [perhaps “hypothesized” would be a better choice of word] that the electric-current therapy was only a form of covert suggestion and had no lasting therapeutic effect.” But its widespread use on psychiatric patients originated in Italy in 1938, when the police commissioner of Rome sent an apparently dazed schizophrenic to doctors Ugo Cerletti and Lucio Bini for treatment. Cerletti and Bini had seen hogs killed at a Rome slaughterhouse after being stunned with electric current. They experimented with the hogs to determine a nonlethal dose of current; this prompted them to theorize that the brain produced a “vitalizing substance” called “acro-amines” in response to a convulsion. The police commissioner’s referral provided them with their first human subject.

  Valenstein describes the ensuing opera buffa:When the current was applied to his head, his body jolted and stiffened, but he did not lose consciousness. Clearly, the voltage was too low, and they decided to try again the next day. Overhearing the two doctors, the patient said, “Not another one! It’s deadly!” As those were the only comprehensible words they had heard the patient utter, they ignored his protests and decided to try again immediately with a higher current.

  We pick up the story in Dr. Cerletti’s words:We observed the same instantaneous, brief, generalized spasm, and soon after, the onset of the classic epileptic convulsion. We were all breathless during the tonic phase of the attack, and really overwhelmed during the apnea as we watched the cadaverous cyanosis of the patient [who is turning blue].... Finally, with the first stertorous breathing and the first clonic spasm, the blood flowed better not only in the patient’s vessels but also in our own. There upon we observed with the most intensely gratifying sensation the gradual awakening of the patient “by steps.” He rose to a sitting position and looked at us, calm and smiling, as though to inquire what we wanted of him. We asked: “What happened to you?” He answered: “I don’t know. Maybe I was asleep.” Thus occurred the first electrically produced convulsion in man, which I at once named electroshock.

  Electroshock therapy, too, was quickly accepted in the New World, mainly because it was deemed easier and safer to administer than the insulin or metrazol shocks. Just three years after the Rome experiment, McLean reported that forty-three patients, eleven men and thirty-two women, had received the new treatment. Psychiatrist-in-chief Tillotson noted that nine of the patients showed no apparent benefit. Thirty-four of them “responded with clinical improvements of varying degree and duration.” Of these, twelve were able to leave the hospital. As was often the case with all of the shock regimens, the patients hurt themselves. Even when securely strapped to a gurney, their bodies sometimes exploded into dramatic and extreme contortions.10 Five patients suffered compression fractures in their spine. Two others dislocated their jaws. Rooting behind a bank of file cabinets in his office, McLean archivist Terry Bragg once showed me the first electric shock apparatus purchased by the hospital, a Reiter Electro Stimulator manufactured in Italy in 1938. It was a chunky, briefcase-like device weighing ten pounds, not unlike the portable radio transmitters that spies use in World War II movies. It had a “Sampler” switch with “Sample” and “Trial” settings, and a “Dosage Scale” with only two calibrations: “Low” and “High.”

  None of the above-mentioned treatments originated at McLean. Indeed, none originated in the United States, and McLean was, in the scheme of things, a cautious adopter of new therapies. But McLean doctors did claim to have invented a curious goulash of the newly available therapies, to which they assigned the name “total push.” In two papers published in 1939, Kenneth Tillotson and Abraham Myerson (who had evinced such an interest in the upper-class predilection for schizophrenia) outlined an ambitious mobilization program that they adopted for a group of thirty-three McLean patients. They chose some of the stupefied, chronic “back-ward” types, “who sit on benches, stand in a corner or pace automatically to and fro, grimacing, passive and absorbed in [their] delusions,” and decided to throw
the book at them. Everything medical psychiatry had to offer was brought to bear on the target population: Nurses rousted them out of bed in the morning and forced them to go out on walks. Daily visits to the hydriatic suite for “showers, douches, massage and rubdowns” were de rigueur. Sports and athletics were emphasized, and the patients received better food. But meals were no longer available through room service; total push forced the patients to show up in the ward dining rooms to be fed. Patients who had been reluctant to eat were given a drug to stimulate their appetites. Vitamins were prescribed. The doctors forced men and women who had hovered around their wards in tattered bathrobes to dress neatly and present themselves to the general population. “Proper conduct” was reinforced with the granting of privileges, like access to “candy, ice cream ... delicacies, cigarettes, and cigars,” which were likewise withheld from malingerers. In his total push manifesto, Myerson seemed to be anticipating the future vogue of behaviorist psychology: “It would be interesting, but entirely impossible, to see what the effect of physical reward and physical pain would be, but society has not yet developed to the point where certain privileges and physical punishment can safely be used.” Beating up on the Brahmin clientele was hardly McLean’s style.

  The psychological mobilization worked, supposedly, in tandem with the physiological shock therapies to get the dulled patients going again. (For some reason, Myerson also recommended the ultraviolet irradiation of the male patients’ testicles, although he freely admitted that this procedure was “not related insofar as we know at present to the general well-being of the individual.”) Not surprisingly, Tillotson declared total push to be a success. Of twenty-two patients he examined, he claimed that all had either slightly, much, or markedly improved. There was no later follow-up study because the outbreak of World War II effectively ended the total push experiment. McLean’s luxurious 2:1 patient-to-staff ratio vanished into the wartime draft. A small army of male aides, nurses, and doctors left Belmont, and the staff-intensive total push experiment fell by the wayside.