Bellevue

by David Oshinsky

  Wertham seemed to relish the chance to embarrass his former boss, whom he clearly despised. His answers ranged from contempt to amazement as he wondered aloud why Gregory hadn’t bothered to take a detailed history of the defendant or to read his letters carefully enough to appreciate their unmistakable depravity. Albert Fish was a virtual encyclopedia of deviant behavior, Wertham concluded. “However you define the medical and legal borders of sanity, this certainly is beyond that border.”

  Two psychiatrists joined Wertham at the trial to support the insanity plea; two others joined Gregory to insist that the defendant understood right from wrong. The low point came when one of the prosecution’s psychiatrists described Fish as “a psychopathic personality without a psychosis,” and therefore “sane,” leading the baffled defense attorney to inquire whether the cannibalistic murder of a child didn’t point to some sort of abnormality. “Well,” came the deadpan reply, “there is no accounting for taste.”

  The death sentence was hardly a surprise. A number of the jurors supported it while also believing Fish to be insane. Their logic, quite simply, was that the crime itself was too demonic to be punished by anything less than the electric chair, regardless of the defendant’s state of mind. Albert Fish saw no reason to protest. “Thank you, Judge,” he said, with a wave of his hand. How thoughtful of everyone to provide the greatest gift one could imagine: unspeakable pain. Getting electrocuted, said Fish, “will be the supreme thrill of my life.”

  The trial would be Menas Gregory’s professional swan song. Humiliated by his junior colleagues, forced into retirement by La Guardia’s allies, he took on some private patients and added a few hobbies to his suddenly uncluttered days. The final headline bearing his name appeared to sum it up well: “DR. GREGORY DIES ON GOLF LINKS: Noted Psychiatrist Stricken [on] Second Tee of Tuckahoe Course.”

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  If one had to pick the ringleader of the coup against Gregory, it most likely was Paul Schilder. Arriving in America in 1928, Schilder had lectured at Johns Hopkins before coming to Bellevue as its first director of psychiatric research. His prime interests were psychotherapy and what he called the “mind-body connection,” with a strong emphasis on child development. “It was extraordinary how under Schilder’s encouragement almost every clinical encounter on the wards became grist for the research mill,” a colleague noted. Schilder attracted those who would form the core of the anti-Gregory revolt, a group that included Lauretta Bender, a recent medical school graduate who became Schilder’s research collaborator—and then his wife.

  Their marriage proved tragically short. Among Schilder’s many quirks was a disdain for traffic lights, which led him to cross major thoroughfares “with books piled to eye level” and an arm extended to halt speeding cars. In 1940, he was run over and killed outside Bellevue after visiting Lauretta and their week-old baby in the maternity ward. He was fifty-four years old.

  Schilder’s death appeared to end two promising careers—his and Bender’s. Married only five years, the couple had published extensively together in the psychiatric journals. Whether Bender could survive professionally without him was doubtful, given the low regard for women in medicine and her duties as a single mother. Her colleagues expected her to cut back her schedule; some even urged her to retire. But Bender, then forty-three, had other plans. She would honor Paul Schilder by continuing their research, she told friends, and her three children would be just fine. “She may not have been home to give us milk and cookies, but there was never [neglect],” her son recalled. “She did everything the men were doing in medicine while also raising a family and running a house.”

  Bender’s own childhood had been chaotic. Her father, a restless sort, had moved the family from one town to another before putting down roots in rural Iowa. And her mother, barely nineteen when Lauretta was born, grew more depressed with each coming child. “She loved her infants as infants,” Bender wrote in her unpublished autobiography. “But once they were out of her arms, there was nothing she could find in her background or limited experience that made her ready or willing to meet their needs.”

  Lauretta’s needs were many. She repeated first grade three times and didn’t learn to read until she was nine. Spelling, grammar, and penmanship remained elusive for years. In fact, Bender was dyslexic—a condition she would study in great depth later on. Had a close relative not been in charge of her elementary school, she recalled, “I doubt that I would have graduated.”

  Spending painful hours each day on the basics of her education, Bender became the valedictorian of her high school. From there she attended the University of Chicago and earned her medical degree at Iowa State. She chose medicine “because of the scientific subjects one could study, not in anticipation of becoming a practicing physician”—which led to a fellowship at Johns Hopkins, where she met Paul Schilder. “I knew immediately,” she wrote, “that he was the man I had been looking for.”

  Bender followed him to Bellevue. Gregory’s new psychiatric building had just opened, allowing patients to be separated by age, sex, and condition. There now were “quiet” wards for the least troublesome, “semi-disturbed” wards for the more difficult, and “disturbed” wards for the violent and suicidal. The hospital contained a children’s ward, another for adolescents, twelve to sixteen, who previously were thrown in with adults, and yet another for prisoners, complete with holding cells, armed guards, and a courtroom to determine the patient’s “mental capacity” to stand trial. “They flock to [us] by the dozen, mostly because they can get a bath, free food, and lodging,” a Bellevue intern wrote in 1934, noting the impact of the Great Depression. “Our treatment of drunks [is] on the whole the noblest aspect of our psychiatric service—nowhere else are they afforded such a convivial welcome.”

  Bender took over the children’s ward in 1934. Mayor La Guardia may have had little faith in her profession—disturbed people needed “more pasta and less psychiatry,” he famously muttered—but no one was better at bringing federal relief dollars to his city. At Bellevue, funding poured in from New Deal agencies for all sorts of projects, most conspicuously the nine elegant murals in the hospital’s main rotunda painted by David Margolis (at $26.50 a week) portraying “Agriculture,” “Industry,” “Research,” and other stories of human progress. A steady flow of “aides” and “assistants” also appeared on Bender’s ward, compliments of the Works Progress Administration. Bender favored aspiring artists, musicians, and dancers—those who might reach the children in novel ways. Her own struggles with dyslexia led her to develop the Bender Visual Motor Gestalt Test, which evaluated the “inner thoughts” of her patients by studying the ways they drew and interpreted different shapes. At times, Bender touched on questions common to the 1930s but harshly dismissed today, such as the role of race in determining behavior. In one instance, she wrote that the “two features which almost anyone will concede as characteristic of [Negroes]” are “the capacity for so-called laziness and the special ability to dance.” These features, she thought, “may be an expression of specific brain impulse tendencies.”

  What most interested her, though, was childhood schizophrenia, a subject barely examined at the time. Her own definition was expansive, covering a wide range of disorders (including autism, which she studied decades before it became a popular diagnosis). “It was almost a pleasure to [see] a brain tumor, because you felt [it] could at least be treated,” a Bellevue colleague recalled of psychiatry in the 1930s. “Before the vast bulk of our material we stood baffled, helpless and forlorn.”

  Then, from Vienna, came a ray of hope. A new treatment appeared to shock the brain of severely depressed and schizophrenic patients into “equilibrium” by inducing seizures akin to an epileptic fit. Researchers called it “convulsive therapy.” Bender was intrigued.

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  The first wave of convulsive therapy involved insulin, discovered by Canadian researchers in the 1920s. Produced in the pancreas, insulin regulates glucose levels in the blood. A lack of
insulin leads to hyperglycemia (high blood glucose), while a surplus results in hypoglycemia, a condition marked by convulsions and seizures when too little glucose reaches the brain. In the 1930s, a European psychiatrist named Manfred Sakel noticed that insulin-induced comas had a dramatic impact on those suffering from depression and schizophrenia. He began to induce these comas in his own patients, claiming that 88 percent of them showed fewer signs of mental illness, but warning that the long-term effects were yet unknown.

  Other methods soon followed. From Hungary came word of a convulsive therapy using metrazol, a chemical stimulant known to cause “explosive seizures” when injected in high doses. Early studies showed it to be effective in treating schizophrenia. The downside was that the violence of the convulsions caused numerous broken bones and vertebrae fractures, though most were optimistically described as “hairline” or “innocuous.”

  Convulsive therapy made its American debut at Bellevue. One of the hospital’s younger psychiatrists, Joseph Wortis, had witnessed Sakel’s insulin comas while studying in Vienna. Amazed by the results, Wortis convinced Bellevue’s new psychiatric director, Karl Bowman, to allow insulin shock treatment on patients in the “disturbed” wards. No one knew then—or knows for certain today—why a seizure restores a patient’s mental faculties, or how it works. The therapeutic qualities of shock treatment remain one of the great mysteries of medical science. Wortis admitted as much in a speech to the New York Neurological Society. “It is not simply a shock…which accomplishes the result,” he said. “It is something else; I do not know what it is, but my opinion is that it is something rather different.”

  The mystery of shock treatment proved no barrier to its use. “Our insulin wards now have 26 beds and I have been provided with two assisting physicians, ten nurses, and a secretary,” Wortis wrote of his work at Bellevue. “We have had many visitors [coming] to learn the technique.” He wasn’t exaggerating. Four years later, the U.S. Public Health Service reported that more than 70 percent of the nation’s mental institutions had experimented with, or were currently using, insulin shock therapy.

  These experiments mirrored the shaky medical ethics of the time. At Bellevue, for example, Wortis never bothered to discuss the risks with patients undergoing insulin shock or to seek their consent. Nor did he explain that multiple treatments would be required, stretching over weeks and sometimes months. In a typical case, involving “an 18-year-old intelligent colored boy” with symptoms of “paranoid schizophrenia,” Wortis admitted that the patient was uncomfortable with the early treatments and probably wanted them to end. The patient complained of headaches. His hands shook, his voice trembled, and he didn’t see any positive results. Rather than stopping, however, Wortis “gradually increased the doses of insulin” until “full epileptic seizures” were produced.

  The patient improved. He no longer heard voices. “I don’t feel confused. I don’t feel afraid,” he said. “I feel all right, like my old self.” For Wortis, the end justified the means. “We can afford to wait for further results and observations,” he wrote in a privately circulated memo, “but in the meantime we have every reason to welcome an important and invigorating new influence in psychiatry.”

  The optimism, though understandable, was premature. Insulin shock soon fell into disfavor. Hospitals found the treatment far too labor-intensive. The patient’s heart rate, blood pressure, and respiration had to be carefully monitored, with a sugar solution at hand in case of trouble. Furthermore, the benefits of insulin shock seemed to wear off quickly, leading some to question whether the risks outweighed the rewards. The answer came in 1942, when a Bellevue patient died following an insulin-induced seizure. There would be no more.

  Wortis was far from discouraged. Convulsive treatments hadn’t disappeared at Bellevue; they’d simply taken a different form. “[Our unit] is now pushing electro-shock work and we expect to be started soon,” Wortis wrote a friend in 1940. “[We’re] already doing work on rats after electro-shock convulsions and the thing is full of interesting research possibilities.”

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  “Electro-shock,” known today as electroconvulsive therapy (ECT), also began in Europe. Its developer, an Italian psychiatrist named Ugo Cerletti, got the idea by watching pigs being stunned with an electric prod before they were slaughtered—the jolt caused pronounced convulsions. At his laboratory in Rome, Cerletti worked to find the “margin of safety” that human experimentation required. What constituted the proper amount of electricity? How long should each shock be? And how many were needed to produce the desired result?

  ECT had its advantages. There were no toxic reactions, and the convulsions were less violent—thus fewer broken bones. Cerletti claimed that schizophrenic and severely depressed patients responded well to multiple sessions of ECT, appearing more relaxed, coherent, and self-aware. There seemed to be no medical complications beyond temporary memory loss—nothing, in Cerletti’s words, which “could damage the nervous system.” Observers who flocked to his Rome clinic were duly impressed. Within months, the procedure had spread across Europe, and on to the United States.

  The biggest hurdle to ECT is one that still haunts the treatment today: its disturbing resemblance to the fictional experiments of Mary Shelley’s Dr. Frankenstein. When an American psychiatrist first proposed a demonstration at the prestigious New York Academy of Medicine in 1940, he got nowhere. “What? Pass an electric current through a patient’s head?” a colleague shouted. You must be crazy.

  There were fewer qualms at Bellevue. One had only to visit the “very disturbed” ward to grasp the problem, a psychiatrist wrote: patients “shrieking and screaming, restrained in straight jackets with only amytal sodium or wet packs available to quiet them temporarily.” Perfect or not, ECT offered hope.

  It also reached America at a moment when an even more controversial treatment was being employed, making it seem almost tame by comparison. Called a “lobotomy,” the rival process involved snipping the nerve fibers that connected the frontal lobe to other parts of the brain, causing irreversible change. No one doubted that a lobotomy could turn an unruly patient into a docile one; the problem, according to several Bellevue psychiatrists who witnessed it, was that those undergoing the procedure emerged as “amiable vegetables.” How many were performed at Bellevue is unclear, though the number appears to be small.

  The pioneers of electric shock at Bellevue included Joseph Wortis, David Impastato, and, most surprisingly, Lauretta Bender in the children’s ward. Impastato administered the first ECT treatment in the United States in 1940, using a clumsy apparatus with precise, if somewhat frightening, instructions:

  1) Place a generous amount of electrode jelly on both sides of the patient’s head.

  2) The electrodes should be applied in the frontal-temporal region with firm pressure.

  3) The large knob marked “SET TO DESIRED VOLTAGE” should be turned counter-clockwise.

  4) Plug the electrode connecting cord into the stimulating unit.

  5) Turn the knob marked “RESISTANCE” until it is opposite the white dot.

  6) Set switch marked “SHOCK DURATION” to 0.10.

  7) Throw the “TREAT” switch from “A” down to “B” position. As this is done the patient will receive the shock.

  Above all, it warned, “NEVER ADMINISTER ELECTRO-SHOCK IN A METAL BED.”

  Thousands would undergo ECT at Bellevue in the coming years—many of them children. Indeed, few units employed it as systematically as Dr. Bender’s. The tragic death of her husband in 1940 may have played a role in her decision, as she grew closer to Karl Bowman, her boss, who strongly favored its use. Whether Bowman encouraged Bender, or whether he simply acquiesced, is lost to history. What is clear is that he didn’t say no.

  Bender would soon be running one of the more questionable experiments in Bellevue’s history. A few years earlier, the leading child psychiatrist in France, Georges Heuyer, had raised eyebrows by using ECT on a handful of “depressed” adolescen
ts. But no one had thought to lower the bar even further—until Dr. Bender in 1942.

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  Over a period of eight years, more than a hundred children in Bender’s Unit (PQ6), some as young as four, would undergo ECT on a regular basis. In an era before medical science demanded random controls, double-blind studies, or informed consent, the experiment nonetheless stood out for the age of its subjects. There was nothing clandestine about it. Bender received generous funding from the U.S. Public Health Service and shared her findings in the leading psychiatric journals. Publicly, she spoke of electric shock as an effective method for treating serious mental disorders. Privately, she described it as the last hope for previously “unreachable” children. “If you were confronted by the cross-section of patients at Bellevue [that I deal with],” she told a British colleague, “you would do everything to try to make life easier for [them] and their families.”

  By the mid-1940s, Bender’s ward was dangerously overcrowded. Children came from every direction, dropped off by parents and relatives, by other hospitals, and by social service agencies. The beds ran out; patients routinely slept on cots in the halls. Bender estimated that 75 to 85 percent of her cases had severe behavior problems resulting from broken families, learning disabilities, and “organic brain disorders.” Those “under observation” spent thirty days at Bellevue before being sent home, or to foster care, or to a state institution. Those receiving “intense therapy” stayed for sixty days and more. The latter group, containing the tougher cases, became candidates for ECT.