Shrinks
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When I was in grade school, individuals afflicted with schizophrenia, bipolar disorder, major depression, autism, and dementia all had little hope for recovery—and virtually no hope at all for stable relationships, gainful employment, or meaningful personal development. Psychiatrists of the era were keenly aware of the abhorrent conditions that their patients experienced inside mental institutions and the overwhelming challenges they faced outside of them, and they longed for something—anything—to relieve their patients’ suffering. Driven by compassion and desperation, asylum-era physicians devised a succession of audacious treatments that today elicit feelings of revulsion or even outrage at their apparent barbarism. Unfortunately, many of these early treatments for mental illness have become forever linked with the public’s dismal image of psychiatry.
The simple fact is that the alternative to these crude methods was not some kind of medicinal cure or enlightened psychotherapy—the alternative was interminable misery, as there was nothing that worked. Even the risks of an extreme or dangerous treatment often seemed worthwhile when weighed against lifelong institutionalization in a place like Pilgrim or Rockland. If we want to fully appreciate just how far psychiatry has progressed—to the point where the vast majority of individuals with severe mental illness have the opportunity to lead a relatively normal and decent life if they receive good treatment instead of wasting away inside the decrepit walls of an asylum—however, we must first confront the desperate measures that psychiatrists pursued in their improbable quest to defeat mental illness.
Fever Cures and Coma Therapy
In the early decades of the twentieth century, asylums were filled with inmates suffering from a peculiar form of psychosis known as “general paresis of the insane,” or GPI. It was caused by advanced syphilis. Left untreated, the spiral-shaped microorganism that caused this venereal disease would burrow into the brain and produce symptoms often indistinguishable from schizophrenia or bipolar disorder. Since syphilis remained untreatable in the early twentieth century, psychiatrists searched frantically for any way to reduce the symptoms experienced by a flood of GPI-demented patients, which included mobster Al Capone and composer Robert Schumann.
In 1917, as Freud was publishing Introductory Lectures on Psychoanalysis, another Viennese physician was about to make an equally astonishing discovery. Julius Wagner-Jauregg was the scion of a noble Austrian family. He studied pathology in medical school and then went to work in a psychiatry clinic, where he cared for psychotic patients. One day, he observed something surprising in a GPI patient named Hilda.
Hilda had been lost to the turbulent madness of the disease for more than a year when she came down with a fever entirely unrelated to her syphilis, a symptom of a respiratory infection. When the fever subsided, Hilda awoke clear-headed and lucid. Her psychosis had vanished.
Since the symptoms of GPI typically progressed in only one direction—worse—the remission of Hilda’s psychotic symptoms piqued Wagner-Jauregg’s interest. What had happened? Since her sanity had been restored immediately after her fever subsided, he surmised that something about the fever itself must be responsible. Perhaps her elevated body temperature had stunned or even killed the syphilis spirochetes in her brain?
Today, we know that fevers are one of the body’s oldest and most primitive mechanisms for fighting infection—part of what is known as the “innate immune system.” The heat of a fever damages both host and invader, but it is often more damaging to the invader since many pathogens are sensitive to high temperatures. (Our more evolutionarily recent “adaptive immune system” produces the familiar antibodies that target specific invaders.) Lacking any meaningful understanding of the mechanics of fever, Wagner-Jauregg conceived a bold experiment to test the effects of high temperatures on psychosis. How? By infecting GPI patients with fever-producing diseases.
He started out by serving his psychotic patients water containing streptococcal bacteria (the source of strep throat). Next he tried tuberculin, an extract from the bacteria that cause tuberculosis, and eventually malaria, probably because there was a ready supply of malaria-infected blood from soldiers returning from World War I. After Wagner-Jauregg injected his GPI patients with the Plasmodium parasites that cause malaria, the patients succumbed to the characteristic fever of malaria… and shortly afterward, exhibited dramatic improvements in their mental state.
Patients who previously behaved bizarrely and talked incoherently now were composed and conversed normally with Dr. Wagner-Jauregg. Some patients even appeared cured of their syphilis entirely. Here in the twenty-first century it may not seem like a favorable bargain to trade one awful disease for another, but at least malaria was treatable with quinine, a cheap and abundant extract of tree bark.
Wagner-Jauregg’s new method, dubbed pyrotherapy, quickly became the standard treatment for GPI. Even though the idea of intentionally infecting mentally ill patients with malaria parasites raises the hair on the backs of our necks—and indeed, about 15 percent of patients treated with Wagner-Jauregg’s fever cure died from the procedure—pyrotherapy represented the very first effective treatment for severe mental illness. Think about that for a moment. Never before in history had any medical procedure been shown to alleviate psychosis, the most forbidding and relentless of psychiatric maladies. GPI had always been a one-way ticket to permanent institutionalization or death. Now, those afflicted with the mind-ravaging disease had a reasonable chance of returning to sanity—and possibly returning home. For this stunning achievement, Wagner-Jauregg was awarded the Nobel Prize in Medicine in 1927, the first ever for the field of psychiatry.
Wagner-Jauregg’s fever cure instilled hope that there might be other practical ways to treat mental illness. With the benefit of modern hindsight, we might point out that compared to other mental illnesses GPI was highly unusual, since it was caused by an external pathogen infecting the brain. We would hardly expect that a germ-killing procedure would have any effect on other mental illnesses after legions of biological psychiatrists had failed to detect the presence of any foreign agent in patients’ brains. Nevertheless, inspired by Wagner-Jauregg’s success, many psychiatrists in the 1920s attempted to apply pyrotherapy to other disorders.
In asylums around the country, patients with schizophrenia, depression, mania, and hysteria were soon infected with a wide variety of fever-producing diseases. Some alienists even went so far as to inject malaria-infected blood through the skulls of schizophrenic patients directly into their brains. Alas, pyrotherapy did not turn out to be the panacea that so many had hoped for. Though the fever cure mitigated the psychotic symptoms of GPI, it proved impotent against all other forms of mental illness. Since other disorders were not caused by pathogens, there was nothing for the fever to kill, except, occasionally, the patient.
Even so, the unprecedented effectiveness of pyrotherapy in treating GPI shined the first glimmer of light into the darkness that had dominated asylum psychiatry for over a century. Spurred by Wagner-Jauregg’s success, another Austrian psychiatrist, Manfred Sakel, experimented with a physiological technique even more unsettling than malaria therapy. Sakel had been treating drug addicts with low doses of insulin as a way of combatting opiate addiction. Often, heavy users of morphine and opium would exhibit extreme behaviors similar to mental illness, such as relentless pacing, frenetic movement, and disorganized thought. Sakel noticed that when addicts were accidentally given higher doses of insulin, their blood sugar would drop precipitously, inducing a hypoglycemic coma that could last for hours at a time—but after they awoke, they were much calmer, and their extreme behavior had abated. Sakel wondered: Might comas also relieve the symptoms of mental illness?
Sakel began to experiment with artificially induced comas. He overdosed schizophrenic patients with insulin, which had recently been developed as a treatment for diabetes. The insulin overdose put them into a coma, which Sakel ended by administering intravenous glucose. After the patients regained consciousness, Sakel would wait a short while, then repeat the proce
dure. He would sometimes induce a coma in a patient six days in a row. To his delight, his patients’ psychotic symptoms diminished and they showed apparent signs of improvement.
As you might imagine, there were significant risks to Sakel’s technique. One side effect was that patients invariably became grossly obese, since insulin pushes glucose into cells. A far more permanent side effect was that a small number of patients never woke from the coma and died outright. The most salient risk was permanent brain damage. The brain consumes a disproportionate share of the body’s total glucose (70 percent) despite the fact that it accounts for only 2 percent of the body’s weight. Consequently, our organ of consciousness is acutely sensitive to fluctuations in blood glucose levels and easily incurs damage if the levels are low for any stretch of time.
Rather than viewing brain damage as a liability, advocates of Sakel’s method claimed it was actually a benefit: If brain damage did occur it produced a desirable “loss of tension and hostility,” or so Sakel’s proponents rationalized.
Like fever therapy, coma therapy became widely adopted by alienists throughout the United States and Europe. It was used at almost every major mental hospital in the 1940s and ’50s, with each institution developing its own protocol for administering coma therapy. In some cases, patients were placed into a coma fifty or sixty times during the course of treatment. Despite the manifest risks, psychiatrists marveled at the fact that finally, finally, there was something they could do to ease the suffering of their patients, even if temporarily.
Nothing an Ice Pick to the Eye Can’t Fix
Ever since the very earliest psychiatrists began conceiving of disturbed behaviors as illnesses (and even long before), they held out hope that direct manipulation of a patient’s brain might one day prove therapeutic. In the 1930s, two treatments were developed that promised to fulfill these hopes. One survived a difficult start and a notorious reputation to become a mainstay of contemporary mental health care. The other followed an opposite track, starting out as a promising treatment that was rapidly adopted around the world, but ending up as the most infamous treatment in the history of psychiatry.
Starting many millennia ago with prehistoric cases of trepanation—the drilling of holes through the skull into the brain—physicians have attempted brain surgery as a means of treating the emotional chaos of mental disorder, always without success. In 1933, one Portuguese physician was undeterred by this legacy of failure. António Egas Moniz, a neurologist on the faculty of the University of Lisbon, shared the conviction of the biological psychiatrists that mental illness was a neural condition, and therefore should be treatable through direct intervention in the brain. As a neurologist, he had learned that strokes, tumors, and penetrating brain injuries each impaired behaviors and emotions by damaging a specific part of the brain. He hypothesized that the opposite should also hold true: by damaging an appropriate part of the brain, impaired behaviors and emotions could be rectified. The only question was, what part of the brain should be operated on?
Moniz carefully studied the various regions of the human brain to determine which neural structures might be the most promising candidates for surgery. In particular, he hoped to find the parts of the brain that governed feelings, since he believed that calming a patient’s turbulent emotions was the key to treating mental illness. In 1935, Moniz attended a lecture at a medical conference in London where a Yale neurology researcher made an interesting observation: When patients sustained injuries to their frontal lobe, they became emotionally subdued, but, curiously, their ability to think seemed undiminished. Here was the breakthrough Moniz had been looking for—a way to calm the stormy emotions of mental illness while preserving normal cognition.
When he returned to Lisbon, Moniz eagerly set up his first psychosurgery experiment. His target: the frontal lobes. Since Moniz lacked any training in neurosurgery, he recruited a young neurosurgeon, Pedro Almeida Lima, to perform the actual procedure. Moniz’s plan was to create lesions—or, to put it more bluntly, inflict permanent brain damage—within the frontal lobes of patients with severe mental disorders, a procedure he dubbed a leucotomy.
Moniz performed the first of twenty leucotomies on November 12, 1935, at the Hospital de Santa Marta in Lisbon. Each patient was put to sleep under general anesthesia. Lima drilled two holes in the front of the skull, just above each eye. Then, he performed the crux of the procedure: He inserted the needle of a special syringe-shaped instrument of his own invention—a leucotome—through the hole in the skull. He pressed the plunger on the syringe, which extended a wire loop into the brain. Next, the leucotome was rotated, carving out a small sphere of brain tissue like coring an apple.
How did Moniz and Lima decide where to cut the brain, considering that brain imaging and the use of stereotactic procedures was still far off in the future and precious little was known about the functional anatomy of the frontal lobes? Favoring the shotgun over the rifle, the Portuguese physicians carved out six spheres of brain tissue from each frontal lobe. If they were dissatisfied with the results—if the patient was still disruptive, for instance—then Lima might go back and slice out even more brain tissue.
In 1936, Moniz and Lima published the results of their first twenty leucotomies. Before the surgery, nine patients had depression, seven had schizophrenia, two had anxiety disorders, and two were manic-depressive. Moniz claimed that seven patients improved significantly, another seven were somewhat improved, and the remaining six were unchanged. None, according to the authors, were worse off after the procedure.
When Moniz presented his results at a medical conference in Paris, Portugal’s top psychiatrist, José de Matos Sobral Cid, denounced the new technique. Cid was director of psychiatry at Moniz’s hospital and had viewed the leucotomized patients firsthand. He described them as “diminished” and exhibiting a “degradation of personality,” and argued that their apparent improvement was actually shock, no different from what a soldier experienced after a severe head injury.
Moniz was undaunted. He also proposed a theory to explain why leucotomies worked, a theory firmly in the camp of biological psychiatry. He announced that mental illness resulted from “functional fixations” in the brain. These occurred when the brain could not stop performing the same activity over and over, and Moniz asserted that the leucotomy cured patients by eliminating their functional fixations. Cid decried Moniz’s after-the-fact theory as “pure cerebral mythology.”
Despite such criticisms, Moniz’s treatment, the transcranial frontal leucotomy, was celebrated as a miracle cure, and the reason is understandable, if not quite forgivable. One of the most common problems for any asylum psychiatrist was how to manage disruptive patients. The asylum, after all, was designed to care for individuals who were too obstreperous to live in society on their own. But short of physically restraining them, how can you control a person who is persistently agitated, rowdy, and violent? For the alienists, the calming effects of Moniz’s leucotomy seemed like the answer to their prayers. After a relatively simple surgery, endlessly troublesome patients could be rendered docile and obedient.
Leucotomies spread like wildfire through the asylums of both Europe and America (in the United States, they became popularly known as lobotomies). The adoption of Moniz’s surgery transformed mental institutions in one way that was immediately apparent to the most casual visitor. For centuries, the standard asylum soundtrack consisted of incessant noise and commotion. Now, this boisterous din was replaced with a more agreeable hush. While most proponents of psychosurgery were aware of the dramatic changes in its subjects’ personalities, they argued that Moniz’s “cure” was at least more humane than locking patients in straitjackets or padded cells for weeks on end, and it was certainly more convenient for the hospital staff. Patients who had previously smacked the walls, hurled their food, and shouted at invisible specters now sat placidly, disturbing no one. Among the more notable people subjected to this dreadful treatment were Tennessee Williams’s sister Rose and Ros
emary Kennedy, the sister of President John F. Kennedy.
All too quickly, the American lobotomy evolved from a method for subduing the most disruptive patients to a general therapy for managing all manner of mental illnesses. This trend followed the trajectory of so many other psychiatric movements—from Mesmerism to psychoanalysis to orgonomy—whose practitioners came to regard a narrowly prescribed method as a universal panacea. If the only tool you own is a hammer, the whole world looks like a nail.
On January 17, 1946, an American named Walter Freeman introduced a radical new method of psychosurgery. Freeman was an ambitious and highly trained neurologist who admired Moniz for his “sheer genius.” He believed that mental illness resulted from overactive emotions that could be dampened by surgically lesioning the emotional centers of the brain. Freeman felt that many more patients could benefit from the procedure, if only it could be made more convenient and inexpensive: The Moniz method required a trained surgeon, an anesthesiologist, and a pricey hospital operating room. After experimenting with an ice pick and a grapefruit, Freeman ingeniously adapted Moniz’s technique so that it could be performed in clinics, doctor’s offices, or even the occasional hotel room.
On January 17, 1946, in his Washington, DC, office, Walter Freeman performed the first-ever “transorbital lobotomy,” on a twenty-seven-year old woman named Sallie Ellen Ionesco. The procedure involved lifting the patient’s upper eyelid and placing, under the eyelid and against the top of the eye socket, the point of a thin surgical instrument that closely resembled an ice pick. Next, a mallet was used to drive the point through the thin layer of bone at the back of the eye socket and into the brain. Then, like Moniz’s coring procedure with a leucotome, the tip of the ice pick was rotated to create a lesion in the frontal lobe. Freeman performed ice pick lobotomies on no fewer than 2,500 patients in twenty-three states by the time of his death in 1972.