Shrinks (22 page)

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 Rosemary 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.

Transorbital lobotomies were still being performed when I entered medical school. My sole encounter with a lobotomized patient was a rather cheerless affair. He was a thin, elderly man in St. Elizabeths Hospital in Washington, DC, who sat staring out at nothing in particular, as still as a granite statue. If you asked him a question, he responded in a quiet, robotic tone. If you made a request, he complied as dutifully as a zombie. Most disconcerting were his eyes, which appeared lifeless and blank. I was informed that at one time he had been unremittingly aggressive and unruly. Now, he was the “perfect” patient: obedient and low-maintenance in every way.

Walter Freeman performing a lobotomy. (© Bettmann/CORBIS)

Astonishing though it may seem, Moniz received the Nobel Prize in 1949 “for his discovery of the therapeutic value of leucotomy in certain psychoses,” marking the second Nobel Prize given for the treatment of mental illness. The fact that the Nobel committee was honoring malaria cures and lobotomies underscores the desperation for any form of psychiatric treatment.

Fortunately, contemporary psychiatry has long since discarded the dangerous and desperate methods of fever therapy, coma therapy, and transorbital lobotomies after the revolution in treatments beginning in the 1950s and ’60s. But one form of therapy from the “snake pit” era has survived as the most common and effective somatic treatment in psychiatry today.

Electrified Brains

As the use of fever therapy and coma therapy spread through mental hospitals around the world, alienists observed another unexpected phenomenon: The symptoms of psychotic patients who also suffered from epilepsy seemed to improve after a seizure. Since fever improved the symptoms of patients with GPI, and insulin dampened the symptoms of psychosis, might seizures also be harnessed as a treatment?

In 1934, the Hungarian psychiatrist Ladislas J. Meduna began experimenting with different methods for inducing seizures in his patients. He tried camphor, a scented wax used as a food additive and embalming fluid, and then metrazol, a stimulant that causes seizures in high doses. Amazingly, Meduna discovered that psychotic symptoms really did diminish after a metrazol-induced seizure.

Meduna’s novel seizure treatment quickly became known as
convulsive therapy
, and by 1937 the first international meeting on convulsive therapy was held in Switzerland. Within three years, metrazol convulsive therapy had joined insulin coma therapy as a standard treatment for severe mental illness in institutions all around the world.

There were problems with metrazol, however. First, before the convulsions actually started, the drug induced a feeling of impending doom in the patient, a morbid apprehension that was only heightened by the awareness that he was about to experience an uncontrollable seizure. This fearful anxiety must have been even worse for a psychotic patient already suffering from frightening delusions. Metrazol also provoked thrashing convulsions so violent that they could become, quite literally, backbreaking. In 1939, an X-ray study at the New York State Psychiatric Institute found that 43 percent of patients who underwent metrazol convulsive therapy experienced fractures in their vertebrae.

Physicians began to look for a better way to induce seizures. In the mid-1930s, an Italian professor of neuropsychiatry, Ugo Cerletti, was experimentally inducing seizures in dogs by delivering electrical shocks directly to their heads. He wondered if electrical shocks might also induce seizures in humans, but his colleagues dissuaded him from attempting such experiments on people. Then one day while buying meat from the local butcher he learned that while slaughtering pigs, butchers often applied electrical shocks to their heads to put the animals into a kind of anesthetized coma before cutting their throats. Cerletti wondered: Would an electrical shock to a patient’s head also produce anesthesia before provoking convulsions?