Manufacturing depression (20 page)

Perhaps for his candor, unusual in the late Victorian era, or simply because his work was exciting to read, Ellis was, according to Wortis, the “
literary and scientific hero
of my college days.” Hero and acolyte met in 1927, and the good feeling was evidently mutual, for when Mrs. Porter approached Ellis six years later, Wortis’s name came to mind. Ellis relayed his interest to Adolf Meyer, by then at Johns Hopkins, who asked around at Bellevue Hospital, where Wortis was beginning his psychiatric training. The Bellevue staff told Meyer that Wortis was “
very unusually talented,”
and the next thing Wortis knew, two of the most prominent medical men in the world were throwing Mrs. Porter’s money at him.

There was only one problem. “
I had no wish
…to become a sexologist,” Wortis said. “I also had some doubts and misgivings about a project that might be intended to involve special pleading on behalf of homosexuals.” But he didn’t let that dissuade him. “I would be glad to accept a fellowship of the sort described,” he told Ellis, “if it allowed me to pursue my general psychiatric training, with a view to later turning my interest to special studies in the field of sex.” (Wortis never did turn his interests in Mrs. Porter’s desired direction—at least in part because after seven years he concluded that he couldn’t agree with “
the views of the widow
…who thought her husband was born this way, couldn’t help it, that his rights needed to be defended, and that science should come to his defense.”)

If you had an active mind, a command of German, a love of Europe in general and Vienna in particular (Wortis got his M.D. at the University of Vienna), the sponsorship of the world’s leading psychologists, and access to a rich widow’s money, you’d probably at least consider doing exactly what Wortis did next. He took the money and ran, using it to fund a little research project of his own. “
Though I am myself skeptical
of the dogmas and claims of the psychoanalysts,” he wrote to Meyer, “don’t you think it would be worthwhile to learn something of the subject at first hand?” Meyer and Ellis were skeptical about Freud, so they did think this was a
good idea and pledged sixteen hundred of Mrs. Porter’s dollars to Wortis’s “training.” Wortis approached Freud in September 1934 and after two meetings Freud told him that his bankroll would pay for four months in analysis, which they could begin presently.

Freud knew that Wortis was associated with Meyer and Ellis and that neither of those men held psychoanalysis in high regard. He must have suspected that Wortis shared their views, but the game was on. “
He [Freud] would have thrown me out
because he got impatient with me, but he didn’t want to acknowledge his failure,” Wortis told an interviewer sixty years later. “I came under the grand auspices of Havelock Ellis and Adolf Meyer…So he had to put up with me.” What Freud didn’t know was that after every session, Wortis was going to a nearby café and writing down as close to a verbatim transcript as he could and sharing the highlights (and eventually the transcripts) with Ellis and Meyer. They wrote back to congratulate him and egg him on. (In this, Wortis falls on the transparency spectrum somewhere between Rosenhan and me: Rosenhan deceived the hospitals outright; I told my doctors that I was recording our interviews and writing about my experiences and that I had published critical articles on the subject of antidepressants and clinical trials.) In the 1994 interview, Wortis, who first published his account of his analysis in 1954, had to admit that he had had some fun on the couch. “
I was taunting Freud,
” he said.

Freud probably was aware that he was being taunted. But there was something else that he couldn’t know—and that Wortis couldn’t know either. Freud, by now a cranky old man, suffering from mouth cancer, struggling to talk with his prosthetic jaw, bitter and scared about the rise of the Nazis, was intemperate (“
It is true you have no palpable symptoms,
but you have no right to be too proud of your health”) and even downright mean (“
You know shit about psychoanalysis
”). He was sometimes pathetic (“
He seemed to be a bit hard of hearing,
” Wortis wrote, “but did not admit it. On the contrary he continually criticized me for not talking clearly and loudly enough”), occasionally pithy (“
Dreaming is nothing but
the continuation of waking thought.” “
No man could tell the truth
about himself”), often doctrinaire (“
You have not yet completed
the transition from the pleasure principle to the reality principle”), and always engaged with Meyer and Ellis at least as much as with Wortis (“
A person who professes to believe
in common sense psychology [i.e., Meyer] and who thinks psychoanalysis is ‘far-fetched’ can certainly have no understanding of it, for it is commonsense which produces all the ills we have to cure.” “
I feel sure
…that Ellis must have some sexual abnormality, else he would never have devoted himself to the field of sex research”).
*
All of this was predictable, if entertaining. The surprise, however, came when, in the midst of his analysis, Wortis made a visit to another doctor in Vienna, an encounter that would change not only his professional life, but the course of psychiatry, and especially the treatment and understanding of depression, in the United States.

Ten weeks into his analysis, in the middle of December 1934, Wortis told Freud about a demonstration he’d attended over the previous weekend. In front of a group of doctors and students, a psychiatrist named Manfred Sakel had injected insulin into a schizophrenic, brought him to the point of death, and then revived him with glucose. After this ordeal, the patient seemed transformed—quiet, oriented, and calm.

Sakel, whose real name was Menachem Sokol, said he was a descendant of Moses Maimonides. He also claimed that he had tested his treatment on animals before administering it to people.
The
New York Times
was satisfied enough that the first claim was true to repeat it in Sakel’s obituary when he died in 1957. No one, not even Sakel himself, was ever able to substantiate the second. Nor could he say exactly why he thought to use hyperinsulinization
in the first place. Sometimes he spoke of vague theories—something about toxins, the digestive tract, the “
vagotropic nervous system,
” and the “restoration of balance.” He didn’t mention that psychiatrists had already discovered that when they gave insulin to asylum patients who were refusing to eat, it not only boosted their appetite but also improved their psychological state. But then again, a would-be maverick genius generally can’t afford to acknowledge his predecessors.

He can, however, flaunt his departures from orthodoxy and turn his ignorance about why his method works into a virtue. He wasn’t even looking for an answer, he said, but rather had “
deliberately abandoned the normal scientific procedure
which first seeks to establish the cause of a disease and then formulates a treatment accordingly.” If he had plodded along scientifically, worrying about comas and convulsions and the causes of disease, he would never have had his “
accidents
” and seen the “dramatic psychological changes” that occurred when patients slipped from mere hypoglycemia into comas and lived to tell about it. (In this respect, Sakel was a harbinger: twenty-five years later the accidental improvement of psychological states led to the antidepressant revolution—and to the theories cobbled together to explain those accidents.)

The idea that a doctor could practically kill someone and thus make him better—a common feature of ancient medicine, with its bloodletting and mercury treatments—was not unheard of in modern medicine. In fact, Julius Wagner-Jauregg, the psychiatrist who testified against Theodor Reik in the Vienna malpractice trial, won his Nobel Prize for infecting neurosyphilitics with malaria—an idea he hit upon when he noticed that high fever often relieved their symptoms. (Actually, he tried tuberculin first, but tuberculosis, while perhaps preferable to general paresis, is still a pretty devastating disease.)

Pioneer or not, Sakel’s colleagues hailed him for having “
courageously persisted in his experiments,
” but the accolades should probably have gone to his patients for enduring such a gruesome
procedure. Once you get a big dose of insulin—assuming you aren’t a diabetic or didn’t just down a thirty-two-ounce Slurpee—it takes about forty-five minutes before the symptoms of hypoglycemia come on. Then you start to become disoriented, your speech slows down until all you can do is murmur or groan, and you may well start to hallucinate. If your doctor, wanting to show an assembled audience just how his treatment works, pricks your arm with a pin, you will wipe the spot over and over, and if he claps his hands next to your ears, you will jump even if you are nearly unconscious—which you probably are. As you slide into a stupor, you might have a convulsion or two, and sooner or later, your whole body will be racked by spasms that will leave your feet extended and your toes curled, your arms outstretched and your fists clenched. You will sweat like crazy, drool from your mouth, and drip mucus from your nose in strings. Your face will get pale, your heart will slow down, your breathing will become irregular and labored and maybe even stop, and your eyes will stop responding to light, their pupils fixed. “
Beyond this point,
” as a how-to manual for psychiatrists put it, “the changes are likely to be irreversible,” which is doctor talk for “you will die.”

But if you are schizophrenic, and if you survive the four or five hours that it takes to induce the coma, and the hour or so for which it lasts (unless your doctor has decided you are a hopeless case, in which case he might extend the coma to twenty or thirty hours), and then you are brought back to life courtesy of some sugar water, chances are good you’re going to feel a lot better. “
One is frequently surprised
by the patient’s changed attitude immediately on awakening,” the manual says. “He asks for help, he is friendly, accessible, interested in his comfort and in the little things of daily life, especially food…The schizophrenic patient becomes
gemütlich.
”

Unfortunately, this state lasts for only thirty minutes or so. But if you get treated six times a week for two or three months, you will very likely be less disturbed and more tractable, less prone to hallucination and delusion, better able to get along with people, able to give and receive affection—in general, an easier patient to manage.
You may be really lucky and have so complete a remission that you can leave the asylum altogether, although you will not necessarily be like this:

One of our patients,
paranoid for 17 years, first improved in every way, but after planning to leave the hospital he declared that he was not able to stand health, that his sickness was a protection from something much more dangerous.

But especially if you were unfortunate enough to be schizophrenic in 1934, you, and anyone around you, would have been amazed. All the advances in medicine of the past fifty years had brought virtually no improvement to schizophrenics—or to manic-depressives. These two major forms of insanity—the diagnoses that no one wanted to hear and that no doctor wanted to deliver—still amounted to a living-death sentence.

This was the news that Wortis was announcing to Freud: that the age of therapeutic nihilism was over, that mental illness could be the subject of proper doctoring, the kind that involved doing things to people’s bodies, and not just the mind-cure malarkey Freud was offering.

You could call the era that insulin coma therapy kicked off—which continues today—the age of therapeutic exuberance. But the doctors of the 1930s didn’t bother naming it. They were too busy finding new therapies.

You can’t blame them for this. To turn psychosis into
gemütlich-keit
was no small accomplishment, even if you didn’t really understand how it had happened. One doctor—the Hungarian psychiatrist Ladislas von Meduna—even had an actual theory for his own contribution to this new zeitgeist. The theory would eventually turn out to be wrong, but at least for a while it gave Meduna the ability to claim that his method was “
the result of research
based upon
a previously developed working hypothesis,” while Sakel’s was “developed in a purely empirical manner.” Sakel, in other words, was still practicing the old way, while Meduna, at least according to Meduna, was leading psychiatry into the modern era.

Meduna’s hypothesis was based on an old observation: that epilepsy and schizophrenia rarely occurred together. Some doctors had tried to use this apparent antagonism to their advantage. For instance,
Paracelsus, the sixteenth-century Swiss physician,
used camphor to bring on fits in psychotic patients in hopes of curing them. But camphor injections caused excruciating pain and sometimes even life-threatening infections, which made the procedure even more forbidding.
Although one doctor went so far
as to transfuse schizophrenic patients with the blood of epileptics in 1932, most psychiatrists by then had given up on inducing seizures to cure psychoses.

Meduna thought he knew the reason for the antagonism between seizures and psychosis. As a psychiatrist in a small hospital in Budapest, he had occasion to autopsy the brains of many people with mental disorders, including epilepsy. He noticed that the epileptics’ brains contained an excess of the glial cells that surround and nourish the brain’s neurons like worker bees around a queen, while the schizophrenics’ brains had a dearth of them. He also found epidemiological studies that not only confirmed the ancient observation but also showed that epileptics who became schizophrenic often stopped having seizures, and that in at least two cases, the reverse was true: schizophrenia remitted when epilepsy developed. Meanwhile, he talked a coworker into secretly biopsying the brains of living epileptics and schizophrenics (of course, it wasn’t a secret to the patients, only to other doctors, who might have objected to the procedure) and found the same results. Armed with what he thought was biological as well as empirical justification, Meduna began to search for a chemical to induce seizures in animals. He tried strychnine, caffeine, and absinthe, among other drugs, but finally decided that the old standby camphor was the most effective and least dangerous of them all.