Manufacturing depression (21 page)

In January 1934, at just about the time that Joseph Wortis was
hatching his plan to drop in on Freud in Vienna, Meduna was in Budapest giving camphor to a man who had been in a catatonic stupor, unmoving and tube fed, for four years. Forty-five minutes later, the patient seized. After the seizure was over, Meduna later wrote, the patient continued to lie in bed “like a wooden statue, oblivious to his surroundings.” But the doctor persisted, and eighteen days later, two days after the fifth injection,

the patient got out
of his bed, began to talk, requested breakfast, dressed himself without any help, was interested in everything around him, and asked how long he had been in the hospital. When we told him, he did not believe it.

Meduna treated five more patients with similar results, and by the end of 1934 had found a better drug than camphor: Metrazol, a newly marketed cardiac drug that at high doses caused seizures. The Budapest medical establishment called Meduna “
a swindler, a humbug, a cheat,
” he wrote later. “How dare I claim that I cured schizophrenia, an endogenous hereditary disease!” But in the larger world, Metrazol therapy joined the insulin treatment to offer hope where there had previously been none.

Of course, as with insulin treatment, it came at a price. Metrazol didn’t work by nearly killing people as insulin did, but it didn’t exactly make for a pleasant afternoon. A drug-induced grand mal seizure is bad enough—limbs extending and contracting violently two to four times per second for up to one minute, the thrashing intense enough to break bones and dislocate joints, breathing so violent and irregular that it might lead to aspiration and pneumonia before it stops altogether for a minute or so at the end of the seizure, not to mention the indignity of vomiting, urinating, and sometimes even ejaculating on the table—but at least the patient didn’t remember most of it. (And as doctors later found out, many of these problems could be avoided with a judicious shot of a paralytic drug like curare, famously used as the poison on the end of a
dart.) What patients could not forget, however, was the awful dread they felt as the drug came on and the amnesia, the individual memories that disappeared and sometimes never came back.

Meduna and Sakel soon came to loathe each other.
The Hungarian missed no opportunity
to tweak the Austrian for his empirical approach and for missing the fact (in his view) that the convulsions his patients had on their way to unconsciousness, and not the comas themselves, were curative. Sakel, apparently unaware that Meduna was a fellow Jew, grew convinced that he was part of
a vast anti-Semitic conspiracy
to give all glory to the racially pure.

But they did agree on one thing: each called his therapy “shock treatment.” The name referred to its putative mechanism, a powerful shock to the system, but it took on a new resonance when Ugo Cerletti, an Italian doctor, decided to replace the drugs with real shocks, the kind you get if you plug yourself into a wall socket.

Cerletti was using electricity to induce seizures in dogs in his Genoa lab. He wasn’t trying to cure anything, just to understand the neurology of epilepsy.
His technique was simple,
if crude: he put an electrode in a dog’s mouth, another one in its rectum, and turned on the juice. If the dog wasn’t killed outright—the current passed through its heart, resulting in a mortality rate of 50 percent—it would generally have a seizure. Later, when the dog was sacrificed, Cerletti could compare its brain to one taken from a dog that hadn’t been shocked, and he began to amass a body of data about the effect of convulsions of the mammalian brain.

Cerletti had heard about Meduna’s work in 1936 and wondered why the Hungarian was “
not using the much simpler method
of inducing fits with electricity.” The next year, at a psychiatric summit in Switzerland, he floated the idea of trying this approach on patients (he was by then running a psychiatric hospital in Rome), and
no one raised an objection.
Of course, they may not have been so accepting had they known about that 50 percent mortality rate, so he went to work on figuring out a method of delivering the shock that was not so dangerous.

Cerletti had heard reports that butchers were using electricity to kill pigs in Rome’s slaughterhouses. He sent his assistant, Lucino Bini, on a fact-finding mission. It turned out that the butchers weren’t electrocuting the pigs, just stunning them into unconsciousness before slicing their throats—exactly what Cerletti wanted to do to people (except for the throat-slitting part). Even better, they had figured out how to bypass the whole rectum-heart-mouth nexus by using
a pair of electrified forceps
to deliver the shock through the pigs’ temples. The abattoirs soon became an impromptu lab, where Bini determined, among other things, that the margin between
the seizure-inducing dose
and time (120 volts for about a tenth of a second) and the lethal dose (400 volts for a minute) was so great that it was safe to start using electricity to do shock treatment.

In April 1938, a patient wandered into the Clinic for Nervous and Mental Diseases at the University of Rome, incoherent and babbling, and was quickly diagnosed with catatonic schizophrenia. He couldn’t tell the doctors his name or anything else about himself. He was, in other words, a perfect subject for an experiment.

Over the next ten days, Cerletti tried to put his new patient—whom he named Enrico X—into seizures. He tweaked the dose and duration of the shock until finally, at 92 volts and a half second, Enrico seized for more than a minute. He ejaculated, stopped breathing for 105 seconds, went pale, and lapsed into unconsciousness for about five minutes. After eleven of these treatments over the next three weeks—many of them witnessed by colleagues summoned from all over the hospital by trumpet blasts—and another month of hospitalization, Enrico was released “
calm, well oriented,
” with “thought and memory unimpaired.” The treatment was announced to the public with the usual miracle-cure fanfare.
A new word entered the Italian language
—
zapare,
which means exactly what you think it does—and a new idea began to take hold in the public consciousness: that if you let psychiatrists take extreme measures, they can actually cure insanity.

*      *      *

These miracle cures all turned out to be too good to be true. Insulin coma therapy proved too dangerous; every treatment was an experiment, as no patient’s reaction to insulin could quite be predicted, and when the experiment failed, the doctor had a dead patient on his hands. With the advent of Cerletti’s device (which
even Meduna hailed
as an improvement), Metrazol fell out of favor; it eventually lost its FDA approval. Doctors are still known to
zapare
their patients—it’s known today as electroconvulsive therapy, or ECT—but reports of nasty side-effects like permanent amnesia and depictions such as Ken Kesey’s in
One Flew Over the Cuckoo’s Nest,
have made it not only infamous but subject to tight legal control in many places, including California. Doctors have for the most part moved on to quieter methods.

But even in their heyday in the 1930s and 1940s, shock therapies raised eyebrows. One scandalized British doctor said to his colleagues, “
Our patients seem
to be in danger of having a very thin time. First we Cardiazolize them [Cardiazol was the British version of Metrazol], then we insulinate them, and now we are proceeding to electrocute them.” But you didn’t have to be a critic to be shocked by the therapies. One of Meduna’s colleagues noted that their treatment amounted to “
driv[ing] the Devil out of our patients
with Beelzebub.” The authors of a manual on shock therapies referred to them as attempts to “
bedevil the psychotic
into a state of normalcy,” and the doctor who introduced their book started his essay with this ringing endorsement: “
Shock therapy has thrust
its none-too-pretty form into the field of psychiatry. Whatever the method of producing ‘shock,’ the process itself is distasteful.” For their part, patients, at least some of them, agreed:

One…patient, when coming out of coma,
usually asked how many times she would have to die, and added that she was happy to be alive again…Another schizophrenic asked
us, “Why do you kill me every day?” One of our paranoid female patients compared the physician forcing her into coma with someone pulling the wings off a fly.

It’s hard to know whether the doctors were bragging or complaining about having all this power—and whatever their enthusiasm it didn’t compare with that of
Walter Freeman,
a doctor who had perhaps the worst case of therapeutic exuberance. He figured out how to perform a frontal lobotomy in his office with a tool modeled on an ice pick, and then packed his gear into a suitcase to take psychosurgery into the American hinterlands. And then there were the
doctors who used drugs
to keep patients asleep for a week at a time or had them breathe nitrogen until they turned blue or refrigerated them until their body temperature dropped below 85 degrees. The really scary part is that none of the shock doctors had any idea, at least any scientific idea, of why their treatments worked.

Cerletti didn’t even try to explain it. He was content to describe himself as no more than an inventor improving on Meduna’s methods. But the theoretical coattails he was riding—Meduna’s vaunted theory—never proved out: there are indeed people with both epilepsy and schizophrenia, and the neurological findings about glial cells remained (and still remain) inconclusive. Maybe, as Sakel thought, insulin coma provoked some kind of biological regression:

The various reflexes disappear
during hypoglycemia in the order of their evolutionary development and they reappear in reverse order…In mental processes too those components of mind which happen to be most dominant and active are most quickly and effectively eliminated…In cases which progress favorably, repeated and correctly managed hypoglycemia states finally serve to produce a permanent dominance of those psychic components which have hitherto been repressed.

Or “
the therapeutic effect
…may be due to the destruction of great numbers of nerve cells in the cerebral cortex”—new brain damage undoing the old. Or maybe the treatment simply focused the mind wonderfully,
the improvement “due to the patient’s experience
of the treatment as a threat to his existence, or as punishment, or as death and rebirth.”

But, as Ladislas von Meduna might have said, you can’t argue with results—even if they aren’t exactly what you expected. That’s the beauty of not having a theory about something like shock therapy: even when you’re wrong you can be right. Or, as Manfred Sakel—who first discovered the benefits of insulin when a heroin addict he was treating with lower doses of insulin slipped into a coma and, upon being revived with a shot of glucose, emerged
gemütlich
—once wrote, “
the mistakes in theory
should not be counted against the treatment itself, which seems to be accomplishing more than the theory behind it.”

So let’s say the treatment you theorized was a cure for schizophrenia turns out to cure something else. Let’s say you aimed at an elephant and brought down a rhino. That doesn’t mean that your bullets are no good—a principle that remains in effect, happily for men of a certain age whose Viagra began life as a not-so-good heart disease drug with a very interesting side effect.

That’s why
when Sakel noticed
(or says he noticed; he was known for revising his autobiography to suit his needs) that depressions seemed to lift in patients who had convulsions while being insulinized, or
when Cerletti concluded that he was getting better results
with depressed patients than with schizophrenics, or when an American doctor wrote that he was using Metrazol to cure depressions, or when Philadelphia psychiatrists reported that 70 to 85 percent of their depressed patients were recovering (and none of their schizophrenics) after electroshock therapy, or when a controlled study in 1945 found that 80 percent of the ECT-treated depressives improved and their average length of hospitalization was cut from twenty-one months to five months, or when suicide rates among
the depressed who received ECT decreased dramatically, and all the while shock treatment’s effect on schizophrenia, the disease it was theoretically supposed to cure, proved more and more disappointing—when all this happened, psychiatrists were happy to skip the theorizing and get on with the treating. Not of schizophrenia, of course, but of depression.

Those 80 percent improvement rates, by the way, are way better than anything that any antidepressant, no matter how cooked the books, has delivered, and they have been replicated often. But before you wonder why ECT is not the treatment of choice, you have to remember one thing: these depressives were very sick. They had
affective psychoses,
which meant that they were immobilized, delusional, nonfunctional—much as you would want people to be before you start shocking them into convulsions.

It’s not that doctors didn’t try to use their methods on the walking wounded. Unhappy people can be every bit as desperate as disabled people. But the shock doctors discovered that, as Lothar Kalinowsky, one of ECT’s major proponents and the man who did the most to spread it in the United States, put it, “
the results [with neurotics]
are as a whole disappointing”—adding that especially if the patients were anxious as well as depressed, ECT was not indicated.

These results would not necessarily have stopped the shock doctors from continuing to make their miracle-cure claims. That’s the other great advantage of having no explanation for why and how your therapy is effective. Because your doctor knows how antibiotics work, he knows which one to prescribe for your particular infection. But if there was no theory, and more to the point, if your doctor was a psychiatrist who knew only that a treatment was getting results with patients who somehow remind him of you even though they have a different diagnosis from yours, then why not try it on you anyway? Or, to put it another way, why not shoot first and ask questions later?