Mad in America

ALTHOUGH LEADING AMERIC AN psychiatrists may have supported eugenic policies, the eugenics agenda as a whole was driven primarily by people outside medicine. Davenport, Grant, Popenoe—none were doctors. As a group, American psychiatry was rather ambivalent about the whole affair, at times embracing state sterilization laws and at other times quietly questioning the science. Yet eugenics provided a societal context for asylum medicine, and that context dramatically influenced the type of medical therapeutics that were adopted in the 1930s for psychotic disorders. At that time, psychiatry embraced a quartet of therapies—insulin coma, metrazol convulsive therapy, electroshock, and prefrontal lobotomy— that all worked by damaging the brain. And from there, one can follow a path forward to the therapeutic failure documented by the World Health Organization in the 1990s, when it determined that schizophrenia outcomes were much better in the poor countries of the world than in the United States and other “developed” nations.

Prior to the introduction of the four treatments just mentioned, asylum psychiatry spent decades experimenting with physical remedies of every type. With the demise of moral therapy in the late 1800s, psychiatry had vowed to turn itself into a scientific discipline, and for all intents and purposes, that meant finding physical, or somatic, treatments for psychotic disorders. Although Freudian theories of the mind grabbed the imagination of American psychiatrists in the early 1900s, psychoanalysis was never seen as particularly useful or practical for treating institutionalized patients. The Freudian couch was seen as a method for treating neurotic patients in an office setting. Asylum psychiatry kept its sights set on finding somatic therapies that could be quickly applied and that would “work” in a quick manner as well.

The reform vision articulated by leaders of American psychiatry in the 1890s was well reasoned. Medical schools, they argued, would need to teach asylum medicine as part of their curriculums. Research laboratories for conducting pathological investigations into the biological causes of insanity would have to be established. It was hoped that the knowledge to be so gained would then lead to treatments that helped correct that abnormal biology. It all made perfect sense, as this was the research paradigm that was leading to such notable progress in general medicine. In the 1880s, the organisms that caused tuberculosis, cholera, typhoid, and diphtheria had been isolated; antitoxins for typhoid and diphtheria were then developed that greatly reduced mortality rates from those two diseases. A scientific approach to illness could clearly produce great results.

However, as psychiatry sought to remake itself in this way, it was also being chased by its own internal devils. The stinging attacks by neurologists had left the public convinced that asylum doctors were incompetents, or worse. Asylum medicine, a Nation writer had sneered, was the “very worst” department in all of medicine. Psychiatry had a palpable need for a therapeutic triumph, one that would rescue its public image and provide a balm for its own inferiority complex. And with that emotional need spurring it on, psychiatry was primed to shortcut the research process and skip straight ahead to the part about announcing therapeutic success. This, in fact, began to happen almost from the moment that the leaders of asylum psychiatry laid out their plans for reform, so much so that the editors of the American Journal of Insanity could happily report in 1896 that the “present summary (of published articles) is an almost unbroken record of medical progress.” In particular, the journal noted, hydrotherapy was producing “remarkable results” that “would have been impossible to get by the old method of treatment.”²

With such claims appearing in the medical literature, hydrotherapy quickly came to occupy a central place in asylum medicine’s armamentarium. Private sanitariums and better-funded state hospitals made their hydrotherapeutic units, with their rows of bathtubs and gleaming plumbing, into clinical showpieces that they proudly presented to the public. At first glance, several asylum doctors admitted, it was difficult for the medically untrained eye to see just what was so new about the water therapies. Warm baths, touted for their soothing effects, seemingly recalled the ministrations of the York Quakers. Other versions of hydrotherapy, such as the continuous bath and needle shower, appeared less benign and looked suspiciously like the discredited therapies of old for restraining, depleting, and punishing patients. But such similarities, asylum doctors assured the public (and each other), were only skin deep.

The prolonged bath involved strapping a disruptive patient into a hammock suspended in a bathtub, with the top of the tub covered by a canvas sheet that had a hole for the patient’s head. At times, cold water would be used to fill the tub and at other times, water that felt hot to the touch. Patients would be kept there for hours and even days on end, with bandages sometimes wrapped around their eyes and ears to shut out other sensations. Ice caps were occasionally applied to their heads as well. Although it appeared simply to be an updated version of Rush’s tranquilizer chair, asylum doctors carefully explained in their medical journals why such an extended stay in the tub was good for the patient. The continuous bath, they said, acted as a “water jacket” that “induces physiological fatigue without the sacrifice of mental capacity” and stimulates “the excretory function of the skin and kidneys.” In their reports, they even provided detailed statistics on how the prolonged baths changed body temperature, respiration, and red blood-cell counts—evidence that the continuous bath was a carefully tested remedy for mental illness. They were also meticulous about detailing the risks of this medical treatment. Heat stroke, heat exhaustion, and “occasional scaldings” had been known to occur. All in all, though, reported Edward Strecker, a prominent psychiatrist at the Pennsylvania Hospital for the Insane, in 1917, patients could be kept in continuous baths “weeks, or even months, without untoward results.” He advised putting pictures on the bathroom walls, making it a more pleasing environment for the patient, as the tub room should be considered a “living apartment.”³

The needle shower, or jet douche as it was sometimes called, consisted of pummeling the patient with pressurized water. Various “prescriptions” for such showers called for dialing up pressures to forty pounds, with water temperatures as chilly as 50˚ Fahrenheit. The carefully timed cold showers would last a minute or two. The pounding was said to provide a variety of physiological benefits, such as stimulating the heart, driving blood to the internal organs, and inducing “glandular action by its tonic effect on the general cutaneous circulation.” It was reported to be particularly useful for rousing depressed patients. But as one physician acknowledged, “we meet with more or less opposition on the part of the patient to the administration of these baths.”⁴

The water therapy most reviled by patients was the wet pack. Attendants would dip sheets into either cold or hot water, then wrap them tightly around the patient “so that he cannot move anything except his head, fingers, and toes.” A woolen blanket might then be pinned to the sheets, and, at times, the entire bundle tied to a bed. Patients would be left trussed up in this manner for hours and, at times, even for a day or two, abandoned in these extended treatments to wallow in their feces and urine. But that was the least of their discomfort. As the sheets dried, they would shrink tightly about the patients. With their bodily heat so snugly retained, they would experience an awful sensation of burning up, and of suffocation. Many struggled mightily to escape, so much so that “cardiac collapse” was an admitted risk. As one patient said at a 1919 hearing on conditions in California asylums, “You are in a vice, and it is inhuman treatment.”⁵

However, asylum doctors saw wet packs through a different prism. In their writings, they took great pains to distinguish them from the cuffs, mitts, camisoles, and tranquilizer chair of yore. “It must appear to many that the chief object of the pack is restraint,” admitted Boston’s Herman Adler, “[yet] nothing can be further from the truth . . . it is a valuable therapeutic measure.” The wet pack, he explained, was a physiologically beneficial treatment for “restlessness.” The excited patient tended to lose bodily heat, and this necessitated the use of the wet pack to “conserve the body temperature.” Once the patient had been quieted and drained by the wet pack, the patient could be treated with the prolonged bath, which would “prevent the evaporation of water from the skin,” providing further conservation of the patient’s body heat. Restraint was decidedly not the aim of the wet pack, he concluded; rather it was simply a means of “applying a therapeutic agent without the cooperation or even the consent of the patient.”⁶

Others echoed Adler’s beliefs. “Hydrotherapy,” said one nurse, testifying at the 1919 California investigation, “is the only scientific treatment for the acute excitement of the insane that has yet been discovered.”⁷ Indeed, this was the very somatic therapy that, in the eyes of many, separated modern hospitals from asylums of old. As Allen Jackson, chief physician at the Philadelphia Hospital for the Insane, rather huffily noted in the Journal of the American Medical Association: “‘Lunatic asylum’ is the proper nomenclature for an institution which has no hydrotherapy unit; to call such an institution a hospital would be a misnomer and, to say the least, exceedingly out of place.”⁸

Much attention also focused on the pathological influence that the vagina and the nerve-rich clitoris could have on the female mind. Women, said one physician, “are deeply concerned about these organs,” and “insanity may occur because their minds are very much agitated” by this undue concern.¹⁰ Direct evidence of a female mind led astray could sometimes be found through measurement of her genitalia: women with “hypertrophy” of the clitoris were presumed to be habitual masturbators. The reason, explained Clara Barrus of Middletown State Hospital in New York, in an 1895 report that carefully detailed clitoral abnormalities in 100 patients, was that masturbation stirred blood flow to the external genitalia, which led to the “exaggerated nutrition of these organs” and thus abnormal growth. Since masturbation was viewed as a cause of insanity, some sought to cure it with clitoridectomy, a surgery invented by an English doctor in 1858. However, Barrus found this remedy, which “has been and is still so much in vogue,” to be futile:

It seems to me to be a very reprehensible practice, inasmuch as the worst case of masturbation I have ever seen is that of a young woman who has had clitoridectomy performed. This patient had masturbated, more or less, all her life, and finally, after suffering from several attacks of nymphomania, decided to have the clitoris amputated. The result was not only failure to relieve the nymphomania, but even an increase in its severity, causing a shameless and, almost literally, continuous indulgence in the habit.¹¹

Another popular line of investigation focused on endocrine therapies. In the early 1900s, much was being learned about the function of various hormonal glands, leading to speculation that psychotic disorders might be tied to their dysfunction. As a remedy, psychiatrists in the United States and abroad tried injecting the mentally ill with extracts from animals’ ovaries, testicles, pituitaries, and thyroids. Extract of sheep thyroid was a particularly popular treatment, having been judged by asylum superintendent William Mabon to have helped nearly 50 percent of his insane patients get better. The extract made the patients quite sick—they grew feverish, lost weight, and their red blood-cell counts declined—but once the treatment ceased, their fevers went away, they gained back weight, and their mental health improved. Mabon, who theorized that the process modified “cell nutrition,” reported in 1899 that only one of his healed patients had ever relapsed, suggesting that sheep extract, when it worked, provided a permanent cure.¹³

Other physicians, armed with speculative theories of various sorts, sought to cure their insane patients by injecting toxic chemicals and other foreign substances into their veins, muscles, and cerebrospinal fluid. Injections of metallic salts—manganese, cadmium, and cesium—were tried and found to be worthwhile. The “strychnotonon cure” consisted of a dose of arsotonin, strychnine hydrochloride, and glycerophosphate. One investigator tried the “intraspinal administration of arsenic.” Robert Carroll, medical director of Highland Hospitals in Asheville, North Carolina, determined that multiple injections of sterilized horse serum into the spinal fluid, which caused aseptic meningitis, could successfully restore schizophrenics to lucidity. Much like those treated with sheep extract, Carroll’s patients had to suffer through physical discomfort for this cure, including backaches, headaches, and vomiting.¹⁴

Henry Cotton, superintendent at Trenton State Hospital in New Jersey, decided in 1916 that he might be able to cure insanity by removing his patients’ teeth. Although Cotton’s work eventually led to a medical misadventure of a notable sort, he was a well-trained physician, having studied under the great Swiss psychiatrist Emil Kraepelin and the equally famous Alois Alzheimer, and there was an underlying logic to his seemingly preposterous hypothesis. Bacteria caused many acute illnesses, and various researchers at that time had speculated that “masked” or “hidden” bacterial infections caused chronic ailments like arthritis. Cotton simply applied this general theory to mental illness. He reasoned that teeth were the site of the “masked” infection because there had been scattered reports in the scientific literature, dating back to 1876, of insanity being cured by the removal of infected molars and cuspids. From this initial site of infection, he reasoned, bacteria could spread through the lymph or circulatory systems to the brain, where it “finally causes the death of the patient or, if not that, a condition worse than death—a life of mental darkness.”¹⁵ Moreover, when Cotton looked into his patients’ mouths, he could always find teeth that were harboring bacteria—evidence, at least to him, that his theory was correct.

He initially removed the infected teeth of fifty chronic patients, only to find that this produced no benefit. Apparently, in chronic patients the deterioration in the brain had already progressed too far, and so Cotton began extracting the teeth of newly admitted patients. This simple procedure, Cotton announced in 1919, cured 25 percent of them. That left 75 percent unimproved, which prompted Cotton to look for other body regions that might be harboring bacteria. Taking out the patients’ tonsils, he said, cured another 25 percent of all new admissions. And if removing their tonsils didn’t work, Cotton moved on to their genitourinary and gastrointestinal tracts. This meant surgical removal of a diverse array of body parts: the colon, gall bladder, appendix, fallopian tubes, uterus, ovaries, cervix, and seminal vesicles—they were all targets of Cotton’s knife. “We started to literally ‘clean’ up our patients of all foci of chronic sepsis,” he explained.¹⁶

His “cleaning up” process apparently produced stunning results. Eight-five percent of patients admitted to Trenton State Hospital over a four-year period, he said, had been cured and sent home. Only 3 percent of those who had recovered had ever relapsed; the rest were “earning their living, taking care of families and are normal in every respect.”¹⁷ As Cotton was a physician with impeccable credentials, it seemed that at last a true medical breakthrough had been achieved. Burdette Lewis, commissioner of New Jersey’s state hospitals, proudly declared that Cotton’s “methods of modern medicine, surgery, and dentistry have penetrated the mystery which has enshrouded the subject of insanity for centuries . . . freedom for these patients appears near at hand.” Newspapers also sung his praises, as did Adolf Meyer, the “dean” of American psychiatry at that time. Cotton, he said, “appears to have brought out palpable results not attained by any previous or contemporary attack on the grave problem of mental disorder.”¹⁸

However, others who tried his surgeries failed to replicate his good results, and at a 1922 meeting of the American Psychiatric Association, several critics questioned whether Cotton was being “blinded” by his own preconceived ideas. And was it ethical to remove body tissues that appeared to be functioning just fine? “I was taught, and I believe correctly, not to sacrifice a useful part if it could possibly be avoided,” one physician said.¹⁹ In 1924, the board for Trenton State Hospital was troubled enough to launch its own investigation. Did Cotton’s surgeries work, or not? Meyer was asked to oversee the inquiry, and a review of Cotton’s patient records quickly revealed that it was all a sham. Nearly 43 percent of patients who’d undergone Cotton’s “thorough treatment” had died. Cotton’s “claims and statistics,” Meyer confessed to his brother in a letter, “are preposterously out of accord with the facts.”²⁰ Cotton had killed more than 100 patients with his intestinal surgeries alone.^b

The first drastic somatic remedy to achieve a more widespread success was deep-sleep therapy, which was popularized by Swiss psychiatrist Jakob Klaesi after World War I. By then, barbiturates—which had been developed by German chemists a decade earlier—were being routinely used in asylums to sedate manic patients, and Klaesi decided to use the drugs to keep patients asleep for days and even weeks on end, hoping that this lengthy rest would restore their nervous systems. He first tried this therapy on a thirty-nine-year-old businesswoman who, following a breakdown, had degenerated to the point where she lay naked in a padded cell. After the prolonged narcosis, Klaesi said, she recovered so fully that her husband marveled at how she was more “industrious, circumspect and tender” than ever before. In the wake of Klaesi’s announced success, deep-sleep therapy became quite popular in Europe. Some who tried it claimed that it helped up to 70 percent of their psychotic patients. Enthusiasm for this therapy began to diminish, however, after Swiss psychiatrist Max Muller reported that it had a mortality rate of 6 percent.

Hope was also kindled in the 1920s by the success of malarial fever therapy for general paresis, a type of insanity that occurs in the end-stage of syphilis. This success story had a lengthy history. In 1883, Austrian psychiatrist Julius Wagner-Jauregg noticed that one of his psychotic patients improved during a bout of fever, which led him to wonder whether a high temperature could reliably cure schizophrenia. For the next three decades, he occasionally experimented with this idea, using vaccines for tuberculosis and other illnesses to induce potent fevers. He reported some success, but his work failed to draw much attention. Then, during World War I, while working at a clinic in Vienna, he abruptly decided to inject malaria-infected blood into a twenty-seven-year-old man, T. M., ill with paresis. After suffering through nine febrile attacks, T. M. improved so dramatically that soon he was delivering wonderfully coherent lectures on music to other asylum patients.²¹

As a remedy for paresis, malarial fever treatment had an evident biological rationale. Syphilis was known to be an infectious disease. By 1906, the spirochete that causes it had been isolated, and a diagnostic blood test had been developed. The high fevers induced by malaria apparently killed or slowed the spirochete, and thus, at least in some instances, arrested the progress of the disease. In 1927, Wagner-Jauregg was awarded the Nobel Prize in medicine for his work.

Others soon tried fever therapy as a cure for schizophrenia and manic-depressive insanity. Elaborate methods were devised for making patients feverish: hot baths, hot air, electric baths, and infrared and carbon-filament cabinets were all tried. None of this, however, produced impressive results. Mental patients were also deliberately infected with malaria, even though, unlike the paresis patients, they weren’t suffering from a known infectious disorder. One physician who tried this, Leland Hinsie at New York State Psychiatric Institute, was remarkably candid about the results: Two of his thirteen patients died, and in several others, “the ill effects were outstanding.”²²

Perhaps the most unusual experiment of all was conducted by two Harvard Medical School physicians, John Talbott and Kenneth Tillotson. Inspired in part by historical accounts of the benefits of extreme cold, they put ten schizophrenic patients between “blankets” cooled by a refrigerant, dropping their body temperatures 10˚ to 20˚ Fahrenheit below normal. The patients were kept in this state of “hibernation” for up to three days. Although one of their ten patients died, several others were said to have improved after they were warmed up and returned to consciousness, which in turn led others to toy with this approach. Two Ohio doctors, Douglas Goldman and Maynard Murray, developed their own version of “refrigeration therapy.” They put their mentally ill patients into a cooled cabinet, packed their bodies with ice, and kept them in this refrigerated state for a day or two, with this treatment then periodically repeated. But after three of their sixteen patients died and others suffered a variety of physical complications, they decided, “with a sense of keen disappointment,” that refrigeration therapy might not be such a good idea after all.²³

The first to arrive was insulin-coma therapy. This treatment, pioneered by Viennese psychiatrist Manfred Sakel, was stunning in its boldness. In the late 1920s, while working at private clinic in Berlin, Sakel had discovered that small doses of insulin helped morphine addicts cope with their withdrawal symptoms. On several occasions, however, his patients had lapsed into dangerous hypoglycemic comas, an often fatal complication. But as they returned to consciousness, brought back by an emergency administration of glucose, they appeared changed. Addicts who had been agitated and restless prior to the coma had become tranquil and more responsive. This led Sakel to speculate that if he deliberately put psychotic patients into an insulin coma, something one ordinarily wanted desperately to avoid, they too might awake with altered personalities.

In 1933, Sakel put his audacious idea to the test. After a few trials, he discovered that in order to produce a lasting change, he needed to put patients into deep comas over and over again—twenty, forty, even sixty times over a two-month period. That exhaustive course of therapy, Sakel reported, led to spectacular results: Seventy percent of 100 psychotic patients so treated had been cured, and another 18 percent had notably improved. The cured were “symptom-free,” Sakel said, “with full insight into their illness, and with full capacity for return to their former work.”²⁵

Sakel struggled to explain why the repeated comas benefited schizophrenics. However, it was known that hypoglycemia could cause brain damage, which suggested that trauma itself might be the healing mechanism. Autopsies of people dead from hypoglycemia revealed “widespread degeneration and necrosis of nerve cells,” particularly in the cerebral cortex, the brain region responsible for higher intellectual functions.²⁶ Might the death of brain cells be good for those newly struck by psychosis? Sakel reasoned that the comas selectively killed or silenced “those (brain) cells which are already diseased beyond repair.” With the malfunctioning brain cells so killed, the healthy ones could once again become active, leading to a “rebirth” of the patient. His treatment, he said, “is rather a fine microscopic surgery . . . the cure is affected [because it] starves out the diseased cells and permits the dormant ones to come into action in their stead.”²⁷

Other European investigators reported equally encouraging results. At a meeting in Munsingen, Switzerland, in the spring of 1937, they announced cure rates of 70 percent, 80 percent, and even 90 percent. And this was with schizophrenics, the very class of patients seen as most hopeless. Positive results began rolling in from the United States as well. Joseph Wortis, who had watched Sakel administer insulin therapy at his Vienna clinic, introduced it at Bellevue Hospital in New York City, and he reported recoveries in 67 percent of his patients. In 1938, Benjamin Malzberg from New York State Psychiatric Institute announced positive results from hospitals around the state: Two-thirds of 1,039 schizophrenics treated with insulin-coma therapy had improved, most of them discharged from the hospital, compared to 22 percent of the patients in a control group. A year later, Malzberg was back with an even stronger statement: “The value of the insulin treatment is now definitely established. Every institution that has given it a fair trial has found it to be effective.”²⁸

American newspapers and magazines quickly celebrated this new medical wonder. The New York Times told of patients who had been “returned from hopeless insanity by insulin,” explaining that, following the dangerous coma, the “short circuits of the brain vanish, and the normal circuits are once more restored and bring back with them sanity and reality.” Harper’s magazine said that with insulin treatment, aberrant thoughts and feelings are “channeled again into orderly pathways.” Time explained the therapy’s success from a Freudian perspective: As the patient descends into coma, “he shouts and bellows, gives vent to his hidden fears and obsessions, opens his mind wide to listening psychiatrists.” Reader’s Digest was perhaps the most breathless of all. After the repeated comas, it said, “patients act as if a great burden had been lifted from them. They realize that they have been insane, and that the tragedy of that condition is behind them.” Its glowing feature was titled “Bedside Miracle.”²⁹

Psychiatry basked in its newfound glory. Insulin coma, recalled Alexander Gralnick at the American Psychiatric Association’s 1943 annual meeting, had opened “new horizons . . . psychiatrists plunged into work and a new measure of hope was added where before mainly despair had prevailed.”³⁰ They did, in fact, now have a therapy that reliably changed the behavior of psychotic patients. They could put newly admitted patients through an intensive course of insulin-coma therapy and regularly discharge the majority back to their families. But it was a therapy that “worked” in a very specific way, one not captured by media tales of bedside miracles.

Insulin, a hormone isolated in 1922, draws sugar from the blood into muscles. The large doses administered to the mentally ill stripped the blood of so much sugar that in the brain, cells would be “starved” of their fuel source and shut down. This cessation of brain activity, Sakel and others observed, occurred in a chronological order that reflected the brain’s evolutionary history. The more recently evolved regions of the brain, those that carried out the higher intellectual functions, shut down first, followed by lower brain centers. As patients slid toward coma, they would begin to moan and writhe, such “decebration symptoms . . . indicating that all the higher and most recently developed levels of the brain are more or less out of action,” Sakel said.³¹ They were in fact now close to death, their brains so depleted of sugar that only the most primitive regions, those controlling basic functions like respiration, were still functioning. Patients would be left in this deep coma for twenty minutes to two hours, then brought back to life with a glucose solution.

As patients emerged from the coma, they would act in needy, infantile ways. They would plaintively ask the surrounding nurses and doctors who they were, often reaching out, like lost children, to hold their nurses’ hands or to hang on to their arms. They would suck their thumbs, frequently call out for their mommies, “behaving as if struggling for life.”³² Here is how Sakel described it:

An adult patient, for example, will say at a particular stage of his awakening that he is six years old. His entire behavior will be childish to the point that the timbre of his voice and his intonation are absolutely infantile. He misidentifies the examiner and mistakes him for the doctor he had as a child. He asks him in a childish peevish way when he may go to school. He says he has a “tummyache,” etc.³³

This was the behavior that was viewed by Sakel and others as evidence of the patient’s return to lucidity. Wortis explained that the treatment “pacified” patients, and that during this awakening period, “patients are free of psychotic symptoms.”³⁴ Another physician said:

[Patients are] childishly simple in mimicry and behavior . . . at this time the patient is by no means any longer out of his mind and be-clouded. These infantile reaction-types correspond to the behavior of his primitive personality—it is, so to speak, a regression to an ontogenetically earlier stage, a regression which we might consider in terms of brain pathology to have been called forth by a temporary suppression of the highest levels of mental functioning.³⁵

Physicians with Freudian leanings, like Marcus Schatner at Central Islip State Hospital in New York, put this “recovery” into a psychological framework:

The injection of insulin reduces the patient to a helpless baby which predisposes him to a mother transference . . . the patient is mentally sick, his behavior is irrational; this “displeases” the physician and, therefore, the patient is treated with injections of insulin which make him quite sick. In this extremely miserable condition he seeks help from anyone who can give it. Who can give help to a sick person, if not the physician who is constantly on the ward, near the patient and watches over him as over a sick child? He is again in need of a solicitous, tender, loving mother. The physician, whether he realizes it or not, is at present the person who assumes that attitude toward the patient which the patient’s mother did when he was a helpless child. The patient in his present condition bestows the love which he once had for his mother, upon the physician. This is nothing else but a mother transference.³⁶

This alteration in behavior was also recognized as consistent with brain trauma. One physician compared it to the “behavior of hanged persons after resuscitation, the sick after avalanches . . . the condition which comes on after head injuries, during the progress of uremic coma, after carbon monoxide intoxication and other types of poisoning.”³⁷ However, a single coma did not produce lasting change. Patients would pass through the reawakening state, when they acted like infants, and then their cerebral cortexes would begin to more fully function, and their difficult behavior and fantasies would return. But gradually, if this trauma were repeatedly inflicted, patients would take longer and longer to recover, and their “lucid” periods would become more prolonged. They would now indeed be different. Most notably, they would be less self-conscious. Their own thoughts would interest them less; they would become “detached” from their preoccupations of before. The “emotional charge” that had once fueled their delusions and inner demons would diminish and perhaps even fade away altogether. At times, Sakel acknowledged, the “whole level of (a patient’s) personality was lowered.” But often, in this new simpler state, they would remain friendlier, more extroverted and “sociable.”³⁸

Various investigations conducted at the time revealed the nature of the brain damage behind this change. Experiments with cats, dogs, and rabbits showed that insulin comas caused hemorrhages in the brain, destroyed nerve tissue in the cortex, and brought about other “irreversible structural alterations in the central nervous system.” Moreover, the greater the number of insulin treatments, “the more severe was the pathology,” reported Solomon Katzenelbogen, a psychiatrist at Johns Hopkins Medical School. Autopsies of patients who had died from insulin-coma therapy similarly revealed “areas of cortical devastation.” Researchers found evidence of neuronal shrinkage and death, softening of the brain, and general “areas of cellular waste.” The pathology often resembled the brain damage that arises from an extended shutoff of oxygen to the brain, leading some to speculate that insulin coma killed cells in this manner as well.³⁹

Indeed, this understanding that anoxia, or oxygen depletion to the brain, might be the curative mechanism led to experiments on ways to induce this trauma in a more controlled manner. Harold Himwich, a physician at Albany Medical School in New York, tried doing so by having his patients breathe through a gas mask and then abruptly cutting off the flow of oxygen, replacing it with nitrogen. They would quickly lose consciousness and then be kept in this oxygen-depleted state for a few minutes. Himwich would apply this treatment to his patients three times a week, which led one popular science writer of the day to describe its mechanism of action with an unforgettable turn of phrase: “Schizophrenics don’t get well merely by being deprived of oxygen,” explained Marie Beynon Ray in Doctors of the Mind, which presented Himwich as one of the latest miracle workers in psychiatry. “Occasionally one may recover after [a botched] hanging—but only temporarily. In a few weeks [relapse] . . . But did a lunatic ever get hanged—and hanged—and hanged?”⁴⁰

Insulin-coma therapy remained a common treatment for schizophrenia into the mid-1950s, in spite of periodic reports suggesting that it was doing more harm than good. One problem was its high mortality rate. In 1941, a U.S. Public Health survey found that 5 percent of all state-hospital patients who received the treatment had died from it. But even those who were successfully treated and discharged from the hospital did not fare well over the long term. Patients came back to the mental hospitals in droves, with as many as 80 percent having to be readmitted and most of the rest faring poorly in society. One long-term study found that only 6 percent of insulin-treated patients remained “socially recovered” three years after treatment, which was a markedly worse outcome than for those simply left alone. “It suggests the possibility that the insulin therapy may have retarded or prevented recovery,” Ohio investigators sadly concluded in 1950.⁴¹ Other researchers in the mid- 1950s echoed this lament, writing of “the insulin myth,” which they chalked up to psychiatry’s desperate yearning, in the 1930s, for a therapeutic triumph.⁴²

In hindsight, it is also evident that many of those harmed by the insulin myth were precisely those patients who would have had the greatest chance of recovering naturally. Sakel had announced early on that the therapy appeared to primarily benefit those who had only recently fallen ill. Moreover, because it was such a hazardous procedure, he wouldn’t try it on patients who had other physical ailments, such as kidney disease or a cardiovascular disorder. As Wortis noted, Sakel picked “strong young individuals” with “recent cases.” Sakel’s results were then confirmed in the United States by New York asylum physicians who also cherry-picked this healthiest group for the therapy. Even Malzberg admitted that in New York “the insulin-treated patients were undoubtedly a selected group.”⁴³ Not only did this hopelessly bias the initial study results, but it led to the therapy being used, over the years, primarily on physically healthy patients. It turned them into people who, as a result of the brain damage, had little chance to fully recover and live fully human lives.

In the late 1930s, however, insulin-coma therapy “definitely” worked. And it did so in a variety of ways. Patients could be admitted to a hospital, given twenty to sixty comas over a short period, and sent home—an apparent set cure for schizophrenia. Both nurses and physicians found their interactions with the insulin-treated patients much more pleasing as well. Nurses, rather than having to quarrel endlessly with raucous patients, could hover over infantilized, yet sometimes surprisingly cheerful, patients, which made them feel “like I do around small children, sort of motherly.” Physicians had the heady experience of performing daily miracles: “I take my insulin therapy patients to the doors of death,” said one, “and when they are knocking on the doors, I snatch them back.”⁴⁴ Patients so treated would spend a great deal of time sleeping between the daily comas, leading to a diminution of noisy, disturbed behavior on the wards, yet another blessing for hospital staff. Hospitals that set up insulin wards could also point to this activity as evidence that they were providing the mentally ill with modern, scientific medicine. All of this made for a medical drama that could be appreciated by many and, further, could evoke public praise.

After testing various poisons in animal experiments, Meduna settled on camphor as the seizure-inducing drug of choice. On January 23, 1934, he injected it into a catatonic schizophrenic, and soon Meduna, like Klaesi and Sakel, was telling a captivating story of a life reborn. After a series of camphor-induced seizures, L. Z., a thirty-three-year-old man who had been hospitalized for four years, suddenly rose from his bed, alive and lucid, and asked the doctors how long he had been sick. It was a story of a miraculous rebirth, with L. Z. soon sent on his way home. Five other patients treated with camphor also quickly recovered, filling Meduna with a sense of great hope: “I felt elated and I knew I had discovered a new treatment. I felt happy beyond words.”

Although metrazol treatment quickly spread throughout European and American asylums, it did so under a cloud of great controversy. As other physicians tried it, they published recovery rates that were wildly different. One would find that it helped 70 percent of schizophrenic patients. The next would find that it didn’t appear to be an effective treatment for schizophrenia at all but was useful for treating manic-depressive psychosis. Others would find it helped almost no one. Rockland State Hospital in New York announced that it didn’t produce a single recovery among 275 psychotic patients, perhaps the poorest reported outcome in all of psychiatric literature to that time.⁴⁷ Was it a totally “dreadful” drug, as some doctors argued? Or was it, as one physician wrote, “the elixir of life to a hitherto doomed race?”⁴⁸

A physician’s answer to that question depended, in large measure, on subjective values. Metrazol did change a person’s behavior and moods, and in fairly predictable ways. Physicians simply varied greatly in their beliefs about whether that change should be deemed an “improvement.” Their judgment was also colored by their own emotional response to administering it, as it involved forcing a violent treatment on utterly terrified patients.

Metrazol triggered an explosive seizure. About a minute after the injection, the patient would arch into a convulsion so severe it could fracture bones, tear muscles, and loosen teeth. In 1939, the New York State Psychiatric Institute found that 43 percent of state hospital patients treated with metrazol had suffered spinal fractures. Other complications included fractures of the humerus, femur, pelvic, scapula, and clavicle bones, dislocations of the shoulder and jaw, and broken teeth. Animal studies and autopsies revealed that metrazol-induced seizures caused hemorrhages in various organs, such as the lungs, kidney, and spleen, and in the brain, with the brain trauma leading to “the waste of neurons” in the cerebral cortex. ⁴⁹ Even Meduna acknowledged that his treatment, much like insulin-coma therapy, made “brutal inroads into the organism.”

We act with both methods as with dynamite, endeavoring to blow asunder the pathological sequences and restore the diseased organism to normal functioning . . . beyond all doubt, from biological and therapeutic points of view, we are undertaking a violent onslaught with either method we choose, because at present nothing less than such a shock to the organism is powerful enough to break the chain of noxious processes that leads to schizophrenia.⁵⁰

As with insulin, metrazol shock therapy needed to be administered multiple times to produce the desired lasting effect. A complete course of treatment might involve twenty, thirty, or forty or more injections of metrazol, which were typically given at a pace of two or three a week. To a certain degree, the trauma so inflicted also produced a change in behavior similar to that seen with insulin. As patients regained consciousness, they would be dazed and disoriented—Meduna described it as a “confused twilight state.” Vomiting and nausea were common. Many would beg doctors and nurses not to leave, calling for their mothers, wanting to “be hugged, kissed and petted.” Some would masturbate, some would become amorous toward the medical staff, and some would play with their own feces. All of this was seen as evidence of a desired regression to a childish level, of a “loss of control of the higher centres” of intelligence. Moreover, in this traumatized state, many “showed much greater friendliness, accessibility, and willingness to cooperate,” which was seen as evidence of their improvement. The hope was that with repeated treatments, such friendly, cooperative behavior would become more permanent.⁵¹

The lifting in mood experienced by many patients, possibly resulting from the release of stress-fighting hormones like epinephrine, led some physicians to find metrazol therapy particularly useful for manic-depressive psychosis. However, as patients recovered from the brain trauma, they typically slid back into agitated, psychotic states. Relapse with metrazol was even more problematic than with insulin therapy, leading numerous physicians to conclude that “metrazol shock therapy does not seem to produce permanent and lasting recovery.”⁵²

Metrazol’s other shortcoming was that after a first injection, patients would invariably resist another and have to be forcibly treated. Asylum psychiatrists, writing in the American Journal of Psychiatry and other medical journals, described how patients would cry, plead that they “didn’t want to die,” and beg them “in the name of humanity” to stop the injections. Why, some patients would wail, did the hospital want to “kill” them? “Doctor,” one woman pitifully asked, “is there no cure for this treatment?” Even military men who had borne “with comparative fortitude and bravery the brunt of enemy action” were said to cower in terror at the prospect of a metrazol injection. One patient described it as akin to “being roasted alive in a white-hot furnace”; another “as if the skull bones were about to be rent open and the brain on the point of bursting through them.” The one theme common to nearly all patients, Katzenelbogen concluded in 1940, was a feeling “of being excessively frightened, tortured, and overwhelmed by fear of impending death.”⁵³

The patients’ terror was so palpable that it led to speculation whether fear, as in the days of old, was the therapeutic agent. Said one doctor:

No reasonable explanation of the action of hypoglycemic shock or of epileptic fits in the cure of schizophrenia is forthcoming, and I would suggest as a possibility that as with the surprise bath and the swinging bed, the “modus operandi” may be the bringing of the patient into touch with reality through the strong stimulation of the emotion of fear, and that the intense apprehension felt by the patient after an injection of cardiazol [metrazol] and so feared by the patient, may be akin to the apprehension of the patient threatened with the swinging bed. The exponents of the latter pointed out that fear of repetition was an important element in its success.⁵⁴

Advocates of metrazol therapy were naturally eager to distinguish it from the old barbaric shock practices and even conducted studies to prove that fear was not the healing agent. In their search for a scientific explication, many put a Freudian spin on the healing psychology at work. One popular notion, discussed by Chicago psychotherapist Roy Grinker at an American Psychiatric Association meeting in 1942, was that it put the mentally ill through a near-death experience that was strangely liberating. “The patient,” Grinker said, “experiences the treatment as a sadistic punishing attack which satisfies his unconscious sense of guilt.”⁵⁵ Abram Bennett, a psychiatrist at the University of Nebraska, suggested that a mental patient, by undergoing “the painful convulsive therapy,” has “proved himself willing to take punishment. His conscience is then freed, and he can allow himself to start life over again free from the compulsive pangs of conscience.”⁵⁶

As can be seen by the physicians’ comments, metrazol created a new emotional tenor within asylum medicine. Physicians may have reasoned that terror, punishment, and physical pain were good for the mentally ill, but the mentally ill, unschooled in Freudian theories, saw it quite less abstractly. They now perceived themselves as confined in hospitals where doctors, rather than trying to comfort them, physically assaulted them in the most awful way. Doctors, in their eyes, became their torturers. Hospitals became places of torment. This was the beginning of a profound rift in the doctor-patient relationship in American psychiatry, one that put the severely mentally ill ever more at odds with society.

Even though studies didn’t provide evidence of any long-term benefit, metrazol quickly became a staple of American medicine, with 70 percent of the nation’s hospitals using it by 1939. From 1936 to 1941, nearly 37,000 mentally ill patients underwent this treatment, which meant that they received multiple injections of the drug. “Brain-damaging therapeutics”—a term coined in 1941 by a proponent of such treatments—were now being regularly administered to the hospitalized mentally ill, and being done so against their will.⁵⁷

Electroshock, the invention of Italian psychiatrist Ugo Cerletti, did just that. Cerletti, head of the psychiatry department at the University of Rome, had been deeply impressed by both Sakel’s and Meduna’s triumphs, and his own research suggested a way to improve on metrazol therapy. For years, as part of his studies of epilepsy, he had been using electricity to induce convulsions in dogs. Other scientists, in fact, had been using electricity to induce convulsions in animals since 1870. If this technique could be adapted to humans, it would provide a much more reliable convulsive method. The problem was making it safe. In his dog experiments—Cerletti would place one electrode in the dog’s mouth and one in the anus—half of the animals died from cardiac arrest. The United States even regularly killed its criminals with jolts of electricity, which gave Cerletti pause. “The idea of submitting man to convulsant electric discharges,” he later admitted, was considered “barbaric and dangerous; in everyone’s mind was the spectre of the electric chair.”⁵⁹

As a first step in this research, Cerletti’s assistant Lucio Bini studied the damage to the nervous system produced by electricity-induced convulsions in dogs. He found that it led to “acute injury to the nerve cells,” particularly in the “deeper layers of the cerebral cortex.” But Bini did not see this damage necessarily as a negative. It was, he noted, evidence that “anatomical changes can be induced.” Insulin coma also produced “severe and irreversible alterations in the nervous system,” and those “very alterations may be responsible for the favorable transformation of the morbid psychic picture of schizophrenia. For this reason, we feel that we are justified in continuing our experiments.”⁶⁰

The eureka moment for Cerletti, however, came in a much more offbeat venue—a local slaughterhouse. Cerletti had gone there expecting to observe how pigs were killed with electroshock, only to discover that the slaughterhouse simply stunned the pigs with electric jolts to the head, as this made it easier for butchers to stab and bleed the animals. The key to using electricity to induce seizures in humans, Cerletti realized, was to apply it directly to the head, rather than running the current through the body. After testing this premise in animal experiments, he said, “I felt we could venture to experiment on man, and I instructed my assistants to be on the alert for the selection of a suitable subject.”⁶¹

The suitable subject turned out to be a thirty-nine-year-old dis - oriented vagrant rounded up at the railroad station by Rome police and sent to Cerletti’s clinic for observation. “S. E.,” as Cerletti called him, was from Milan, with no family in Rome. Later, Cerletti would learn that S. E. had been previously treated with metrazol, but he knew little of S. E.’s past when, in early April 1938, he conducted his bold experiment. At first, it went badly. Neither of the initial two jolts of electricity, at 80 and 90 volts, successfully knocked out S. E.—he even began singing after the second. Should the voltage be increased? As Cerletti and his team discussed what to do—his assistants thought a higher dose would be lethal—S. E. suddenly sat up and protested: “Non una seconda! Mortifera!” (“Not a second! It will kill me!”) With those words ringing in his ears, Cerletti, intent on not yielding “to a superstitious notion,” upped the jolt to 110 volts, which quickly sent S. E. into a seizure. Soon Cerletti trumpeted his achievement: “That we can cause epileptic attacks in humans by means of electrical currents, without any danger, seems to be an accepted fact.”⁶²

Electroshock, which was introduced into U.S. hospitals in 1940, was not seen as a radical new therapy. As Cerletti had suggested, his achievement had simply been to develop a better method for inducing convulsions. Electricity was quick, easy, reliable, and cheap—all attributes that rapidly made it popular in asylum medicine. Yet, as soon became clear, electroshock also advanced “brain-damaging therapeutics” a step further. In comparison with metrazol, it produced a more profound, lasting trauma. Sakel, who thought the trauma too extreme, pinpointed the difference from his own insulin treatment: “In the amnesia caused by all electric shocks, the level of the whole intellect is lowered . . . the stronger the amnesia, the more severe the underlying brain cell damage must be.”⁶³

Indeed, asylum medicine was now pitching headlong down a very peculiar therapeutic path. Was the change effected by brain trauma a good or a bad thing? How one answered that question depended in great part on one’s beliefs about the potential for the severely mentally ill to recover and whether there was much to value in them as they were. Criticism of the shock therapies, which came primarily from Freudians, was memorably articulated in 1940 by Harry Stack Sullivan, a leading psychoanalyst:

These sundry procedures, to my way of thinking, produce “beneficial” results by reducing the patient’s capacity for being human. The philosophy is something to the effect that it is better to be a contented imbecile than a schizophrenic. If it were not for the fact that schizophrenics can and do recover; and that some extraordinarily gifted and, therefore, socially significant people suffer schizophrenic episodes, I would not feel so bitter about the therapeutic situation in general and the decortication treatments in particular.⁶⁴

Electroshock, the newest “decortication” treatment in asylum medicine, worked in a predictable manner. With the electrodes placed at the temples, the jolt of electricity passed through the temporal lobes and other brain regions for processing memory. As patients spasmed into convulsions, they immediately lost consciousness, the brain waves in the cerebral cortex falling silent. “A generalized convulsion,” explained Nolan Lewis, of the New York State Psychiatric Institute, in 1942, “leaves a human being in a state in which all that is called the personality has been extinguished.” ⁶⁵ When patients came to, they would be dazed, often not quite sure of who they were, and at times sick with nausea and headaches. Chicago psychiatrist Victor Gonda noted that patients, in this stunned state, “have a friendly expression and will return the physician’s smile.”⁶⁶

Even after a single treatment, it would take weeks for a patient’s brain-wave activity, as measured by an electroencephalograph, to return to normal. During this period, patients frequently exhibited evidence of “organic neurasthenia,” observed Lothar Kalinowsky, who established an electroshock program at New York State Psychiatric Institute in 1940. “All intellectual functions, grasp as well as memory and critical faculty, are impaired.” Patients remained fatigued, “disoriented in space and time . . . associations become poor.”⁶⁷ They also acted in submissive, helpless ways, a change in behavior that made crowded wards easier to manage.

Early on, it was recognized that the dulling of the intellect was the therapeutic mechanism at work. Psychosis remitted because the patient was stripped of the higher cognitive processes and emotions that give rise to fantasies, delusions, and paranoia. As one physician said, speaking of brain-damaging therapeutics: “The greater the damage, the more likely the remission of psychotic symptoms.”⁶⁸ Said another: “The symptoms become less marked at the same time as a general lowering of the mental level occurs.”⁶⁹ Research even directly linked the slowing of brain wave activity to diminishment of “hallucinatory activity.”

The memory loss caused by electroshock was also seen as helpful to the mentally ill. Patients, physicians noted, could no longer recall events that had previously caused them so much anguish. “The mechanism of improvement and recovery seems to be to knock out the brain and reduce the higher activities, to impair the memory, and thus the newer acquisition of the mind, namely the pathological state, is forgotten,” explained Boston psychiatrist Abraham Myerson, speaking at the American Psychiatric Association’s annual meeting in 1943.⁷⁰

As quickly became evident, however, electroshock’s “curative” benefits dissipated with time. When patients recovered from the trauma, their mental illness often returned. “That relapses will come, that in many cases the psychosis remanifests itself as the brain recovers from its temporary injury is, unfortunately, true,” Myerson admitted. “But the airplane has flown even if shortly it has crashed.” Given that problem, logic suggested a perverse next step. If the remission of symptoms were the desired outcome, and if symptoms returned as patients recovered from the head injury, then perhaps electroshock should be repeated numerous times, or even on a daily basis, so that the patient became more deeply impaired. In his 1950 textbook Shock Treatment, Kalinowsky dubbed this approach “confusional” treatment. “Physicians who treat their patients to the point of complete disorientation are highly satisfied with the value of ECT [electroshock] in schizophrenia,” he noted.⁷¹ Bennett, echoing Kalinowsky’s arguments, advised that at times a patient needed to be shocked multiple times to reach “the proper degree of therapeutic confusion.”⁷² Such guidance led Rochester State Hospital in New York to report in 1945 that its mental patients were being shocked three times weekly, as “this regime has to some extent increased and maintained [their] confusion.” The patients were said to be “more amused than alarmed by this circumstance.”⁷³

One woman so treated was seventeen-year-old Jonika Upton. Her family committed her to Nazareth Sanatorium in Albuquerque, New Mexico, on January 18, 1959, upset that she had run off to Santa Cruz, California, several weeks earlier with a twenty-two-year-old artist boyfriend. Her family was also alarmed that she’d previously had a boyfriend whom they suspected of being “homosexual,” that she had developed peculiar speech mannerisms, and that she often “walked about carrying ‘Proust’ under her arm.” Her admissions record described her as “alert and cooperative but [she] makes it plain that she doesn’t like it here.”⁷⁴

Over the next three months, Upton was shocked sixty-two times. During this course of treatment, her doctors regularly complained about her slow progress: “Frankly,” her supervising physician wrote on March 24, “she has not become nearly as foggy as we might wish under such intensive treatment but, of course, there is considerable confusion and general dilapidation of thought.” Two weeks later, the doctor’s lament was the same: “We are not really satisfied with her reactions to intensive treatment up to the time. Under this type of treatment a patient usually shows a great deal more fogging and general confusion than she has.” But by the end of April, Jonika Upton had finally deteriorated to the desired “confusional” point. She was incontinent, walked around naked, and was no longer certain whether her father was dead or alive. A few days later, she was seen as ready for discharge. She was handed back over to her parents, whom she “did not seem to recognize,” the nurses observed. However, her symptoms had indeed remitted. Her memory of her boyfriend had been erased, and certainly she was no longer carrying Proust under her arm. Upton’s physician chalked her up as a therapeutic success, writing, on the day of her discharge, to a fellow doctor: “She showed marked changes in her thinking and feeling and I believe that she has developed some insight.”^d

By the time Upton was treated, researchers had better identified the basic nature of the trauma inflicted by electroshock. Max Fink, at Hillside Hospital in Long Island, who was a proponent of the treatment, had shown that electroshock, as a single event, produced changes very similar to “severe head trauma.” The alterations in brain-wave activity were the same, and both produced similar biochemical changes in the spinal fluid. In fact, electroshock did not produce changes similar to epileptic seizures but rather induced changes similar to a concussive head injury. The similarity was such that “convulsive therapy provides an excellent experimental method for studies of craniocerebral trauma,” Fink concluded.⁷⁶

What remained controversial was whether such trauma led to permanent brain damage. Although there was much debate on this question, a number of studies had turned up evidence that it did, making intensive treatment that much more problematic. At autopsy and in animal experiments, researchers had found that electroshock could cause hemorrhages in the brain, particularly in the cerebral cortex. “Areas of [cortical] devastation” were found in one patient who died. “Increased neuronal degeneration and gliosis” were reported in 1946. Various investigators announced that repeated electroshock treatments could lead to “permanent impairment of behavioral efficacy and learning capacity,” “lower cognitive functioning,” “extended memory loss,” and a “restriction in intuition and imagination and inventiveness.” Leon Salzman, from St. Elizabeth’s Hospital in Washington, D.C., noted in 1947 that “most workers agree that the larger the number of shocks the greater damage produced.” One year later, a study of schizophrenics shocked more than 100 times found that in some, their inner lives were “apparently barren,” their “ego function . . . extremely reduced,” and their perception of reality extremely impaired.⁷⁷

Until muscle-paralyzing agents were introduced, the physical trauma from electroshock was much the same as it was for metrazol injection: Up to 40 percent of patients suffered bone fractures with electroshock. This problem was lessened after Bennett reported in 1940 that the drug curare could be used to temporarily paralyze patients, preventing the wild thrashing that could break bones. But such paralyzing drugs were not always given, and even eliminating the bodily trauma didn’t eliminate patients’ fears. After experiencing shock a few times, Kalinowsky said, some patients “make senseless attempts to escape, trying to go through windows and disregarding injuries.” They “tremble,” “sweat profusely,” and make “impassioned verbal pleas for help,” reported Harvard University’s Thelma Alper. Electroshock, patients told their doctors, was like “having a bomb fall on you,” “being in a fire and getting all burned up,” and “getting a crack in the puss.” Researchers reported that the mentally ill regularly viewed the treatment as a “punishment” and the doctors who administered it as “cruel and heartless.”⁷⁹

That is how doctors, in their more candid moments, reported on their patients’ reactions. In their own writings, patients regularly described electroshock in even stronger terms as a horrible assault. In her 1964 memoir, The White Shirts, Ellen Field told of the great terror it evoked:

People tend to underrate the physical damage of anticipating shock. At any rate, they think of it as purely a mental fear. This is so false. The truth is that electric shock is physical torture of an extreme type . . . the fear is intensely physical . . . The heart and solar plexus churn and give off waves of—I don’t know the word for it. It hasn’t the remotest resemblance to anything I’ve ever felt before or since. Soldiers just before a battle probably experience this same abdominal sensation. It is the instinct of a living organism to fear annihilation.⁸⁰

Sylvia Plath, in The Bell Jar, described how it led to both physical and emotional trauma:

Doctor Gordon was fitting two metal plates on either side of my head. He buckled them into place with a strap that dented my forehead, and gave me a wire to bite. I shut my eyes. There was a brief silence, like an indrawn breath. Then something bent down, and took hold of me and shook me like the end of the world. Whee-eeee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant. I wondered what terrible thing it was that I had done.⁸¹

Dorothy Washburn Dundas, a young woman when she was shocked, recounted in Beyond Bedlam a similar story: “My arms and legs were held down. Each time, I expected I would die. I did not feel the current running through me. I did wake up with a violent headache and nausea every time. My mind was blurred. And I permanently lost eight months of my memory for events preceding the shock treatments. I also lost my self-esteem. I had been beaten down.”⁸² Others described hospital scenes of patients being dragged screaming into the shock rooms. “Believe me when I say that they don’t care how they get you there,” Donna Allison wrote, in a letter to the editor of a Los Angeles paper. “If a patient resists, they will also choke him until he passes out, and lay him on his bed until he comes to, and then give him treatment. I have also had that happen to me.”⁸³

Faced with such resistance, American physicians and hospitals simply asserted the right to shock patients without their consent. Historian Joel Braslow, in his review of California patient records, found that only 22 percent of shocked patients had agreed to the treatment, and this was so even though physicians regularly told their hospitalized patients that electroshock was safe and painless. ⁸⁴ “We prefer to explain as little as possible to the uninformed patient,” Bennett explained in 1949. Shock, he said, should be described to patients as “sleep induced by electricity,” the patients assured that “there is no pain or discomfort.”⁸⁵ Other leading electroshock doctors, like David Impastato at Bellevue Hospital in New York City, argued that the mentally ill shouldn’t even be told that they were going to be shocked: “Most patients associate EST with severe insanity and if it is suggested, they will refuse it claiming they are not insane and do not need the treatment . . . I recommend that patients be kept in ignorance of the planned treatment.”⁸⁶ Such forced treatment might not even be remembered, shock advocates reasoned, as patients often had “complete amnesia for the whole treatment.”⁸⁷

Such thinking reflected, of course, societal views about the rights—or non-rights—of the mentally ill. By any standard, electroshock was a profound event. Psychiatrists saw it as a method, in Fink’s words, to produce “an alteration in brain function.”⁸⁸ It was designed to change the mentally ill in a pronounced way. The treatment might make their psychotic symptoms and depression disappear, but such relief would come at the cost of their ability to think, feel, and remember, at least for a period of time. Yet the prevailing opinion among America’s leading electroshock doctors in the 1940s and 1950s was that in the confines of mental hospitals, they had the right to administer such treatment without the patient’s consent, or even over the patient’s screaming protests—a position that, if it had been applied to criminals in prison, would have been seen as the grossest form of abuse. Indeed, after World War II ended, when the United States and its allies attended to judging Nazi crimes, the International Red Cross determined that prisoners in concentration camps who had been electroshocked should be compensated for having suffered “pseudomedical” experiments against their will. As some of the shocked prisoners were later killed, “the electroshock treatments could be seen as a prelude to the gas chamber,” noted historian Robert Lifton.⁸⁹ But in the United States, forced electroshock remained a common practice for more than two decades, with easily more than 1 million Americans subjected to it.

Like so many somatic remedies of earlier periods, electroshock was also used to frighten, control, and punish patients. Braslow found that in California, asylum physicians regularly prescribed electroshock for those who were “fighting,” “restless,” “noisy,” “quarrelsome,” “stubborn,” and “obstinate”—the treatment made such patients “quieter” and “not so aggressive.”⁹⁰ Other scholars, writing in medical journals, reported how physicians and hospital staff chose to shock patients they most disliked. One physician told of using it to give women a “mental spanking.” An attendant confessed: “Holding them down and giving them the treatment, it reminded me of killing hogs, throwing them down in the pen and cutting their throats.” Hospital physicians spoke of giving misbehaving patients “a double-sized course” of electricity.⁹¹

Many hospitals used electroshock to quiet the wards and set up schedules for mass shocking of their patients. “Patients could look up the row of beds,” Dr. Williard Pennell told the San Francisco Chronicle, “and see other patients going into epileptic seizures, one by one, as the psychiatrists moved down the row. They knew their turn was coming.”⁹² Bellevue Hospital in New York touted the use of electroshock as a “sedative” for acutely disturbed patients, shocking them twice a day, which left the “wards quieter and more acceptable to all patients.”⁹³ And at Georgia’s Millidgeville Asylum, where 3,000 patients a year were being shocked in the early 1950s, nurses and attendants kept patients in line by threatening patients with a healthy dose of a “Georgia Power cocktail.” Superintendent T. G. Peacock informed his attendants: “I want to make it clear that it is hospital policy to use shock treatment to insure good citizenship.”⁹⁴

A Bounty of Remedies

The Rise of Shock Therapies

The Elixir of Life

The Benefits of Amnesia

No Consent Necessary