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00:00arts you know what kind of a place this is yes what kind of a place is a birthplace of
00:12jesus
00:12christ this is the birthplace of jesus christ and the name of the city uh franco america
00:28there's pleasure and pain in america is that what the voices are saying
00:36do you have a voice talking to you now besides mine yes what is it saying
00:48hollywood joe namus everyone's in love with joe namus
00:50uh yeah out of nowhere to be able to go from jesus christ to joe namus
01:38at stony brook hospital on long island steve koloff is a patient of dr max fink
01:44since late adolescence he has been the subject of contradictory psychiatric diagnoses and the
01:50victim of many years of unsuccessful treatment he's about to undergo the controversial procedure
01:56of electric convulsive therapy or ect on the morning when we visited the hospital
02:02several other patients of dr fink were about to receive the same treatment do you mind if we
02:07you talk for a moment no go ahead and talk you want to tell dr miller why you came to
02:12the hospital
02:12this time i came because i was transferred here i didn't want to come but my daughters had it all
02:20set
02:20up they're only make believe they're phonies no yes how could they be phonies and come to you here
02:28do they look like your children yes i do can you tell them in what way are they different from
02:35the real
02:35children from what way it would be very difficult to tell you that i don't know what happened to them
02:43they became a blade of breath
02:49he was brought to us a so-called last resort recommended convulsive therapy he refused family
02:56was upset actually the family refused finally we educated them he went home for a few days
03:01couldn't make it came back he's had four treatments by now i think it's four yes how do you feel
03:08about
03:08them do they help you i think they're helping yes he is exactly in the middle of his treatment course
03:14my expectation would be he'll be treated probably twice this week twice next week maybe once thereafter
03:36i'm just going to use some alcohol first mr friedman is there any reason why you should be in the
03:42hospital
03:44no are you sick in any way and that's how much i didn't understand the words say it again i
03:50didn't
03:51touch my husband first and me second who touched your husband first and you second who touched no
03:57talked oh talked oh you talked to your husband first you say i was at the wedding my uh
04:03two other i guess we need time to wear it it's very difficult she has a speech which is rambling
04:14there are periods of coherency some responses are direct majority are not
04:19we have a videotape for you if you wish of her just continually talking
04:25what is that what is that talking to me i'm doing my nails you're doing your nails with this yeah
04:37with the nail polish i'm doing right talking to my mom yeah talking to your mother
04:42my mother i think of something on my own what what is this what what is this
04:46i don't want my sister my eyes all wet them parts all of it all wet them parts i do
04:52on my
04:54would you like the book oh really
05:01even its most enthusiastic sponsors concede that the administration of an electric shock through the
05:07skull is a comparatively crude assault on the underlying brain
05:11and in the early days when it was administered without anesthetics and without muscle relaxants
05:17to limit the convulsions that result from the shock it was widely regarded as a punitive ordeal
05:23and this perhaps is one of the reasons why the treatment still has a somewhat dubious reputation
05:28the question is does he have catatonia disease and is that schizophrenia and even now
05:40when it's administered with all the safeguards that normally accompany surgery there are many
05:44hospitals that forbid its use although the convulsion has been limited to a barely detectable tremor in
05:58the foot and the electric shock is comparatively mild the brain has undergone a major upheaval and as
06:05yet there's no real explanation for its frequently helpful results in that flat yeah seizure's over
06:11in recent years this treatment has been used most effectively in cases of severe depressive illness
06:18but even then it's only used very sparingly and usually as a last resort
06:23dr fink however has a much more optimistic view and employs it for conditions which in
06:28other hospitals might have been treated by drugs alone one of the consequences of a seizure
06:34is that the brain produces all sorts of chemicals in large amount and all the cells get bathed with
06:40these chemicals which are expressed during the seizure particularly if you repeat seizures one
06:45after another as we do no patient benefits from one seizure years ago we would treat six eight
06:52treatments and stop and the relapse rate was horrendous up to 80 percent within one year in some studies
07:00that means that we stimulated the brain to do something but we didn't sustain it
07:06last few years we've gone back to an old technique of maintenance treatment
07:10and we try to keep the patient in treatment for three four six months we're not sure that that's going
07:17to be
07:19the final answer but it surely is an interim answer because we now have a number of patients here and
07:25in other hospitals
07:26mostly academic hospitals where this is being done and the patients do well by continually being stimulated to produce
07:33an unknown substance so in some senses it's really rather like an orange squeezer um that you're as
07:40it were inflicting a brain squeeze and uh hoping that something will be squashed out of these cells which will
07:48replace a deficit yes with one addition that is that it's we're trying to stimulate the brain then
07:56by this maneuver to produce this substance itself i see mental illness very similar to diabetes
08:04that is in diabetes there are some glands allens of langerhans which are deficient in producing insulin
08:09we can only replace it because we've identified the insulin the mentally ill patient has a substance that's
08:16missing i can foresee the day when we will not need the seizure or the electricity or anything as
08:23complicated as we now have it if we once understand the chemical imbalance which is the basis for the
08:31psychosis and the affective illness the theories and treatments sponsored by dr fink take their place in
08:42a long historical line of physical explanations of madness
08:50in spite of the architectural similarities there's a whole world of imaginative difference between the
08:58stony brook hospital on long island and this institution which was established at the end of the 18th
09:04century to house the viennese insane this is the narrentum or fool's tower which was built in 1784
09:15under the auspices of the hapsburg emperor joseph ii it looks to all intents and purposes like the
09:23keep of a medieval castle with 140 locked cells stacked one above the other on five circular floors
09:33in contrast to its english counterpart in bedlam where the patients were freely and frequently visited by a
09:40public who were only too eager to feast their eyes on the bizarre antics of the unfortunate inmates
09:47the narrentum was designed as an undifferentiated custodial space which was completely impenetrable to the
09:54public gaze locked in solitary confinement and more often than not chained to their beds
10:05the patients were supervised rather than observed
10:11well in spite of its apparently benevolent purpose this establishment was virtually indistinguishable from
10:18a prison anyway no one has yet availed themselves of the opportunity for scientifically examining and
10:25generalizing the signs and symptoms which such a large collection of disordered individuals offered
10:32in fact it wasn't until the asylum was entirely reconceived as a curative therapeutic establishment
10:38that it was understood that by putting large numbers of mad people together in one place there was
10:44an unprecedented opportunity not merely to oversee and regulate their conduct but to observe and
10:50theorize about the variety and causes of madness an early sign of that attitude is the 19th century
10:59blossoming of psychiatric illustration these uh heads which are according to the caption the heads of
11:08idiot women are taken from um johann casper lefato's physiognomic fragments he has very detailed readings of
11:18what the form of the nose means what the form of the grin means uh the lines on the forehead
11:25so in other words he separates out things like the permanent features like noses from the fleeting
11:31expressions which pass and reform themselves from moment to moment he does i mean one of the things that
11:37is so interesting for levante is that he makes the assumption that temporary expressions leave
11:43permanent traces yes and yet again one is struck by looking at this picture from such a long time ago
11:51not so much by the representation of insanity if indeed one could recognize any of them as particularly
11:56insane but by the repertoire of art historical types absolutely absolutely all of the conventions are
12:04our representations from art and what is interesting of course is that with the introduction of psychiatric
12:09textbooks they become the way that physicians are trained to see their patients until the late 19th
12:18century the emphasis upon the appearance of the insane took unaccountable precedence over what they
12:23thought believed or said and with the advent of photography which was regarded as the epitome of objective
12:30representation patients were all too frequently classified in terms of their external appearance
12:53the increasing interest in the face of the mad was accompanied by a growing conviction that madness itself
13:02was the result of something going wrong immediately behind the face in the brain
13:08well of course this wasn't altogether a new idea on the contrary the suspicion that the mind is in the
13:16head
13:16is probably as old as human thought itself but although the mind was located in the head
13:23the sources of its disorders were more often than not identified as coming from elsewhere
13:31in various imbalances of the so-called four physiological humors which were supposed to be the fundamental
13:37substances of the human body so that an excess of yellow bile was supposed to make a man angry too
13:45much phlegm
13:45gave him a complacent or phlegmatic temperament and an excess of black bile made him sad or melancholy hence the
13:54name
13:55now if any of these mild imbalances went to extremes it produced one of the different forms of madness
14:03well associated with this humoral psychopathology indeed a direct corollary of it was the idea that various
14:11abdominal organs were the sources of mental disorder the liver for example the intestines and particularly the spleen
14:21and the fact that the word hysteria entered the medical vocabulary at such an early stage proves that the womb
14:29or hysteria with its imputed tendency to rise into the chest was regarded as a peculiarly culpable organ
14:40now although procedures based on a humoral theory has to say bleeding purging and vomiting
14:47long outlived the theories themselves the new emphasis on the nervous system meant that some
14:52of the new treatments were directed or at least they were thought to be directed at the brain itself
15:17when you see pieces of apparatus like this especially when they've been housed in a rather unalarming and
15:24picturesque museum they simply strike you as obsolete and rather exotic curios left over from an unenlightened
15:31age rather like the rack or the iron maiden but even when you know that they have a medical rather
15:40than a
15:40penal function it's so easy to confuse something like this with an instrument of torture that it's easy to
15:47think of the men who invented and used such devices as medieval brutes or idiots and yet the odd thing
15:55is that they were neither
15:59in fact the paradox is that although this fearsome object looks as if it belonged to the sheriff of nottingham
16:06it was invented and used by a man who is widely regarded as one of the paragons of the 18th
16:14century enlightenment
16:16it was invented by benjamin rush the philadelphia physician who is now thought of as the father of american
16:24psychiatry and this chair which was used for tranquilizing raving maniacs was used by its inventor
16:33in order to exemplify certain rational principles of medicine it worked quite simply the arms were
16:40restrained inside these hollow containers here
16:47on both sides
16:50and the feet were confined strapped into this sort of double shoe box
16:59and the head meanwhile was put inside this canopy here
17:05with the vision obscured by this dark
17:10gauze
17:11meanwhile this close stool arrangement took care of the patient's evacuations which i imagine under these
17:18circumstances were frequent and full
17:22the theory was that by calming and restraining the patient cerebral blood flow would improve
17:28and the brain would return to normal function
17:33in the effort to accelerate and intensify these effects machines were invented to whirl
17:38swirl shock rock and douche the patient back to sanity
18:18in the effort to accelerate and to make a noise
18:30These drastic and rather punitive interventions
18:34were directed at the patient's brain
18:36rather than at the humours or bodily fluids,
18:40although one suspects that the patient's bodily fluids
18:44would soon have been in evidence as a result.
18:47But the assault upon the brain
18:49was completely undifferentiated,
18:51if only because the functional architecture of the organ
18:55was as yet undisclosed.
18:57And in the absence of more accurate information
19:00about its physiological function,
19:02the sick brain was treated with a series of traumatic assaults,
19:08presumably in the hope that its disordered parts
19:10would simply be jolted back into place.
19:13It's not all that different from striking a television set
19:17in the hope of restoring the picture.
19:21Shamed by the advances in every other field of medicine,
19:24the psychiatric profession was eager to appropriate anything
19:27that gave the impression of decisive scientific action.
19:30In 1928, the Viennese physician Manfred Sackle
19:34was treating a diabetic patient
19:35who also happened to be a schizophrenic.
19:38In the effort to manage the diabetes,
19:40he accidentally gave the patient an overdose
19:42of the recently discovered hormone insulin
19:44and was surprised to find that the mental symptoms
19:47appeared to have undergone a remission.
19:50He then embarked on an ambitious program
19:53of insulin therapy with non-diabetic schizophrenics.
19:57The insulin produced a dramatic fall in blood sugar
20:00and the brain was briefly deprived
20:02of an essential ingredient for normal physiologic function.
20:05The patient began to sweat profusely
20:08and as the blood sugar fell,
20:10major convulsions followed.
20:30Since this was a life-threatening procedure,
20:32it was necessary to counteract the effect
20:34by administering glucose through an intragastric tube.
20:39Unless the glucose was administered punctually,
20:42irreversible brain damage or even death might result.
20:45In most cases, however, the patient rapidly revived
20:48and after a brief euphoric phase,
20:51there were usually marked signs of psychological improvement.
20:54I sat in a coffee house in Vienna.
20:58The custom during my student days,
21:00the waiter handed me the weekly Viennese medical journal,
21:06the Wiener Medizinische Wochenschrift.
21:08And there, to my amazement,
21:11I saw an account of this new insulin shock treatment
21:15which was being published serially
21:17in the journal at that time.
21:19And it had actual stenographic accounts
21:22of people recovering from their schizophrenic psychosis
21:28after a series of insulin treatments.
21:31I immediately went over to the hospital
21:35and sought the sackle out
21:37and saw the treatments.
21:39And I was amazed.
21:40I had already spent a year
21:42in a psychiatric hospital at Bellevue
21:44and I had never seen a schizophrenic patient recover at all.
21:50And there before my eyes,
21:51I saw this remarkable phenomenon
21:53and it fascinated me.
21:56And I brought the news back to the States
21:58and helped sackle come to this country subsequently.
22:02Meanwhile, the Hungarian physician Ladislav Meduna
22:05was working on an alternative form of convulsive therapy.
22:10His theory was based on a somewhat slipshod anecdotal observation
22:14that epileptic patients rarely, if ever,
22:17suffered from schizophrenia.
22:19In the belief that it was the fits
22:21that produce the beneficial effect,
22:23he tried to induce them artificially.
22:30He achieved this by injecting
22:32the convulsant chemical metrazole.
22:34And although the original theory
22:36had no real foundation,
22:38there were enough favorable results
22:40to encourage its widespread use.
23:03Enthusiasm for artificially induced convulsions intensified
23:08and it was only a matter of time
23:09before electricity was exploited.
23:12In 1936, the Italian Ugo Cerletti
23:15found that the otherwise lethal effect of electricity
23:18could be turned to therapeutic advantage
23:20if the current was passed across the head
23:22so that the heart was not affected.
23:43After two years of extensive animal experiments,
23:47Cerletti administered electroconvulsive therapy,
23:50or ECT,
23:51to the first human subject.
23:53One of the earliest witnesses
23:54of these experiments was Lothar Kalinowski,
23:57who later brought the treatment to the USA,
23:59where it quickly triumphed over metrazole.
24:02Let me tell the story.
24:04He came home for lunch,
24:05as white as a sheet,
24:07and said,
24:08today I saw something terrible.
24:10And he described the first electric truck treatment
24:13and he ended with,
24:15I will never want to see this again.
24:18And then I don't know
24:19how many thousands of truck treatments he gave.
24:23Well, doctor,
24:24just how well does this therapy work?
24:26Many patients have been returned to their homes and jobs
24:30who might still be here
24:32if it were not for this helpful form of treatment.
24:35Well, thank you both very much.
24:37From the start,
24:38ECT was beset by a problem of public relations
24:41because of its threatening resemblance
24:43to the more notorious use of electricity
24:45in judicial execution,
24:47so that every effort was made
24:48to underplay the violence of the procedure.
24:51What kind of treatment is given here?
24:53This patient is prepared for electric shock therapy,
24:55which is often very effective
24:58in helping to bring
24:59mentally troubled patients back to normal.
25:01How is electric shock therapy done?
25:03We use these electrodes.
25:05We place them on the patient's head like this,
25:09and then by means of this machine,
25:11we place a controlled electric current
25:13through the brain
25:14just for a fraction of a second.
25:16The patient doesn't feel it.
25:18And yet in the early days,
25:20the realities of the treatment
25:22were considerably less reassuring
25:24than the profession was prepared to admit.
25:26...of confusion.
25:36The passage of the current
25:37induced immediate unconsciousness,
25:39and although the patient retained no memory
25:42of the violent convulsions which followed,
25:44the muscular spasms almost always caused
25:46serious bruising
25:47and lacerations of the tongue and lips.
25:50There were often more serious injuries,
25:52such as fractures of the limbs
25:53and even of the spine.
26:08After the Second World War,
26:09the introduction of muscle relaxants
26:11prevented some of the more atrocious
26:13physical consequences of the new treatment.
26:15And although by the 1960s
26:17there was mounting evidence
26:18of dangerous psychological effects,
26:20such as memory loss,
26:22the fact that it was the only treatment
26:23which seemed to offer any prospect of improvement
26:26to many of the patients
26:27in the overcrowded mental hospitals
26:28throughout the Western world
26:30encouraged the profession to continue with it
26:32despite its understandably sinister reputation.
26:38For all their superficial resemblance
26:40to 20th century science,
26:42ECT, metrazole, and insulin
26:44have much more in common
26:46with the whirling chairs
26:47and rotating cradles
26:48which they superseded
26:49in that they were addressed to the brain
26:51as if it were a single undifferentiated organ.
26:55Paradoxically, the opportunity
26:57to take a more sophisticated view of the brain
26:59had already been in evidence for 150 years.
27:03At the beginning of the 19th century,
27:05the Austrian anatomist Franz Josef Gall
27:08had claimed that each of the psychological faculties,
27:11such as affection, intelligence, and memory,
27:13were located in different parts of the brain
27:15and that therefore,
27:17instead of being a single entity,
27:19the brain was a bundle of separate organs.
27:22He went on to claim
27:23that by inspecting the skull
27:25whose shape was determined
27:26by the contours of the brain underneath,
27:28one could predict the distinctive character
27:31of the individual in question.
27:34Phrenological ideas spread rapidly
27:36throughout the Western world
27:37where they had an enormous influence
27:39on anyone who was interested
27:40in the causes of lunacy.
27:42Well, it was only a matter of time
27:44before the logically absurd territories
27:47which had been marked out by the phrenologists
27:50lost their hold on the scientific imagination.
27:56Actually, it was someone
27:58who had previously held
27:59strong phrenological opinions
28:01who was responsible for inaugurating
28:04a more realistic picture
28:06of cerebral localization.
28:09In the early 60s,
28:11the French neurologist Broca
28:13discovered that injury to a small area
28:17in the left frontal lobe
28:18seriously impaired the power of speech.
28:22Well, this was followed by another discovery
28:24that disease in the left temporal lobe
28:28interfered with the understanding of language.
28:31Well, once you begin to entertain the idea
28:33that the brain is a system
28:35of physiological offices
28:37interacting with one another
28:38and that certain morbid interactions
28:40might cause clinical symptoms
28:42and possibly insanity,
28:44the stage is set
28:46for surgical intervention.
28:50It would be hard to regard the accident
28:52that befell Phineas Gage
28:54as a surgical maneuver.
28:56In 1848,
28:58while he was helping to build a railway in Vermont,
29:00he was supervising the placing
29:02of a dynamite charge
29:03when it exploded unexpectedly
29:05and blew the tamping iron
29:07upwards through his left cheek
29:09and out through the top of his head.
29:12It's only by hindsight
29:13that he has acquired
29:15an almost mythical role
29:16in the history of psychosurgery.
29:19And was he unconscious
29:20immediately after the accident, or...?
29:22The description suggests
29:23that he was sort of thrown backwards
29:25onto his back
29:26and that for a second or two, perhaps,
29:29that he made a few convulsive
29:31or twitching movements
29:32but was immediately up
29:34and able to account for himself
29:36and actually made a few entries
29:38into the time log
29:39to be sure that he got full credit
29:40for the time that he worked.
29:42How long did he live
29:43after the accident, then?
29:45A bit over 13 years.
29:46As long as that.
29:48Now, how soon was it, then,
29:49that they first started to notice
29:50that there was something wrong
29:51with his personality?
29:52Well, I think the physician
29:54that treated him first
29:57makes some allusions
29:58to the fact
29:59that there had been some change
30:00in his personality.
30:01He promises that,
30:04after his initial report,
30:05that in a later paper on the subject
30:08that he'll tell us more
30:09about the mental manifestations
30:10of the disease.
30:12Now, what you've done,
30:13you've taken an atlas
30:15of 19th century cerebral anatomy
30:19and shown the path
30:21of the tamping iron.
30:22What you can see here
30:23is the brain in cross-section
30:26and everything that I've sort of
30:28outlined in red here
30:29would be the minimal site
30:31of injury of the bar
30:32passing upward
30:33and out through the top
30:34of his head.
30:34And I think you can see
30:35that it's really devastated
30:36almost all of the frontal lobe
30:38on one side.
30:39So this has left him
30:41with his limbs intact.
30:43He's not like a stroke patient
30:44paralyzed on one side.
30:46So this is a disorder
30:47of person
30:48rather than a disorder
30:49of a person's bodily parts, really.
30:52Yes.
30:53I think the key feature here
30:56was that gauge wasn't gauge,
30:59that the things
31:00that make someone
31:01a unique personality
31:02had been either subtly
31:05or in many cases
31:06not so subtly altered.
31:07It was as if he was
31:08a different person
31:10than all of a sudden
31:11this man
31:12who's almost
31:12the model citizen
31:14suddenly can't hold a job,
31:17isn't to be trusted
31:18in the presence of women
31:19because he might offend
31:20their delicate sensibilities
31:22with his profanity
31:23or his inappropriate remarks.
31:27He couldn't follow
31:28any sort of a plan.
31:30It was as if he darted
31:31from job to job
31:32or thing to thing.
31:34And I think at this point
31:35when this was highlighted,
31:37this suddenly fit in so well
31:39with what was coming
31:40to be understood
31:41about what the frontal lobes
31:44of the brain might do.
31:46The therapeutic implications
31:48of this bizarre accident
31:50took a hundred years
31:51to emerge.
31:53In 1949,
31:55the Nobel Prize for Medicine
31:58was awarded
31:59to the Portuguese neurologist
32:01Igas Moniz,
32:02by which time
32:03literally thousands
32:05of patients
32:05had been subjected
32:07to the operation
32:08of lobotomy
32:09which Moniz
32:10had inaugurated
32:11more than ten years earlier.
32:13At the time,
32:14it was widely believed
32:15that the prize
32:16should have been shared
32:17with the American
32:19neurophysiologist
32:20John Fulton
32:21since it was his
32:22experimental work
32:23that had encouraged
32:24Moniz to embark
32:26on this hazardous procedure
32:27in the first place.
32:28In his lab
32:30at Yale,
32:31Fulton had established
32:32a vigorous program
32:34of experimental research
32:35into the behavior
32:36of higher primates
32:38and he was intrigued
32:40to find
32:40that experimental neuroses
32:43which he deliberately
32:44induced in chimpanzees
32:45by inflicting
32:46various forms
32:47of traumatic stress
32:49could be abolished
32:50by surgical procedures
32:52which interrupted
32:53the nervous traffic
32:54between the intellectual
32:56or cognitive functions
32:57of the frontal lobes
32:59and the more primitive
33:00emotional centers
33:01in the lower parts
33:03of the brain.
33:08In the operation
33:10which Moniz recommended,
33:12the surgeon followed
33:12almost exactly
33:13the same anatomical track
33:15as Gage's tamping iron
33:16except that instead
33:18of entering
33:18through the cheek,
33:19he went directly upwards
33:20through the roof
33:21of the eye socket.
33:22And although
33:23the post-operative results
33:25were given
33:26only the most
33:27perfunctory analysis,
33:28within a few years
33:30the practice
33:30of lobotomy
33:31had spread like wildfire
33:32throughout the western world.
33:35Especially
33:35in the United States
33:37where the American
33:38psychiatrist
33:39Walter Freeman
33:40was one of its
33:41most enthusiastic sponsors.
33:43The early operations
33:45which he recommended
33:46were carried out
33:47by his neurosurgical
33:48colleague,
33:49James Watts.
33:50Prefrontal lobotomy
33:51in the treatment
33:52of mental disorders.
33:53I don't believe
33:54I've seen this.
33:56Well, I must have.
33:59Because both your names are...
34:00Well, I guess
34:01I can't deny that.
34:03A review of the landmarks
34:05on the skull...
34:06Well, I could have written that
34:07this part,
34:09but I was not narrating it.
34:11...of the operation.
34:13But this comes from
34:15my operative notes.
34:17Oh, I see.
34:19An incision through the scalp
34:20along the indicated line...
34:21We didn't any of the patients
34:23under local anesthesia.
34:26And Dr. Freeman
34:27would carry on
34:28the conversation
34:29with the patient.
34:30A fur hole
34:30is placed in the coronal suture
34:32by means of successive drill.
34:34The patients didn't mind
34:35that crunching sound
34:36as the...
34:37The dura is open
34:38and the cortex is...
34:39Well, I don't think
34:39they liked it.
34:40No.
34:42No, it was unpleasant
34:43but not painful.
34:45By entering
34:46through the side
34:46of the skull
34:47they persuaded themselves
34:49that they were making
34:50a more discriminating
34:51interruption
34:51of the traffic
34:52between the emotions
34:53and the intellect.
34:54These were always bilateral,
34:56were they?
34:56Always bilateral.
34:58I'll have to take it back.
35:00That is a picture of me.
35:01Really?
35:02Yeah.
35:04And there's Walt Freeman.
35:06See, there's the leucotone.
35:08Oh, another one.
35:08The surgeon implants
35:09the hemostat
35:10on the blunt disector,
35:12introduces it
35:12into the incision
35:13and cuts to within
35:14one centimeter
35:15of the midline.
35:16I had no misgivings
35:18about lobotomy
35:21until Dr. Freeman
35:24began to do
35:26the transoptal lobotomies
35:27in his office.
35:29And one day
35:31I walked in
35:32and as he was doing
35:33a lobotomy
35:34and he's a great man
35:39for recording things
35:41photographically.
35:42And so he usually
35:44had someone
35:45hold the ice pick
35:46while he took
35:48the photograph.
35:49And he asked me,
35:51he says,
35:51Jim, will you hold
35:52that ice pick
35:53while I take
35:54the photograph?
35:55I didn't want to be,
35:58have a picture of me
35:59holding an ice pick
36:01at a patient's head.
36:02So I said,
36:03no, I'd rather not.
36:04And he was pretty
36:06understanding about that.
36:07Even before
36:08the psychotropic drugs
36:10there was a reaction
36:11to lobotomy.
36:13Yeah.
36:14What was that due to?
36:15Well,
36:17one thing Andy,
36:20I believe it's
36:21from Mississippi,
36:23was operating
36:23on children
36:25for,
36:26and instead of
36:27calling them
36:28schizophrenia
36:28or something like that,
36:30he said
36:31for aggressive behavior.
36:33Now,
36:34I was opposed to that
36:36and I'll tell you
36:37one real good reason
36:38to be opposed to it.
36:39We got
36:40some improvement
36:41in about two-thirds
36:42of our patients,
36:43but we failed
36:45in the third.
36:46And I thought,
36:48well,
36:48if I operate
36:49on three patients
36:50and I fail
36:52in a third
36:53and I'm operating
36:54on this guy
36:55for aggressive behavior,
36:57he may come down
36:58to
37:03kill me.
37:04and I did have
37:05one patient
37:06come back
37:07to Washington
37:07and says,
37:08he came down
37:09to kill me.
37:10He thought
37:10it should be done.
37:12Well,
37:12I didn't think
37:13it should be done,
37:14but I didn't want
37:15to get into
37:16this aggressive
37:17behavior business
37:19for a personal reason
37:20aside from
37:22the scientific reasons.
37:24Well,
37:25because he come
37:25and get you.
37:26Yeah.
37:27Isn't that
37:27a pretty good reason?
37:28That's a pretty good reason.
37:29I thought
37:30it was a good reason.
37:35As with
37:35the convulsive therapies,
37:37the profession
37:38was encouraged
37:38by the dramatic
37:39and relatively
37:40inexpensive improvements.
37:42This woman,
37:43for example,
37:44diagnosed
37:45as a catatonic
37:46schizophrenic,
37:47is transformed
37:48into a sociable
37:48human being
37:49soon after surgery.
37:53In this man,
37:55a condition
37:55of catatonic
37:56immobility
37:57yielded
37:58to the same
37:58procedure.
37:59In fact,
38:01by 1955,
38:02over 40,000
38:03patients had
38:04undergone
38:04the operation
38:05of lobotomy
38:06in the United
38:06States alone.
38:11Advances
38:12in radiography
38:13and instrumentation
38:14improved
38:15the anatomical
38:16precision
38:16of the procedure.
38:17But when
38:18equivalent advances
38:19in post-operative
38:20psychological testing
38:21occurred,
38:22misgivings
38:23about the whole
38:23operation
38:24began to emerge.
38:30nowadays,
38:31surgical intervention
38:32is limited
38:33to a few
38:33carefully chosen
38:34patients.
38:3523,
38:36the distance.
38:3623.
38:37And in the effort
38:38to make the procedure
38:39even more accurate,
38:40the use of electrodes,
38:42or as in this case,
38:43small pellets
38:44of radioactive metal,
38:45have sought
38:46to minimize
38:46the injuries
38:47that were previously
38:48inflicted
38:49by the surgeon's knife.
39:01Oh, there you are.
39:03Just like Farnborough,
39:04bang on target.
39:07But even if you
39:09make allowances
39:09for these
39:11technical refinements,
39:12it's surprising
39:13that there was
39:14so little compunction
39:15about inflicting
39:17irreversible damage
39:18on the nervous system.
39:21But as with so many
39:22therapeutic novelties,
39:23the optimism
39:25was so unqualified
39:26and the prospect
39:28of professional
39:29immortality
39:30so great
39:31that objections
39:32which seem obvious
39:33to us
39:34were either
39:35brushed aside
39:36at the time
39:36or dismissed
39:38as envious carping
39:39or else
39:40as political
39:41interference.
39:47in Pilgrim State
39:49Hospital
39:49on Long Island
39:50it's still possible
39:51to see
39:52some of the results
39:53of unsuccessful
39:54lobotomies.
39:55And leaving aside
39:56the fact
39:57that the intended
39:58outcome
39:58was questionable
39:59to say the least,
40:01it seems quite astonishing
40:02that so little attention
40:03was paid
40:03to the unintended
40:04side effects.
40:06the slipshod
40:07unsociability
40:08of so many
40:08of the victims
40:09the peculiar
40:10loss of initiative
40:11the profound
40:12alterations
40:13in character
40:14and intelligence
40:16and as here
40:17the fact
40:17that so many patients
40:18can still be found
40:19in large mental hospitals
40:20rendered completely
40:22incapable
40:22by an operation
40:24which had earned
40:24its originator
40:25the highest prize
40:26in medical science.
40:29I think things
40:31should be good.
40:33Well the sad thing
40:35is that there are
40:35no memorials
40:37to the victims
40:38of this neurosurgical
40:39Passchendaele
40:40and as with the
40:41First World War
40:42it's quite hard
40:43to tell
40:44whether the casualties
40:45were justified
40:46in terms of the
40:47ground that was
40:48actually won.
40:50But in any case
40:51the guns
40:52soon fell silent
40:54over this western front
40:55but meanwhile
40:57a campaign
40:58was being mounted
41:00elsewhere.
41:02Well the ground
41:04on which this campaign
41:06was to be fought
41:06had already been prepared
41:08by the discovery
41:09of something
41:09which was to alter
41:10the entire character
41:11of neurological thought.
41:14At the end
41:15of the 19th century
41:16improvements in microscopy
41:18and the introduction
41:19of special
41:19microscopic stains
41:21revealed that the brain
41:22was not as had
41:23previously been supposed
41:24a continuous uninterrupted
41:26network of fibres
41:27but that it was made
41:29upstead of individual
41:30cells whose branching
41:31filaments only made
41:33contact with one another
41:34across a microscopic
41:35interval or gap
41:36and that in order to bridge
41:38this gap or synapse
41:40transmission had to undergo
41:41a fundamental change
41:42in character.
41:44Whereas traffic
41:45along the nerve fibre
41:47was known to be
41:48electrical
41:48traffic across the synapse
41:50or gap
41:51it eventually became clear
41:52was chemical.
41:56well the implication
41:58of this discovery
41:58was that
41:59if you could
42:00introduce
42:01other chemical substances
42:03natural or artificial
42:04into the brain
42:06it would
42:06perhaps block
42:08or enhance
42:09the transmission
42:10at these critical sites
42:11of neurological
42:12interaction.
42:15The new drugs
42:16that began to pour
42:18from the pharmaceutical
42:19factories
42:19had a much more
42:20discriminating effect
42:21upon disordered
42:22mental processes
42:23and at the time
42:25of the pharmacological
42:26revolution
42:26in the mid-1950s
42:28increasing doubts
42:29about ECT
42:30and lobotomy
42:31meant that mechanical
42:32restraint
42:33was the only way
42:34of controlling
42:35inmates of asylums.
42:38This meant
42:39that those
42:39who were responsible
42:40for looking after
42:41these patients
42:42welcomed the
42:43introduction of drugs
42:44as a humane
42:45alternative
42:46to the violence
42:47which they had been
42:48forced to inflict
42:49on their patients
42:49up to that moment.
42:52I was there
42:53when they first
42:54started using Thorazine
42:55at the psych center
42:56and down through
42:57the years
42:58as they improved
42:59upon that medication
43:00and developed
43:01other medications
43:01a big change
43:03not only in the
43:04patient's behavior
43:05but a big change
43:06in the way
43:06we could treat
43:07the patients.
43:08Many times
43:09when you'd visit
43:10a hospital
43:10the superintendents
43:11would take you aside
43:12and remark
43:14on how dramatic
43:16the changes had been
43:17and how much
43:17the nurses
43:18and the aides
43:19and those people
43:20in the hospital
43:21who dealt
43:22directly with the
43:23patients
43:23how it helped them
43:25in their day-to-day
43:26activities
43:27and instead of
43:28becoming custodians
43:29they rather became
43:31treatment oriented.
43:33With the medication
43:34the patient
43:34was more amenable
43:35to therapy.
43:37It controlled
43:38their symptoms
43:39to a degree
43:39where the patient
43:40could sit down
43:41they could listen
43:42they could talk
43:42and they could benefit
43:44from any kind
43:45of activity
43:45that we offered
43:46to them.
43:47Now may I beg you
43:48whatever you do
43:48to stay on the drugs
43:50and stay on them
43:51for the next two years
43:52at least.
43:52Two years?
43:52Yes, at least two years.
43:54These are the combined
43:55antidepressants?
43:55Yes, she's on
43:57post-it only known
43:58so long ago.
43:59Is that alright?
44:00Will you please
44:01keep on them?
44:01Yes, certainly.
44:02Very good.
44:03Well now, when you're up
44:04to 8 stone age
44:05you're going to leave here
44:06but she'll also have
44:07to stay on the drugs
44:08for years.
44:09In spite of the optimism
44:10which was expressed
44:11by certain leading
44:12psychiatrists
44:13such as William Sargent
44:14there was a suspicion
44:16even at the time
44:17that drugs were just
44:18a chemical counterpart
44:20to the mechanical
44:21restraints
44:22which they had replaced.
44:23When I went to the
44:24Mausley in 1934
44:25only one third
44:26of Mausley's
44:27got better.
44:28Now the point is
44:29that with these treatments
44:30people are going in
44:31for quick treatments
44:32and they're quickly out again
44:33now this would be
44:34a revolving door.
44:35What bothers me a bit
44:36about this, Will
44:37is that you are a man
44:39who's very keen
44:40on helping patients.
44:42Yes, very keen
44:42on curing patients
44:43but what is not clear
44:46is what you cure them of.
44:48I have nothing against
44:49the treatment of depression
44:50by drugs
44:50but I'm concerned
44:51about the human trouble
44:52that underlies it
44:53and as you know
44:54these conditions
44:55are allowed to occur.
44:57Similarly in schizophrenia
44:58the symptoms of schizophrenia
44:59can be well controlled
45:00by drugs
45:01but as you also know
45:03the problem thereafter
45:04is to ensure
45:04that the patient
45:05goes on taking this drug
45:06that is that he remains
45:08in this chemical
45:09straight jacket
45:09for the rest of his life.
45:12Straight jacket or no
45:13it's hard to get away
45:15from the fact
45:15that the inmates
45:16of the asylum
45:17were much more manageable
45:18now than they had been before
45:19but this fact alone
45:21had unforeseen side effects.
45:23The fact that the patients
45:24became so tractable
45:25meant that asylum superintendents
45:27were much more willing
45:27to yield to voices
45:29calling for deinstitutionalization.
45:33In the 1960s
45:34governments were increasingly
45:36suffering fiscal pressures
45:37and they seized upon
45:39deinstitutionalization
45:40I think increasingly
45:41as a way of dumping patients
45:42out of expensive institutions
45:44into the streets
45:45into communities
45:46that were very reluctant
45:48to take them back
45:49and in most cases
45:50shunned them
45:50and ignored them.
45:52and one had over the next two decades
45:55a growing crisis
45:57posed by the abandonment
45:59of these people
46:00either in the United States
46:01into the clutches of people
46:02running board and care homes
46:03and so-called welfare hotels
46:05or indeed into the streets themselves
46:07the phenomenon of sidewalk psychotics
46:09littering the urban landscape.
46:17I would say now
46:18since they opened up
46:19a lot of the institutions
46:20anywhere from
46:2375 to 80 percent
46:25a little bit
46:27I guess
46:29disturbed
46:30and I would say
46:31in this terminal
46:32genuine homeless
46:34very few.
46:36Good evening
46:37you okay?
46:38We're gonna be closing up.
46:41we're gonna be closing up.
46:42Let's go.
46:44This way.
46:48Straight out to Lexington please.
46:50Have a nice evening.
46:54We've seen people
46:55who have been deinstitutionalized
46:57who've been released
46:58from the hospital
46:59given a number 10 envelope
47:01with a batch of
47:01prescription medicine in it
47:03with instructions written on it
47:04telling them to take
47:05three pills every four hours
47:06or one before you go to bed
47:08some of these folks can't read
47:10some of these folks
47:11started out by eating the envelope
47:13some of them
47:14just threw the envelopes away
47:16you can't simply give people
47:18who are mentally disabled
47:19a batch of medication
47:20and say go out on your own
47:21and take it
47:22you know go live in an alley
47:23somewhere in an abandoned building
47:24and get up at
47:25three o'clock in the afternoon
47:26and swallow a couple of pills.
47:30Rise and shine.
47:31If we saw them as human beings
47:32and understood their humanity
47:33we wouldn't let them live that way
47:35so everyone on the streets
47:36is frightened
47:37and everyone on the streets
47:38is lonely
47:38whether they're in or out
47:39of their right mind
47:40and I know many mentally disabled people
47:42who are very quick to say
47:43we may be crazy
47:43but we're not stupid.
47:48In spite of these social implications
47:50it would be hard to find
47:52a hospital psychiatrist today
47:54prepared to go into action
47:55without the ammunition
47:57provided by modern pharmacology.
48:01Well there are two major groups
48:03the major tranquilizers
48:05or neuroleptics
48:06and we use that
48:07mostly in the illness
48:08of schizophrenia
48:09and the other group
48:10are the antidepressants
48:12which speak for themselves.
48:14Certainly I would dread
48:15to work in psychiatry
48:17without the use of these drugs.
48:18It allows people
48:19to come and go
48:20on and off the ward
48:21as they wish
48:21to sit with their families
48:22to go out at weekends
48:24within two or three days
48:26of an admission
48:26being very, very, very
48:28dangerously disturbed
48:29and that is just
48:30a marvellous thing.
48:33This particular drug
48:34chlorpromazine
48:35when it first came in
48:36that has been responsible
48:38for clearing
48:39the mental hospitals
48:40and all the psychotherapy
48:42in the world
48:43I think would not have helped
48:44in that way.
48:46This way.
48:48This way.
48:50Fine, fine, fine.
48:51Fine, fine, fine, fine, fine, fine.
49:01It isn't a perfect world
49:03but I wouldn't practice medicine
49:06in this branch of medicine
49:07without the help of this
49:09because it helps people
49:10and they come and say
49:11I feel better.
49:14I feel much better.
49:19And yet, even with substances
49:21which the manufacturers
49:22optimistically describe
49:23as designer drugs
49:25implying that they're
49:26accurately targeted
49:27at specific symptoms
49:28and nothing else
49:29the issue for those
49:31taking the drugs
49:31is not quite so simple.
49:33Leave the water alone.
49:36Thorazine is horrible.
49:37You live in a chaos
49:38of thirst.
49:39Your throat is on fire.
49:41You cannot speak a sentence
49:42in English.
49:43It takes ten minutes.
49:44You can't think.
49:45You cannot...
49:46At this moment
49:47of great danger
49:48to your liberty
49:49when you really must
49:50be very sane
49:51when you're living
49:52really grace under pressure
49:54and right on the edge
49:56your powers of thought
49:58cognition,
49:59rationalization
50:00and articulation
50:02are all taken from you.
50:03And there are much more
50:05worrying long-term effects.
50:07Patients who've undertaken
50:08prolonged treatment
50:09with the major tranquilizers
50:10often suffer serious
50:12and permanent disorders
50:13of muscular coordination
50:14and in the chronic wards
50:16of large public hospitals
50:18it's still possible
50:19to see the casualties
50:20of this optimistic
50:21overuse of pharmacology.
50:23All we can do
50:24in psychiatry
50:25is what's available
50:26at that point in time.
50:27It has occurred to me
50:29as I look back
50:30on some of the things
50:31we did
50:31with insulin shock
50:32and ECT used
50:34and electroconvulsive therapy
50:36used in excess
50:39wrapping people in blankets
50:40for long periods of time
50:43some of the cold water treatments
50:45those seem very primitive
50:47to me and to us
50:48as we think back
50:49but I think that perhaps
50:51ten years from now
50:53we may look back
50:54at some of our current medications
50:55as being
50:57not totally desired
50:59as a way of treatment
50:59however
51:00it's the best we have today.
51:02It's all very well
51:03to talk about the best
51:04we have today
51:05but that presupposes
51:06that there's some objective standard
51:08by which all psychiatrists
51:10agree to identify the best
51:12but there isn't.
51:13Now you may remember
51:15that at the beginning
51:16of the program
51:16we saw several patients
51:18who seem to have been
51:20more or less
51:20given up for lost.
51:22And yet this is how
51:24they looked
51:24several weeks
51:25after their
51:27electroconvulsive therapy.
51:29Sometimes I don't feel
51:30as happy as I'd like to feel.
51:32And this thought of suicide
51:33what's happened to that?
51:35It's gone.
51:37And I
51:38and I know that
51:39you know
51:40now
51:42that I'm well
51:43that that was
51:44not the right thing
51:45for me to be thinking about.
51:46There only is
51:47black belief.
51:48Could I have
51:49said that?
51:50Yes.
51:51Did you say that?
51:51I don't know.
51:53You know I really
51:53don't know.
51:55I don't know.
51:56You could
51:56you could tell me anything.
51:57and anything
51:58you tell me
51:59I'll believe
52:00because I was
52:01so mixed up then.
52:03Was there something
52:04wrong when you came
52:05to this hospital?
52:07I never
52:08straight then.
52:10You say you're well
52:11but when I look
52:12at you right now
52:12I'm not sure.
52:14Do you really?
52:15Yes because
52:16I feel like
52:17I am able to
52:19reflect on
52:20what's happened to me.
52:22What is the main
52:22problem in your
52:23thinking today?
52:25Can you concentrate
52:26enough to read?
52:27Like read a book
52:28or something like that?
52:31Um
52:32yeah I guess
52:33I could read a book.
52:34Are you 10% better
52:3620% better
52:37or what?
52:38I think I'm all the way
52:40100%.
52:41Really?
52:42You've had these
52:42shock treatments before.
52:44Do you think
52:44they've been of any
52:45help to you now?
52:47Yeah.
52:51The psychiatrist
52:52who administered
52:53the treatment
52:54to these patients
52:55concedes that
52:56there's no
52:56satisfactory
52:57explanation
52:58for how they work.
53:00Although it's
53:01interesting to note
53:01that he also
53:02invoked the effect
53:04of neurotransmitters.
53:05Now personally
53:06I find that
53:07explanation
53:08rather unconvincing.
53:10And anyway
53:10there are psychiatrists
53:11who would probably
53:12be puzzled
53:13by the range
53:14of patients
53:15to whom he
53:16administers
53:17the treatment.
53:18Even so
53:19the fact that
53:20it has an
53:20undeniable effect
53:21effect on some
53:22of these patients
53:23illustrates the
53:24peculiar
53:25awkwardness
53:26of psychiatric
53:27wisdom
53:27in the last
53:28years of the
53:2920th century.
53:30You see
53:31here we have
53:32something that
53:33undeniably helps
53:35some patients
53:36but for which
53:37as yet
53:38there's no
53:38convincing or
53:39intelligible
53:40explanation.
53:41And on the
53:42other hand
53:43where we do
53:44have explanations
53:45which are much
53:46more plausible
53:47we have difficulty
53:48in producing
53:49treatments that
53:50unequivocally
53:51help.
53:52You've had these
53:53shock treatments
53:54before.
53:54Do you think
53:55they've been of
53:55any help to you
53:56now?
53:56Yeah.
53:57In what way?
54:02I don't know
54:03in what way
54:03that they help me.
54:06The more
54:07optimistic
54:08neuropharmacologists
54:09insist that
54:10this is simply
54:11an awkward
54:12intermediate stage
54:13on the way
54:14to complete
54:15understanding.
54:17well one of
54:17the reasons I
54:18suspect this
54:19optimism is
54:21that it
54:21underestimates the
54:22complexity of the
54:23human nervous
54:24system probably
54:25by several
54:25orders of
54:26magnitude.
54:27And as we
54:27know more
54:28about neurophysiology
54:29it only serves
54:30to show how
54:31little we know
54:32about the
54:32human brain
54:33which is
54:34almost without
54:34doubt the
54:35most complicated
54:37thing in the
54:38universe.
54:39As things
54:40stand no one
54:42would expect
54:42neurophysiology
54:44to explain how
54:45Mozart composed
54:47the marriage
54:47of Figaro.
54:48But actually
54:49the problem
54:49is much more
54:50serious than
54:51that.
54:51In the present
54:52state of
54:53neurological
54:53knowledge we
54:54can't even
54:54explain how
54:55he recognized
54:56his clothes
54:56from a
54:57crumpled heap
54:57on the floor.
54:59Well in any
55:00case it may
55:01well be that
55:03when it comes
55:03to understanding
55:04something like
55:05insanity
55:05something that
55:06is which
55:07affects that
55:08puzzling entity
55:09we call
55:09the person
55:10that neurophysiology
55:12will never
55:12yield a
55:13comprehensive
55:14explanation.
55:16Now that
55:16doesn't mean
55:16that I'm
55:17recommending the
55:18suspension of
55:20scientific research
55:21into the brain
55:21but rather that
55:23that sort of
55:24research will
55:25have to be
55:26counterbalanced
55:26by something
55:27completely different
55:28and perhaps as
55:30an English
55:31sociologist has
55:32said for
55:33scientific purposes
55:34and I repeat
55:35for scientific
55:36purposes it may
55:37turn out that
55:38it's advisable to
55:39treat people as
55:41human beings.
56:04have to
56:08see
56:09SOON
56:11THAT THEY
56:11WILL
56:12TELL
56:13THAT
56:13THEY KNOW
56:16THEY
56:17THEY
56:22THEY
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