An Experimentalist's Journey in Psychiatry
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1 Max Fink: An Experimentalist’s Journey in Neurology and Psychiatry: 60 Years in Clinical Neuroscience Redacted and edited for the Fink Collection in INHN ‗s electronic Archives, April 11, 2018 The ultimate court of appeal is observation and experiment, and not authority. Thomas H. Huxley 1 Contents 01 Starting Out 4 02 Schooling 10 03 Inducing Seizures: Hillside 1952-1962 32 04 After Missouri Hiatus, Interest in Seizures Renewed 1966- 47 Electroshock in the Public Eye 61 06 The Enigma of How Seizures Alter Behavior 80 07 Introduction to Clinical Psychopharmacology 91 08 Psychopharmacology: The St LouisHiatus 105 09 Opioid and Cannabis Studies 110 10 The Science of Quantitative Pharmaco-EEG 123 11 The Road to Catatonia 132 12 Epilogue 150 In Retrospect and In Gratitude 157 Notes and References 159 4 01 Starting Out I came of age in America during the war years of the 1940s and 1950s,and for six decades have been atreating clinician and researchercaring for neurologic and psychiatric ill. For many decades, the mentally ill had been warehoused in large sanitaria far from city centers, at least until the seizure therapies, electroshock and insulin coma, were introduced in the 1930s +slowing the growth of mental hospital populations from the peak in 1955 at 560,000 patient beds in the United States. The efficacy and the mystery of these treatments, inducing grand mal seizures, became my lifelong challenge. The treatment methods, however, were highly controversial in the public and within the profession. For my interest I was often berated and have thought that a less hostile life might have been preferred. The 1950s and 1960salso brought new psychoactive medicinesthat changedbrain chemistry and physiology allowingtens of thousands of the severe psychiatric ill to leave U.S. hospitals and live at home, or on the streets, in jails, in flophouses, or in and out of community hospitals. By 2010 the number of accredited psychiatric hospital beds had fallen to 43,000. Identifying the benefits and developing treatment protocols for these new medicines became a professional challenge. As the effectsof the new agents were measurable in the electrical readings of the scalp recordedelectroencephalogram (EEG) patterns, and the digital computer revolution offered means to quantify these effects, the new science of pharmaco-EEG occupied 35 years of my research life. My interest in the effects of psychoactive medications on the human brain included active studies of the opioids and cannabis that were interdicted by governments as addicting and life- threatening. In my later years I actively led aneffort to rescue the disorder ofcatatonia from its entombment within the poorly understood concept of schizophreniaand show that it was an independent, identifiable, verifiable, and treatable syndrome. Bringing it out of its closet encouraged worldwide recognition. Catatonia is unique among the behavior disorders in having two effective treatments and a useful verification test, which makeseach recognition of the syndrome life-saving. The arc of my professional career runs from a childhood in the Bronx, medical school in New York City, a decadeorganizing Hillside Hospital‘s research facilities, a brief stint as an Psychiatric Institute head in Missouri, back to New York for a continuing academic career in different hospitals, spending35 years teaching psychiatry at the State University of Stony Brook. 5 After meeting requirements for professional certification in neurology, psychiatry, and psychoanalysis, I spent my years as an experimentalist researcher and teacher. Beginnings I began my medical school trainingin 1942,an optimistic time for students of neurology and psychiatry. New tools imagedthe brain and its blood vessels andrecorded the brain‘s electrical activitygiving more accurate pictures of the brain‘s functions. The epilepsies were tamed by phenytoin and barbiturates. Antisepsis, local and systemic anesthetics, and improved surgical skills assured safer brain surgery. The drastic treatments of malarial fevers and arsenicals gave some relief for neurosyphilis, but by the end of the war penicillinwas recognized as a specific treatment for this dread disease, relieving the ill and liberating social andsexual behaviors by reducing the fear of venereal disease. Repeated inductions of grand mal seizures by insulin, Metrazol, and electricity decreased the agitation of manic-depression and the psychoses, halting the exponential rise in the numbers of hospitalized chronic illthat marked the first decades of the 20th Century. An enthusiasm for Freudian psychoanalysis enticedphysicians and psychologists to open offices and clinics for the care of the emotionally wounded. Even before the early successes of psychotropic drugs, the pessimism of the asylum was breached and psychiatry had become a favored medical specialty. Of the graduates of my medical school class in 1945, more than 10% opted for advanced training in psychiatry, and a fewlike me trained in both neurology and psychiatry. The opportunity to become an experimentalist was encouraged by the war. By my second medical school year the leading teachers at the New York University Medical School were in military service, staffing a major overseas hospital center. Much patient care fell to the students, who were expected to draw blood and spinal fluid, test experimental medicines,and learnsurgical techniques. We cared for patients with minimal supervision. During residency training in the immediate post-war years, returning veteran teachers, imbued with the excitement and enthusiasms of experiments encouraged during the war, testednew medicines and new methods with minimal attention to patient consent that are core questions in the today‘s medical care and study. 6 Marriage and Personal Life When I returned from a trip as the ship's surgeon on the Grace Line's Santa Monica in March 1948, I was introduced to Martha Pearl Gross, a student at Barnard College who was dockside awaiting her parents. I was then a resident at Montefiore Hospital and I visited her parents in Great Neck and courted her. We married a year later, on September 11, 1949.1 I continued my resident training in neurology and psychiatry residency years at Bellevue and then at Hillside Hospital. Late in 1952, Hillside Hospital's Medical Director, Joseph S. A. Miller, asked me to supervise the ECT/ICT service on a half-time basis. I happily accepted as it offered an assured salary while I built up a community clinical practice.2 Two general medical hospitals opened: Long Island Jewish Hospital on the grounds of Hillside Hospital and the North Shore Hospital in Manhasset a few miles nearby. I was appointed to the Neurology services of both hospitals, and organized their EEG Departments. My community practice blossomed, reports of the Hillside studies I had conducted were being published and presented at national and international meetings. Our family grew with our son Jonathan born in May 1951, and daughters Rachel in 1956 and Linda in1958.An offer of a full-time appointment to Hillside at double my salary in the spring of 1958 was so enticing that within six months I had closed my office, resigned from the staffs of other hospitals, and began the life of a full-time academic.3In 1962 I moved to St Louis to head a research institute, returned to New York in 1966 to join the faculty of the New York Medical College, then taught at Stony Brook University in 1973, until my retirement in 2005. Peregrinations In 1962, I was invited to direct a new research institute, the Missouri Institute of Psychiatry on the grounds of the St. Louis State Hospital, with the academic affiliation as Research Professor with Washington University School of Medicine. We found a home in the Lake Forest suburb, and our children were soon registered in their schools. When our youngest child, Linda was schooled daily, Martha enrolled at Washington University for an M.A. in Education, which led to her lifelong elementary school teaching career. We adjusted to a new community even though warnings of religious intolerance appeared early. When we were looking for a home, I asked George Ulett, the head of the State mental health services who had invited me, where he lived. ―In Ladue,‖ continuing with the advice, 7 ―You would not be happy there.‖ I did not catch the warning but we soon experienced the strong smells of anti-semitism and nativism that pervaded the St. Louis communities, the state, and even the hospital government during our stay. My appointment to the MIP was announced as ―Austrian Heads Institute.‖ Two years later the Missouri State legislature failed to renew the biennium funding for the Institute, and I and the other scientists fled. I found a position at the New York Medical College to lead the opioid detoxification center at New York City‘s Metropolitan Hospital beginning in July 1966. Martha and I found a home in Great Neck and enrolled our children in the community schools. Martha began teaching students at the elementary schoolin Port Washington and then the Great Neck schools. I set up my computer center to analyze EEG at the Psychiatry Department offices on East 102ndStreet, developed an ECT study at Gracie Square Hospital, and obtained a Federal contract to study the systemic effects of hashish in users in Athens, Greece.4I had remarkable students in Richard Abrams, Michael Taylor, and Robert Levine and was fortunate in the collaboration of Rhea Dornbush, Jan Volavka, and Donald Shapiro. In July 1969 Herman Denber, the director of psychiatric research at Manhattan State Hospital, invited me to join him on a single-engine Cessna 172 flight that he piloted over the Hudson Valley and the New York harbor. It was a day of brilliant sunshine and I decided to learn to pilot a small plane. A flying school was still active at LaGuardia Airport and I began my flying lessons on July 4, 1969.