The Icepick Surgeon

by Sam Kean

  Again, though, Moniz ignored Lucy, focusing instead on the crisp, clean story of Becky—tormented before, placid afterward. Even more powerfully, he imagined all those millions of people suffering in asylums worldwide, and he vowed to help. Let lesser doctors waste their time with seizures and electroshocks. He would, in his word, “attack” the very roots of mental illness inside the brain, through a new discipline called psychosurgery. And if it won him glory in the process, well, he certainly wasn’t opposed to that.

  By the mid-1930s, Moniz was in his sixties and running out of time to establish his legacy. He therefore skipped all safety tests in animals and directed his first psychosurgery—which he called a leucotomy—just three months after the conference in London.2

  His first leucotomy patient was a sixty-three-year-old woman who’d been in and out of psych wards for decades; she suffered from crying fits and battled hallucinations and paranoia about being poisoned. Moniz instructed a neurosurgical colleague to open two holes in the woman’s skull, wafers smaller than dimes. Then they slid a syringe deep into the frontal lobes and injected a tiny shot of pure alcohol—Everclear, essentially—which destroyed the surrounding cells by dehydrating and choking them.

  Even considering how much of a hurry he was in, Moniz betrayed a shocking indifference to following up with his patients, to ensure that leucotomies actually worked. In this first case, he asked the woman some silly questions a few hours after surgery (“Do you prefer milk or bouillon?”), and learned that she didn’t know her age or where she was. He then sent her back to the asylum a few days later, where her crying fits resumed. He nevertheless declared her cured in early 1936, based on his impression that her paranoia and delusions were less intense. By then, he’d already moved on to other patients anyway, having injected alcohol into the brains of seven more men and women. He claimed glowing results in those cases, too, based on similarly superficial analyses.

  Privately, though, Moniz feared that the alcohol was destroying more brain cells than he wanted. He decided to switch things up and start cutting instead. This new and hopefully improved technique involved sliding a thin rod deep into the flesh of the frontal lobes. A loop of wire popped out of the rod at this point, and by rotating the loop, he could “core out” some tissue there. The cutting seemed to work on the first patient, so Moniz quickly lined up a dozen more. He declared one of these patients cured of mental illness after just eleven days, which is too short to even recover from brain surgery, much less judge its success. To him, the only real hiccup occurred when one woman groaned while the assistant was coring her— possibly because, as Moniz soon learned, the wire loop had snapped while buried inside her brain.

  Already by 1936, Moniz had enough material to publish a book on leucotomies. In it, he declared that a third of his patients had been cured, a third had their symptoms significantly reduced, and a third were no worse than before. Given the futility of treating mental illness then, these would have been stunning results, if true.

  True or not, people wanted to believe Moniz—they wanted the hope of a cure. That was especially the case in the United States, which had scads of squalid asylums from coast to coast. Moniz’s book quickly found its way into the hands of Walter Freeman, the chatty, carnival-barking neurologist who’d set up a booth next to Moniz at the London conference. Freeman wanted to help the insane just as badly as Moniz—and would prove even more reckless in his pursuit of virtue.

  Freeman called himself the Henry Ford of psychosurgery—the man who took lobotomies to the masses.

  In 1936 Freeman held two posts in Washington, D.C., one at George Washington University and one at a nearby insane asylum. He liked the job at GW, where he’d gained a reputation as an electrifying teacher, someone who could pack a classroom even on Saturday mornings. With his glasses, thick eyebrows, and unfashionable mustache and goatee, he resembled Groucho Marx, and he proved no less entertaining during lectures. He could draw on the blackboard equally well with both hands, and would wow his students by sketching out two different parts of the brain simultaneously, the chalk flying. More uncomfortably, he’d scour local hospitals for interesting neurology patients and parade them in front of the students for show. For instance, one old woman with dementia had essentially deteriorated into an infant, to the point that her suckling reflex reemerged. Freeman demonstrated this by having her suck greedily on a bottle, then the bowl of his pipe. (“That’s a picture they’ll not soon forget,” he boasted in a letter.) His students, mostly male, loved the classes so much they often brought their girlfriends along. It was better and cheaper than the movies.

  In contrast to teaching, Freeman’s second appointment, at the insane asylum, depressed him. Every single person there seemed miserable, from the inmates to the administrators, and the waste of human potential nauseated him. So when Egas Moniz published his book on leucotomies, detailing all the supposed cures, Freeman was ecstatic. “A vision of the future unfolded” in his mind, he recalled, something akin to a religious conversion. Freeman also had a bravado streak, and this bold new psychosurgery appealed to his sense of adventure. He quickly recruited a collaborator at GW, neurosurgeon James Watts, and got busy.

  Moniz’s book came out in June 1936, and already by September, Freeman and Watts had their first patients on the operating table. Now, as a neurologist, not a neurosurgeon, Freeman had no business performing operations himself. But he was too much of an alpha to just sit back and watch: once Watts opened up a skull, Freeman often took over. (To be fair, Freeman was a world-class expert on brain anatomy, his knowledge far outpacing that of Watts.) At first the duo simply copied Moniz’s method of coring out brain tissue with a loop of wire. Eventually they modified the surgery, ditching the loop and cutting tissue instead with what looked like a giant butter spreader—an elongated blade with a dull edge. They slid the blade into the dime-sized holes in the skull and swished it around at different angles, to sever connections between the frontal lobes and emotional centers. Because they were using new tools and a new technique, they gave the procedure a new name, the lobotomy.

  Freeman and Watts churned through a patient per week during the last four months of 1936, and their results encouraged them. Roughly half their patients calmed down enough to return home to their families, which the duo considered a huge improvement over living in an asylum. Furthermore, those who remained in the asylums were much more docile. As Freeman later put it, in a somewhat different context, “The noise level of the ward went down, ‘incidents’ were fewer, cooperation improved, and the ward could be brightened when curtains and flowerpots were no longer in danger of being used as weapons.”

  To be sure, there were setbacks. In swishing the knife around, Freeman sometimes nicked a blood vessel, and one of his early patients died of a hemorrhage. Nor did patients always improve. On Christmas Eve in 1936, one alcoholic patient staggered from his bed, pulled a hat over his surgical bandages, and wandered out the front door of the hospital. After a long search, Freeman and Watts found him ringing in the holiday at a local watering hole, so drunk he could barely walk. As a result of the misadventure, Freeman missed the birth of a son. But Freeman never let setbacks bother him. In many cases he simply scheduled another lobotomy for the patient, since he clearly hadn’t carved up enough tissue the first time.

  To his credit, Freeman followed up on patients far more dutifully than Moniz did, and he was intellectually honest enough (at least at first) to acknowledge the limits of lobotomies. Overall, Freeman decided that the surgery did little good for schizophrenics, alcoholics, and people with criminal perversions. (Sometimes, in fact, the perversions grew worse, since the patients lost all sense of shame after surgery. Freeman once quipped that if you gave a peeping Tom a lobotomy, instead of peering into the window, he’d barge in through the front door.) Lobotomies proved much more successful on people with severe depression and other emotional disorders, blunting their dark edges and lifting their moods. Partly for this reason, most early lobotomy patients
were women, who suffered from (or were at least diagnosed with) depression and emotional disorders at higher rates than men.

  Freeman was also candid about the side effects of lobotomies. None of his patients were reduced to drooling, brain-dead vegetables; that’s a Hollywood stereotype. But many had to relearn basic skills like eating with utensils and using the toilet. More troubling, Freeman admitted that many patients lost their “sparkle.” That is, their personalities dulled, and they lost all initiative. If someone suggested an activity to them, they’d shrug and go along, but without much enthusiasm. And if not prodded into doing something, they’d just sit around for hours, staring. Loss of frontal-lobe control also unleashed their appetites. Patients would wolf down huge meals of whatever was set in front of them, then vomit and start right up eating again. Others saw their libidos spike, and would demand sex from their spouses up to six times a day in the week after surgery. (As one writer remarked, “The knife… dulled Hamlet but not Romeo.”) Most disturbing of all was the lack of self-awareness and social grace. One man started applauding after sermons at church, hooting and hollering as if he’d just seen a vaudeville act. Other patients stopped grooming and washing. As Freeman once said (he had a way with words), his patients exhibited “the Boy Scout virtues in reverse”: a decided lack of cleanliness, courtesy, obedience, reverence, and so on.

  Freeman’s most notorious failure occurred in 1941. Joseph Kennedy, patriarch of the political clan, talked Freeman into lobotomizing his daughter Rosemary, who suffered from mood swings and angry outbursts. The lobotomy left the twenty-three-year-old Rosemary unable to speak or walk at first, and drained her of all vitality. Despite having pushed for the operation, Kennedy was furious with Freeman. Appalled and ashamed, he locked his daughter away in an institution for the rest of her life.3

  Given that even the “cured” patients suffered serious side effects, lobotomies came in for some harsh criticism. One doctor declared, “This is not an operation but a mutilation.” Another said, “the psychosurgeon is indeed treading on dangerous ground when he decides that a patient without a soul is happier than a patient with a sick soul.” Many doctors also raised the question of whether disturbed or insane people could truly consent to radical, experimental surgery. One of Freeman’s own sons once said, “Talking about a successful lobotomy was like talking about a successful automobile accident.”

  Freeman didn’t take such criticism lying down. He loved combat and eagerly swung back at his critics, whom he viewed as namby-pambies wringing their hands over ethics instead of actually helping people. He had a point, too. Even his detractors had to admit that—as strange as this sounds today—many people did benefit from lobotomies. Again, few real treatments existed for mental illness then, and lobotomies at least quieted down the most severely disturbed patients. Rather than bite anyone who came near them, or slam their heads against the wall until they passed out in a bloody heap, they could now do simple, human things like eat meals with other people or go outside to get a little sunshine. In Freeman’s judgment, if the procedure “enables the patient to sleep on a bed instead of under the bed, it is worthwhile.” There was no curing these people, but psychosurgery gave them something akin to normalcy. For this reason, several eminent neurologists defended Freeman, and his work garnered qualified support in publications like The New England Journal of Medicine.

  In sum, as a treatment of last resort, the lobotomy might have had a valuable place in mid-century medicine. If only Walter Freeman had been modest enough to accept such limitations.

  By the mid-1940s, Freeman was starting to have doubts about frontal lobotomies. Opening up the skull was too invasive, and worsened the effects of an already debilitating procedure. Furthermore, standard lobotomies would never put a real dent in the problem of asylums. After all, there were hundreds of thousands of mental patients in the United States, and he could operate on only one per week. Even if he taught the surgery to others, they’d still need to have an anesthesiologist and neurosurgeon on hand during the procedure. Few asylums could bear these costs, so Freeman began scouting around for a cheaper, easier surgery in 1945. He soon came across, quite literally, a new angle of attack.

  Rather than drill holes through the top of the skull, Freeman read up on ways to get at the frontal lobes through the eye sockets. The orbital bones behind the eyes are relatively thin, and he realized that a slim rod, maybe eight inches long, could slide past the eye, puncture the orbit, and reach the brain behind. Then, by wagging the rod back and forth, he could sever the limbic system–frontal lobe connections from below. Based on the access point, Freeman called the procedure a transorbital lobotomy.

  Stilettos used by Walter Freeman during his transorbital lobotomies. They were modeled after an icepick he found in his kitchen. (Courtesy of Wellcome Trust.)

  All he needed was the right tool. He got some cadavers and began experimenting with spinal-tap needles, but they proved too weak to crack the orbital bone. He finally found the perfect tool in his kitchen, when he opened a drawer one day and spotted an icepick—long, sharp, sturdy. A few cadaver tests confirmed his hunch. Suitably armed, he began scouting around for patients.

  He did so secretly, however, since his partner James Watts didn’t approve of the new procedure. As a surgeon, Watts was precise. He wanted to see exactly what he was cutting in the brain, not jab blindly with an icepick. Ticklishly for Freeman, he and Watts shared an office in D.C., which made operating in secret a bit awkward. Freeman nevertheless started sneaking patients upstairs to his chambers and performing transorbital lobotomies on the sly.

  The procedure went like this. For “anesthesia,” Freeman pulled out an electroshock machine the size of a cigar box and attached the leads to the patient’s skull. A few zaps knocked her senseless. (Virtually all asylums had electroshock machines, so Freeman felt confident they could conk their patients out this way.) When the patient was insensate, Freeman pinched one of her eyelids and tented it upward, exposing the moist pink tissue beneath. Then it came time to pierce the socket. For later operations, Freeman employed a custom-made stiletto that he bragged could “practically lift a door off its hinges without it either breaking or bending.” But for the first few lobotomies in his office, Freeman used his trusty kitchen icepick. He’d drop to one knee for leverage, then ease the tip of the stiletto into the tear duct. When he felt the resistance of bone behind it, he’d grab a hammer and start tapping, until he heard a crack. Once the tip slid into the brain, he’d swing the handle side to side at different angles to complete the lobotomy. Then it was on to the other socket. The operation rarely took longer than twenty minutes, and the patient often headed home within an hour. A few days later, two black eyes would bloom on her face—real shiners. Beyond that, if everything went smoothly, she felt minimal discomfort or pain.

  Of course, things didn’t always go smoothly. The electroshocks induced wild, thrashing seizures sometimes, and after a few broken limbs, Freeman had to enlist his secretaries to help hold patients down. The lobotomy had its own hazards, including infections. Freeman always pooh-poohed what he called “all that germ crap,” and often operated without gloves or a face mask. On one occasion, two inches of steel actually broke off inside a patient’s brain, necessitating a run to the emergency room.

  (Later on, rumors swirled about even worse violations. Freeman was a serial philanderer, and while there’s no firm confirmation of this, colleagues suspected that he slept with patients from time to time. Perhaps not coincidentally, he twice had to wrestle pistols away from female patients who stormed into his office. There were also rumors that Freeman would summon patients in for electroshock therapy, then secretly lobotomize them while they were groggy. How he explained their telltale black eyes was never clear.)

  Given all the chaos going on upstairs, Freeman’s partner James Watts soon got wise to what was happening—although the two men told different stories about how he found out. Freeman claimed he was honest and open, and invited Watts up to
witness the tenth transorbital. Watts claimed he walked in on Freeman accidentally and caught him red-handed. He also claimed that Freeman, shameless as ever, just shrugged upon being busted. Then he asked Watts to hold the icepick while he snapped a few photographs.

  Regardless, Watts was outraged, and demanded that Freeman stop doing experimental brain surgery in their office. However reasonable a request, Freeman bristled, and they got into a heated argument. Watts would continue to champion psychosurgery over the next decade for desperate cases, as an operation of last resort. But he refused to endorse Freeman’s Jiffy Lube lobotomies, and the two had a falling-out that resulted in Watts moving out of the office.

  Ever affable, Freeman didn’t hold the split against Watts. In fact, it proved a blessing. Free to operate openly now, he soon got to work on his master plan: to become the Johnny Appleseed of psychosurgery, and spread lobotomies across the land.

  Freeman had always loved summer road trips—hopping into a car and crisscrossing the byways of America. After perfecting the transorbital lobotomy, he decided to combine his annual excursion with work. His marriage had more or less disintegrated by that point, in part due to his workaholic habits. (He would regularly come home after dark, eat a sad dinner alone in the kitchen, then pop some barbiturates to crash asleep—only to rise at 4 a.m. the next morning to start working again.) With little keeping him at home, Freeman started bouncing from asylum to asylum in the summer of 1946 to train other doctors on doing lobotomies. Now, there’s no truth to the rumor that Freeman dubbed the car he used on these trips the “lobotomobile”—but probably only because he didn’t think of it.4 He loved irreverent jokes, and did refer to these trips in his letters as “head-hunting expeditions.”