The Icepick Surgeon

by Sam Kean

  On a typical day he’d rise at dawn at some campground and drive three or four hours to a rural mental hospital. After a tour of the grounds, Freeman might give a lecture,5 followed by lunch. Then it was time for the show to start—and a show it was.

  Hospitals would line up a half-dozen or so patients, and Freeman would march down the row of beds, performing one lobotomy after another. Hearkening back to his days of drawing on the chalkboard with both hands, he developed a way to do ambidextrous lobotomies, with one stiletto in each fist. Freeman claimed that these double-barreled lobotomies saved time, and they probably did, but he was also showing off for the crowd of doctors and reporters following him around. He’d even glance up midway through, grinning like Groucho, waggling the stilettos back and forth like mischievous eyebrows. One witness recalled, “I thought I was seeing a circus act… He was so gay, so high, so up.” He also loved making people pass out. One old-time doctor—who’d worked as a medic during World War I on some of the goriest battlefields in history—fainted dead away when Freeman slammed the stiletto home through the eye socket. Freeman lectured at high schools as well, and often showed a filmstrip of a lobotomy that left half the student body light-headed. He later joked that he made more teenagers swoon than Frank Sinatra.

  While a crowd looks on, Dr. Walter Freeman performs a transorbital “icepick” lobotomy through his patient’s eye socket in 1949. Notice his bare arms, bare head, and uncovered face. (Courtesy of MOHAI, Seattle Post-Intelligencer Collection, 1986.5.25616.)

  As always with Freeman, there were mishaps. Infections abounded, and he regularly nicked blood vessels and had to staunch hemorrhages. He also liked to photograph patients mid-surgery for documentation purposes, with the stiletto in situ. But during one operation in Iowa, gravity took over as soon as Freeman let go of the stiletto, and it plunged downward and buried itself in the patient’s midbrain. The man died without regaining consciousness.

  Despite the occasional fatality or three, asylum directors clamored to get Freeman through their doors. Many were no doubt sincere in wanting to help their patients, but it’s hard not to be cynical about their motives when they also talked openly about all the money they’d save by sending their wards home. One calculated that, if lobotomies spread nationwide, asylums could dump 10 percent of their population and save U.S. taxpayers a million bucks a day.

  The asylum tours won Freeman widespread fame—as did the fawning press coverage that accompanied them. One reporter dubbed the lobotomy the “surgery of the soul.” As a result, letters from prospective patients began pouring in to his office in Washington. Most came from the miserable and wretched, who saw lobotomies as their one last shot for a normal life. Odder requests arrived, too. One man asked whether a lobotomy might cure his asthma. Another asked Freeman to lobotomize his greyhound, so it would be less skittish on the track.

  Throughout the hoopla, Freeman never stopped working. He once did two dozen lobotomies in a single day; his hands would often be sore by nightfall. Then he’d say sayonara to the asylum, grab dinner somewhere on the road, and pop some barbiturates at the next campground to crash asleep. A forearm fracture one summer barely slowed him down. Even after suffering a mild stroke in 1950, he redoubled his efforts in 1951 and covered 11,000 miles that summer—and this was before the Interstate Highway System and its nice, smooth expanses. In all, he lobotomized 3,500 people over the years, bragging that he “left a string of black eyes all the way from Washington [D.C.] to Seattle.”

  Still, while the head-hunting expeditions made Freeman famous, they never made him rich. He paid for the travel out of pocket, charging most asylums just $20 per patient ($220 today) and often working for free. In addition, he made a determined effort to visit poor and rural areas, to help the truly neglected. This included Black communities in the South, the poorest of the poor. He had long championed—even gotten into brawls over—the rights of Black doctors to join professional medical groups. In a scary coincidence, he also tried to convince some forward-thinking doctors in Tuskegee, Alabama, to let him perform a rash of lobotomies at a veterans hospital there, since no Black neurologists lived nearby and no white neurologists would tend to the patients. The Tuskegee syphilis study was well underway by then, and if Freeman had gotten his wish, two of the twentieth century’s most reviled medical practices would have collided in this unlucky town. To his disappointment, a national VA group banned lobotomies and scuttled his plan.

  However charitable with the poor, Freeman could be mercenary with those who could afford it. He once charged $2,500 ($27,000 today) for a lobotomy in Chicago. In another incident, he nicked a blood vessel while operating in front of a live audience in Berkeley and watched his patient start to bleed out. “We got trouble!” he announced, and he did. Cranial pressure began to rise dangerously, and a quick neurological test (scraping a key along the bottom of the patient’s foot, to test for a toe-curl reflex) showed that she was suddenly paralyzed on her right side. But instead of focusing on the patient, Freeman hopped up and left the operating theater, to shake down her husband in the waiting room. He demanded $1,000 for the trouble of fixing the mess he’d just created. One grand richer, Freeman strolled back into the operating theater, pulled what looked like a bicycle pump out of his bag, and began pumping saline into the hole in the eye socket. Moments later a clotted mass of crimson began oozing out. Freeman repeated the pumping and flushing several times, chatting all the while in his gay old way as the audience gaped. Finally, the crimson sludge oozing out got thinner, then turned pink, then clear. Freeman injected some vitamin K to encourage clotting. As a final touch, the key was dragged across the patient’s foot several more times until—voilà—her toes curled. All in all, no harm done.

  As disturbing as such incidents were, Freeman’s real scientific sin during this period involved a shift in attitude. Neurosurgeons like James Watts restricted lobotomies to the most disturbed patients, and only as a last resort.6 Freeman had approached them similarly at first. But as the years passed, and his celebrity swelled, he began promoting the operation as a prophylactic instead. That is, he started pushing for lobotomies early on during mental illness, for people who’d been institutionalized for just a few months. Even at the time, doctors knew that such people often got better on their own after a year or two; their prognosis wasn’t terrible. Freeman brushed aside such numbers, arguing that psychosurgery was safer than waiting. Why not nip things in the bud, and send people home as soon as possible? He even began operating on children, some as young as four years old. The surgery of last resort had become the first line of defense.

  Thanks to Freeman’s tireless training of doctors, the number of lobotomies performed annually in the United States jumped tenfold between 1946 and 1949, from 500 to 5,000. Then an unexpected announcement in the fall of 1949 pushed the procedure to even greater heights.

  Back in 1939, a psychotic patient had barged into the office of Egas Moniz in Portugal and shot him five times. Moniz survived, but given his gout and advanced age, he more or less retired from research, content to let Freeman and others spread psychosurgery. Still, Moniz was as indefatigable as ever in trying to secure credit for himself, and in the late 1940s he once again began asking colleagues (including Freeman) to nominate him for the Nobel Prize. He received nine nominations in 1949 alone, and in the fall of that year he finally won. He thereby rose to greater prominence than perhaps any Moniz in history.

  In retrospect, however, the Nobel Prize was something of a last huzzah for psychosurgery. It wasn’t so much that the criticism got to be too heated. Foes did continue to attack Freeman’s head-hunting expeditions, but with no better treatment options to offer as a replacement, their criticisms never gained any traction. However imperfectly, Freeman was trying to solve a real problem, and people will always flock to even a bad solution rather than sit pat. No, what finally did psychosurgery in wasn’t ethics at all but C17H19ClN2S, a compound called chlorpromazine.

  Doctors in France first used c
hlorpromazine to treat shock, and by 1950 they were dosing inmates in asylums with it, with miraculous results. People who’d been locked away in padded cells for decades, muttering gibberish, could suddenly sit up and have conversations. Groping for an analogy, some doctors called chlorpromazine a “chemical lobotomy,” but in reality the drug was far superior. It was the first true antipsychotic: a compound that didn’t just deaden people (like barbiturates) but genuinely relieved their symptoms. In short, it transformed people from inmates back to patients, and few drugs in history have had a bigger social impact. Fifty million people took chlorpromazine in its first ten years on the market, and other antipsychotics like lithium quickly followed. Walter Freeman had dreamed of vacating asylums worldwide with the transorbital lobotomy; chlorpromazine actually did so. Before long, one of the most notorious features of Western society—the Bedlams that haunted every city—all but vanished.

  At first Freeman praised chlorpromazine and even prescribed it to patients. Shamefully, though, as soon as the drug began to rival lobotomies, he turned against it and became a critic. To be sure, chlorpromazine wasn’t perfect. As Freeman pointed out, repeatedly, the drug didn’t address the root of mental illness (i.e., brain function) as much as just relieve symptoms. Indeed, many people still heard voices or hallucinated while taking the drug; the voices just didn’t bother them anymore. Moreover, the drug had significant side effects: weight gain, jaundice, blurred vision, purple-tinted skin, and a Parkinson’s-like shaking disorder.

  Most poignant of all, chlorpromazine didn’t prepare people for life after lunacy. Upon getting their minds back, patients often had no idea what year it was. The last thing one man remembered was storming an enemy trench during World War I, an event that had taken place decades earlier; then he essentially blinked, and woke up an old man. And when people left the asylum for the real world, they found that their spouses had remarried, that their skills were obsolete, that society had moved resolutely on. Even today, we’re still dealing with the fallout of these drugs. Partly because of them, sanctuaries for mental illness fell out of fashion, and many people who once would have been sheltered in asylums, for better or worse, are now locked in prisons or have to fend for themselves on the streets.

  On balance, however, antipsychotic drugs have done more good than harm, salvaging millions of otherwise lost lives. Beyond the social impact, these drugs have also changed our understanding of how the brain works. Back when Moniz and other scientists viewed the brain as an electrical switchboard, severing faulty “wires” with a lobotomy seemed reasonable. The advent of antipsychotics shifted our thinking. Chlorpromazine works by affecting neurotransmitters, the chemicals that send messages within the brain. As a result, scientists began to view the brain as a chemical factory, and the role of mental-health treatments was to correct chemical imbalances.

  Overall, chlorpromazine had just as big an impact in psychiatry as antibiotics did in infectious-disease medicine and anesthesia did in surgery. The drug appeared just as suddenly, and it forever divided treatment into Before and After. If chlorpromazine and similar drugs had never been discovered, we’d probably still be doing lobotomies today on a limited basis—again, problems demand solutions, however imperfect. But the drugs were discovered, and for most doctors not named Walter Freeman, the choice between an imperfect drug and an icepick lobotomy was no choice at all.

  Egas Moniz died serenely in 1955, confident in his legacy as both a true Moniz and a benefactor of humankind. Walter Freeman had the misfortune of being twenty years younger, and lived to see himself become a pariah.

  After chlorpromazine appeared on the scene, Freeman’s surgery-first attitude came to be seen as barbaric, and his brash and combative personality turned even former allies against him. In the mid-1950s he fled Washington, D.C., for Northern California, hoping for a fresh start; he even shaved off his signature beard and mustache and went barefaced for a while. But given his reputation, psychiatrists there were reluctant to make referrals to him, and he struggled to find new patients to operate on.

  Instead, Freeman spent more and more time following up on old patients. He racked up gargantuan long-distance phone bills chatting with them, and tracked some as far as Australia and Venezuela—as well as the odd state prison. From these conversations he gathered reams of data, and he purchased a state-of-the-art IBM punch-card computer to sort through it all. Unlike Moniz, Freeman took follow-up seriously.

  Yet however scientific this might sound, Freeman’s work was too haphazard and anecdotal to have much value. For one thing, he never included control groups in his studies—asylum patients that he didn’t operate on, and whose outcomes he could compare to lobotomy patients. Without such controls, his claims about the benefits of lobotomies were meaningless, since it’s possible that his surgical patients would have improved on their own, without a lobotomy—or might even have fared better. Furthermore, given the all-too-human tendency to interpret data in the most favorable way possible, there’s reason to wonder whether an ideologue like Freeman was objective in presenting his results.

  Freeman performed his last lobotomy in 1967, at age seventy-two. The patient was actually one of the ten original transorbital cases he’d operated on back in his office in D.C. This was her third lobotomy, as the first two hadn’t really taken. Sadly, Freeman nicked yet another blood vessel and watched her bleed out and die. His operating privileges were revoked soon after.

  Instead, like Moniz, Freeman turned toward shoring up his legacy—a difficult task at that point. One reason Freeman was so dogged about following up on patients was that he could use them to deflect criticism. He never failed to mention during his talks that some of his patients had returned to productive lives as lawyers and doctors and musicians, including one at the Detroit Symphony Orchestra. When the anecdotes failed to impress, he resorted to bluster. In 1961, eleven years before his death from colon cancer, Freeman appeared onstage at a medical conference to promote lobotomies for children, and he endured some withering remarks from doctors in the audience. At which point an enraged Freeman reached down, picked up a box beside him, and spilled its contents onto a table. It contained five hundred holiday letters from grateful lobotomy patients who were still in touch with him. “How many Christmas cards did you get from your patients?” he demanded. It was a powerful moment—but it makes you wonder why he had the box right there. Did he suspect that this conference would be particularly hostile? Did he always carry the box around, hoping to deploy it? Or did he carry it as a balm instead, his moral shield against reproach? Regardless, the moment was pure Freeman: bold, theatrical, and defiant till the very end.

  As crazy as it sounds, the Central Intelligence Agency actually commissioned a secret report on Freeman’s work in the 1950s, to see whether lobotomies might help sap the zeal of communist agitators. After some thought, the agency demurred—not out of any pesky human-rights concerns, but because the surgery likely wouldn’t work as intended.

  As we’ll see over the next two chapters, however, there were plenty of scientific abuses on both sides of the Cold War. The CIA perverted academic studies on psychological stress to develop harsher and frankly torturous interrogation techniques. The Soviet Union abused psychology, too—as well as groomed spies to ferret out secrets about the deadliest science experiment in history, the atomic bomb.

  Footnotes

  1 In addition to insulin coma therapy and electroshock therapy, some doctors tried Freudian talk therapy on asylum patients. But it soon became clear that propping inmates on a couch and chatting through their mommy issues was impotent in the face of real insanity, which often had roots in organic brain disorders. For this reason, Moniz and Freeman doubted that talk therapy had much to offer the truly disturbed. Freeman once quipped that any halfway-decent bartender could perform the same essential function as a psychoanalyst—listening sympathetically.

  2 The influence of the London conference on Moniz is a controversial point. Moniz later claimed he’d been worki
ng secretly on psychosurgery for years before he ever heard of Becky, and some historians believe him. But this version seems rather self-serving, and other historians dispute the idea. For one thing, Moniz also claimed to have had conversations with colleagues about psychosurgery long before London; but when asked about this, the colleagues had no recollections of any discussions. Moniz’s many writings on neurology also contain no evidence that he was working on such surgery before 1935. But again, the truth remains debated.

  3 Rosemary’s troubles dated from her birth. Her mother’s water broke unexpectedly one day in September 1918, and no doctor was available to oversee the delivery. Incredibly, a nurse on hand told Mrs. Kennedy to squeeze her legs together to hold the baby in. When Rosemary started emerging anyway, the nurse shoved her back inside. As a result, Rosemary’s brain was deprived of oxygen for a few minutes, and she was never quite normal; as a child she struggled to hold a spoon properly and ride a bike.

  By all accounts, Rosemary was still a vivacious young woman, and she was widely considered the prettiest Kennedy daughter. But to an ambitious family, she was an embarrassment, and they confined her to a convent as a teenager. Rosemary naturally rebelled at this, turning mouthy with the nuns and sneaking off at night—possibly, they feared, to pick up men. Given the time, a pregnant daughter would doom the family’s political fortunes, so Rosemary’s father Joseph started looking into lobotomies. Rosemary’s sister Kathleen looked into the procedure as well and actually recommended against it, but Joseph overruled her and had Rosemary lobotomized while his wife was out of town.