Blood and Guts

by Richard Hollingham

  Psychiatric hospitals were known as snake pits. They were ware-houses where society dumped the mentally ill; locked people away – often for years, sometimes for a lifetime. They were places of horror and hopelessness. Wards were packed with beds, with hardly any space to move between them. The sheets would be soiled, many of the patients ignored. There were too few staff, and many of those acted more like prison warders than hospital carers.

  As he walked through the wards, past the padded cells and through the heavy steel doors, Freeman saw things that would make a lasting impression on anyone. There were young men squirming on the floor, their hands tied so that they could no longer claw at their skin. He saw patients being force-fed, their jaws clamped open by burly orderlies. Some patients would suddenly become violent and abusive, only to be dragged off to a cell. Others would be sitting, just sitting, staring into nothingness, as if their brain had simply shut down.

  Although St Elizabeths was one of America's largest mental institutions, it was typical of others around the world. Admissions to psychiatric hospitals were growing by some 80 per cent each year, but the worst thing was that they could offer little in the way of treatment. For the most part, the best the staff could do was keep the patients alive. Those who attempted suicide were restrained or constantly monitored. The only hope was that the mentally ill would recover spontaneously after their period of 'rest' in the hospital. For most patients the stay in hospital had the opposite effect and their condition simply deteriorated.

  By the 1940s what treatments there were relied on shocking the brain back to health – sometimes quite literally. Doctors would overdose their schizophrenic patients with injections of insulin to induce convulsions. Others preferred to use a drug called Metrazol to induce seizures. Metrazol convulsions were so violent that patients were contorted in agony, and many suffered fractures to their spine. Patients begged doctors not to put them through this torture but, as some doctors reported that the seizures were resulting in dramatic cures, their pleas usually fell on deaf ears.

  The most controversial of all the shock therapies was ECT – electroconvulsive shock therapy. Invented by an Italian who had seen electric shocks used to stun pigs prior to slaughter, it appealed to psychiatrists because it was quick, cheap and easy to use, and was much more controllable than Metrazol. The other advantage of ECT was that it could be used to control the behaviour of patients. There is plenty of good evidence that ECT is effective at treating mental illness, and it is still used today under controlled conditions and with the full consent of the patient. However, in the 1940s, as ECT spread to hospitals across the world, it was quickly adopted as a way of keeping patients subdued.

  The procedure was simple enough. Patients would be held down on a bed while electrodes were placed on either side of their head. Some ECT machines employed a Y-shaped electrode, like a catapult, that could be held by the doctor. When the current was turned on the electricity induced a seizure, leaving the victim passive and quiet. Aggressive patients could be given several shocks a day to keep them under control. Patients would be threatened with ECT if they did not behave.

  This is the world Dr Walter Freeman was working in – a world he was determined to change. The theory of localization was now widely accepted and Freeman was convinced that mental illness was a result of a physical defect in the brain. It was a view backed by the apparent effectiveness of shock therapies. But rather than fire jolts of electricity through the brain, he wanted to change the whole way it was wired up.

  Freeman was determined to get to the root cause of mental illness. In his laboratory he worked tirelessly, examining thousands of brains – slicing them, dissecting them. Day and night he measured the brains of dead mental patients and compared them with 'healthy' brains. Freeman was becoming an expert in brain anatomy, but however much he sliced, diced, measured and dissected, he could find nothing to distinguish the brain of a severely mentally ill patient from the brain of anyone else. It seemed like he had reached a dead end. He had wasted years of his life in pursuit of a physical defect that didn't exist. Then he came across the work of Portuguese surgeon Egas Moniz.

  In 1935 Moniz had carried out a radical new operation. He called it a leucotomy. The procedure involved drilling several holes in the front of the patient's skull above the frontal lobes of the brain. Moniz then inserted an instrument he had devised, known as a leucotome. The device acted like an apple corer. When the surgeon pressed down on a plunger and rotated the leucotome, he could extract a brain core one centimetre wide. Usually, he would take about four cores of brain during an operation. Moniz could claim, with some justification, that around one-third of his operations were successful. He never came up with a scientific explanation for why leucotomies worked, but said they made his patients calmer and less agitated; they removed many of the symptoms of anxiety and psychosis. He believed the procedure had no effect on the intelligence of the patients and that it enabled them to lead normal lives once again.*

  * In 1949 Moniz received a Nobel prize for his 'discovery of the therapeutic value of leucotomy in certain psychoses'. There have been campaigns to have the prize posthumously taken away from him.

  When Freeman learnt of Moniz's research he became wild with excitement. Moniz had proved what Freeman believed all along: surgery was the answer. Freeman became convinced that many types of mental illness were caused by the connections between the thalamus – a small structure deep in the brain – and the frontal lobe. The thalamus, he believed, was the seat of human emotions. If he could only sever the connections in the front of the brain, it would dampen down all these terrible emotions and his patients would be cured.

  Freeman became the Portuguese surgeon's biggest fan. He decided that he would adopt Moniz's operation and make it his. He could finally help the patients of St Elizabeths. It could make him famous – his name would be cited alongside other great medical pioneers. He could imagine it now: Walter Freeman – the inventor of the lobotomy.

  But Freeman had a problem: he was not a surgeon. So he enlisted the assistance of someone who was – a young neurosurgeon named James Watts. Together they planned the first of Freeman's new lobotomy operations on sixty-three-year-old Alice Hammatt. The woman had been suffering from depression, anxiety and insomnia. She was sometimes suicidal, invariably agitated. Without treatment she would end up being admitted to a mental institution, where she would undoubtedly spend the rest of her life. To Freeman she seemed like the ideal patient. On 14 September 1936 in an operating theatre at George Washington University Hospital in Washington DC, Hammatt was put to sleep.

  With Freeman directing the operation from a stool a few feet away, Watts cautiously cut three incisions into Hammatt's shaved scalp. Next he drilled a hole on both sides of her skull – above her ears and behind her forehead – and stuck the leucotome into the left-hand hole. Watts pressed the plunger on the instrument and cut the first core of brain tissue. It was like cutting through butter. Leaning closer, Freeman instructed Watts to take more cores. Eventually, under Freeman's guidance, Watts took a total of twelve cores from the two holes. It was not a particularly precise procedure. At one point Watts managed to get a blood vessel caught in the instrument and blood gurgled from the aperture. Still, the patient seemed OK. Nothing to worry about. An hour or so later the world's first lobotomy operation was over.

  Hammatt recovered quickly. She seemed alert but much calmer. Her anxiety had disappeared; in fact she had forgotten what had caused all her problems in the first place. Hammatt could read, could name members of her family and, for the first time in months, was sleeping well. Freeman later reported how Hammatt could now manage 'home and household accounts, enjoys people, attends theatre, drives her own car'. It was wonderful. 'Great improvement,' he concludes. Then, a few months after her operation, Hammatt suffered a convulsion. It was probably related to her surgery. She fell, breaking her wrist and, according to Freeman, became 'indolent' and 'sometimes abusive'. Nevertheless, her anxiety never returned
and she lived a relatively normal life.

  Freeman declared the operation a great success and rushed off to tell his colleagues. When he published the details of the case, his lobotomy operation won mixed reviews. While some considered it a fine idea, others were outraged that such an untested, extreme operation was even being attempted. But Freeman was completely convinced that a surgical breakthrough had been made. Moreover, he knew how to convince others: he would ignore the medical establishment and take his radical new operation straight to the public.

  In a typically long-winded headline (but with the admirable use of a semicolon) the front page of the New York Times proclaimed: 'Surgery Used on the Soul-Sick; Relief of Obsessions Is Reported'. The article referred to Freeman's new surgical technique as 'psychosurgery' and 'surgery of the soul'. His operation could cut away 'sick parts of the human personality' and transform 'wild animals into gentle creatures'. Out of the twenty patients Freeman had treated, the article said, 15 per cent (three) were 'greatly improved', with a further 50 per cent (ten) of them being 'moderately improved'. The article went on to detail two case histories, including Hammatt's, with only passing mention of two deaths following the procedure and unattributed criticism from some 'leading neurologists'.

  The New York Times was not alone in trumpeting this new and exciting operation. It was proclaimed a miracle, an incredible cure and even, according to one gushing news report, 'one of the greatest scientific innovations of this generation'. For the first time in history, here was a doctor who could cure madness; heal the mind with surgery.

  As ever with these things, the reality did not quite live up to the hype. Many of Freeman's early patients were soon suffering relapses. His answer was to go back and repeat the operation, gouge out more bits of brain. Other patients were suffering terrible side effects. Following their operations they were acting like children: they had to be retaught how to carry out basic functions (such as using a toilet); they were lacking in energy and self-control. It was what had happened to Phineas Gage. They were not the people they had been before the operation.

  Over the next five years Freeman and Watts perfected their technique as they conducted more and more lobotomies. Other surgeons took up the procedure, while Freeman worked his way through an ever-increasing list of patients. Soon he and Watts were conducting operations on conscious patients using local anaesthetic. Freeman would have them count or sing a song so that he could tell what effect the leucotome was having. In one instance he is even said to have asked his patient to recite the Lord's Prayer – an unfortunate choice, given the circumstances.

  In 1941 Freeman was approached by Joe Kennedy and asked to operate on his daughter Rosemary – the sister of future President John F. Kennedy. Strictly speaking, Rosemary was a poor candidate for a lobotomy. Quiet and beautiful, there is little evidence that there was anything much wrong with her. She might have been suffering from a learning disability, or perhaps depression. People whispered that she was not quite right in the head, and that would not do for an overachieving Kennedy. Joe Kennedy was very persuasive, so Freeman and Watts agreed to go ahead with the surgery.

  The procedure was carried out in secret. Joe Kennedy did not even tell his wife. When Rosemary came round from the anaesthetic, she was a very different person. Slow and emotionless, she was hardly able to move or speak. Although she eventually learnt to walk again, she was left permanently disabled and ended up in a residential institution in Wisconsin. If anyone asked, they were told that Rosemary was suffering from a mental illness. Better than saying she had been lobotomized. Freeman never said a word about the case. It was in his best interests not to publish the details of any high-profile failures.

  Despite the odd setback, everything was going well for Freeman, but he was not satisfied. Lobotomy operations were taking too long and the asylums were filling up fast. There was no way he was going to get through all the patients that needed this miracle surgery of the soul. To add to Freeman's frustration, the procedure had to be carried out by a qualified neurosurgeon, but he wanted to do it himself. He needed a way to make it simpler and faster. Up until this point he had always made sure to describe the lobotomy as surgery of 'last resort', but this was about to change.

  PRODUCTION-LINE LOBOTOMIES

  Washington DC, January 1946

  * * *

  Twenty-nine-year-old Ellen Ionesco arrived at Freeman's office accompanied by her husband and daughter. Freeman was their last hope; otherwise they feared that Ellen would have to be admitted to hospital before she killed herself. Over the past few weeks her condition had worsened. She suffered from terrible depression and would lie in bed for days. She was paranoid, suicidal and lapsed into terrifying bouts of violence. At one point Ellen had even attempted to smother her six-year-old child.

  Sunlight streamed through the windows as Freeman examined the patient and carefully explained what he was planning to do. It was clear to him that she needed immediate treatment. Of course, any new procedure had its risks, but Freeman was so kind and reassuring that it did not take long for them to agree. Didn't the doctor always know best? Freeman ushered the patient through to a back room, where the equipment was already laid out and asked Ellen to lie down on the examination couch. The operation would not take long, he told her. Before she knew it she would be on her way home. He asked his secretary to order her a taxi.

  Freeman slipped a rubber tube between Ellen's teeth and powered up the ECT machine. He fastened a belt containing electrodes around her head. The ECT machine hummed. He asked Mr Ionesco to help hold down his wife. Freeman flicked the switch. The electrodes crackled as Ellen convulsed on the couch, her jaw locked, her head twisting from side to side. Freeman pushed the switch again until his patient was finally rendered unconscious by the electricity. He was ready to begin.

  After draping a cloth beneath her eyes, Freeman pulls back one of Ellen's upper eyelids and picks up an ice pick. It is an ordinary ice pick – the type found in many American homes. It looks like a chisel with a wooden handle, a long shaft and a strong, sharp point. It even has the company's name on the side: the Uline Ice Company.

  Holding the upper eyelid in his left hand, with his right he inserts the tip of the ice pick into the top of the eye socket. He is careful not to damage her eyeball as he pushes the ice pick diagonally upwards into her tear duct, following the line of her nose.

  Steadying the pick, he reaches for a hammer.

  Bang, bang.

  There is a crunch as the ice pick punches through the thin transorbital bone at the top of her eye socket. Freeman pushes the pick through the bone and into the frontal lobe of the brain. He wiggles the tool from side to side, slicing through the nerve tissue. He pushes it in further, sweeping it across like the blade of a windscreen wiper. After a couple of minutes, he gives the pick a final twist and yanks it out of Ellen's eye socket.

  In less than ten minutes, the operation is over and the patient starts to come round. She is helped from the table but can hardly walk. She is disorientated; the eye Freeman operated on is black and blue. She looks as if she has been beaten up.

  A week later, Freeman performs a second lobotomy through her other eye. In future he plans to do both eyes at once. After a few days in bed, Ellen is transformed. She is calm, her crazed mind now at peace. She takes up gardening, works in a shop and eventually trains as a nurse. Ellen Ionesco has her life back.

  Freeman called his new procedure the transorbital lobotomy. It was quick and easy. It didn't need an anaesthetist, surgeon or operating theatre. There was no faffing around with antiseptics, masks or gloves. As long as he made sure the ice pick was sterilized, that was good enough. The best thing was that the whole operation was so simple that almost anyone could do it. Freeman was tremendously excited. He would be able to transform the lives of thousands of people with mental illness?he could train other doctors?it would be a new era of psychosurgery for the masses! Just as Henry Ford had invented the production-line car, so Freeman had devised the pr
oduction-line lobotomy.

  Dr Freeman jumped into his camper van and set off across the United States to spread the word. During the next few years he crisscrossed the country performing his transorbital lobotomies. He travelled through Europe; he visited clinics and hospitals, operating on one patient after another. As he became more adept, he began to refine the procedure. He would hold the ice pick in his left hand, even though he was right-handed, drive two ice picks in at once, and even carried out operations with a carpenter's mallet. It was wonderfully easy. On one particularly memorable day Freeman got through twenty-five patients. His operations became performances, as doctors, reporters and the occasional interested bystander watched with horrified fascination.

  The sight of an ice pick being pushed into a patient's eye socket was bad enough, but the sounds were, if anything, even more gruesome: the buzz of the ECT followed by the thump of the hammer and the crack of bone, the swishing back and forth of the ice picks and the faint plop as Freeman yanked them out. As each disorientated patient staggered from the table, their black eyes smarting, the doctor could notch up another success.

  Freeman was getting through an awful lot of patients. He personally performed around three and a half thousand lobotomies, and trained doctors across the world. In total, it is thought that around one hundred thousand people were lobotomized. The results were mixed. Some, like Ellen Ionesco, returned to their families to lead relatively normal lives; Ellen's daughter speaks of Freeman with affection. Other patients were not so fortunate. Following lobotomy their personalities were irrevocably changed; they became docile, placid, mindless; dead to the world around them. A slip of the ice pick left some patients paralysed after the operation. Some died from complications. But Freeman seemed blind to the failures and oblivious to criticism. By the 1960s his notion that lobotomy was a surgery of 'last resort' – to be performed only on the desperately ill – had gone completely out of the window.