Happy Accidents: Serendipity in Major Medical Breakthroughs in the Twentieth Century (36 page)

In conducting a lobotomy, Egas Moniz first passed a long-needled syringe containing alcohol through drill holes in the skull and through the brain to destroy the fibers that connect the frontal lobes to the main body of the brain. Then he used a specially designed knife, called a leucotome, to cut away the frontal lobes. Whether or not the patient's anxiety truly abated as a result of the surgery was difficult to prove. What was apparent was that the patient simply did not care. Indifference, apathy, dullness, and disorientation came to dominate
the patient's behavior. In a barrage of grandiose publications, Egas Moniz claimed a high success rate of “cure” or “improvement,” but these were only very short-term observations and were poorly documented.
⁶
He performed several more operations before World War II began. Soon thereafter, psychosurgery—a term coined by Egas Moniz—was being performed all over the world.

P
ERSONALITY
, C
UT TO
M
EASURE

In the United States, the procedure was enthusiastically picked up by Walter Freeman, professor of neurology at George Washington University in Washington, D.C. Since he had no qualifications as a surgeon, he required a neurosurgeon, James Watts, as a collaborator. They practiced on brains from the morgue before selecting their first patient. Within only a few months, in the fall of 1936, they performed twenty lobotomies. They varied the technique in several ways and first adopted a narrow steel blade, blunt and flat like a butter knife. Indeed, in assessing its ease of use in arcing through nerve matter, Watts commented, “It goes through just like soft butter.” Basically, however, the technique remained blind; surgeons couldn't see or monitor what they were cutting.

They then began to perform the procedures under local anesthesia so that the patient could be asked to sing a song or to perform arithmetic. As long as these functions remained intact, the scalpel chopped away at more and more “cores” of the brain tissue. Amazingly, an editorial in the influential
New England Journal of Medicine
proclaimed: “The operation is based… on sound physiological observations.” Yet classical analysts were in an uproar. In 1939 an English psychiatrist named William Sargant attended the American Psychiatric Association's convention in St. Louis and witnessed the antagonism and outrage at Walter Freeman, who was in attendance: “They felt so insulted by this attempt to treat otherwise incurable mental disorders with the knife that some would almost have used their own on him at the least excuse.”
⁷
Sadly, the reservations of psychiatrists and psychoanalysts were not voiced to the public.

Freeman was adept at self-promotion. He effectively publicized a
widely read article, “Turning the Mind Inside Out,” that appeared in the
Saturday Evening Post
in 1941. Freeman had explained the operation to the writer, the science editor of the
New York Times,
as one that separated the prefrontal lobes, “the rational brain,” from the thalamic brain, “the emotional brain.” The following year, Freeman and Watts's book
Psychosurgery
stimulated worldwide professional interest. Freeman himself wrote the jacket copy, and in a phrase that reveals not only his hubris but the anticipation of wider applications than those he first cautiously espoused, he claims: “This work reveals how personality can be cut to measure.”
⁸
For many years Freeman had a “psychosurgery exhibit” at the AMA's annual meeting. There he buttonholed journalists and, according to his partner, Watts, often behaved “like a barker at a carnival,” using “a clicker which made a sharp staccato noise” to attract attention.

In 1945 Freeman undertook a new surgical approach by himself: transorbital lobotomy, also known as “ice pick” lobotomy. After practicing on corpses, he developed a technique of perforating the back of the bony orbit (the eye socket) behind the eyes with a modified ice pick he found in his kitchen drawer,
⁹
to cut the nerves at the base of the frontal lobes. Now the procedure could be accomplished more widely by physicians without the need for a neurosurgeon. The
popular press hailed it as a major advance, while many in the profession viewed it as “not an operation, but a mutilation.”

“I'd Like to Pick Your Brain”

Professor Walter Freeman became an indefatigable evangelist for the ice-pick lobotomy procedure. As Freeman's biographer Elliot Valenstein describes it, “On one five-week summer trip [in 1951], he drove 11,000 miles with a station wagon loaded, in addition to camping equipment, with an electroconvulsive shock box, a dicta-phone, and a file cabinet filled with patient records, photographs, and correspondence; his surgical instruments were in his pocket.” The most important of his surgical instruments was the ice pick. He performed the procedure at mental institutions across the country, demonstrating it before audiences, on as many as thirteen patients in one day.

The awarding of the Nobel Prize for Medicine to Egas Moniz in 1949 for prefrontal leucotomy broke down any barriers of resistance among superintendents of overcrowded, underfunded asylums for the mentally ill. “A new psychiatry may be said to have been born in 1935,” proclaimed the
New England Journal of Medicine,
“when Moniz took his first bold step in the field of psychosurgery.” Within eight months, 515 transorbital lobotomies were performed in Texas alone. More people were lobotomized in the three years after Egas Moniz received the prize than in the previous fourteen years.

Two lobotomy cases in particular reached national consciousness: At the request of Joseph Kennedy, ambassador to Britain and father of JFK, his daughter Rose Marie (Rosemary) when in her early twenties was lobotomized by Freeman and Watts at the George Washington University Hospital in 1941. She was mildly retarded and very outgoing, and the family feared she might embarrass them by getting pregnant. After the procedure, she lost her personality and regressed into an infantlike state. She lived out the rest of her long life in a private sanitorium run by nuns.

Frances Farmer, a 1930s film star and radical political activist, had rebelled against authority and injustice all her life. The institutions of society, law, and psychiatry converged to restrain this behavior. Institutionalized at a state hospital, she was subjected to insulin shock and electroconvulsive treatments and then underwent transorbital lobotomy by Freeman in 1948.
¹⁰
A 1982 Hollywood movie,
Frances
, is graphic in its portrayal of these events.

In the severely psychotic, the operation did result in relief from compulsive and morbid anxieties. Although aberrant behavior often continued, many patients were able to live outside an institutional setting. Many, however, became the “walking wounded,” with loss of imagination, foresight, sensitivity, and some loss of individual personality. Initially proposed as an operation of last resort, it had become the first step in creating a manageable personality.

By 1955, more than 40,000 people in the United States had undergone psychosurgery to treat psychotic and various other forms of
abnormal behavior. Nearly twice as many women as men were lobotomized.
¹¹
Freeman himself was responsible for 3,500 operations.
¹²

In March 1954 Thorazine (chlorpromazine) was approved by the Food and Drug Administration. This and the rapid succession of other psychoactive drugs led to the marked decrease and ultimate abandonment of lobotomy. Not only had simple, inexpensive, and effective alternatives arisen, but the awareness had grown that lobotomy had created many brain-damaged people. The procedure fell into disrepute, replaced by psychopharmacology.

“T
HE
W
RONG
E
ND OF THE
R
IGHT
P
ATH
”

Looking back, it is remarkable that the theoretical bases for all these modes of somatic treatment were so ill-founded and yet so widely accepted. Theories were proposed, sometimes forcefully, and were often so vaguely stated that they strain scientific plausibility. There may have been critics, but it is a fact that these radical treatments were quickly embraced by mainstream medicine. Psychotic conditions did not lend themselves to treatment by psychoanalysis, and many considered Freud's contributions to be greater in the field of literature than in medicine.

An English psychiatrist, speaking of his experiences at a mental institution in the period before the new organic treatments, is disarmingly frank:

We developed a self-protective intellectual atmosphere of its own…. We improvised special formalities, such as recording very lengthy case-histories for every admission [sometimes running] to more than thirty pages of detailed information. Today such long screeds would generally be laughed at, the simple treatments now available often making them superfluous, but then they gave us a feeling that we were doing something for the patient by learning so much about him, even if we could not yet find any relief for his suffering. We also compiled “social” histories…. This, too, was often a waste of time, but what else could one do? Nowadays [we have no] need for elaborate case-history or social investigation, still less for the former eternity of talk.
¹³

While accepting that “no one really claimed to understand the cause, nature or cure of this dread malady [schizophrenia],” the
New England Journal of Medicine
in 1938 applauded the idea that these new therapies, including shock treatment and ice-pick surgery, seemed “to bring the field of psychiatry a little closer to that of general medicine.”

Medicine has long accepted that successful results may be shown empirically before an understanding of a treatment's scientific basis is reached. Manfred Sakel offered an insight on the bounty of accidental discovery:

I have a high regard for strict scientific procedure and would be glad if we could follow the accustomed path in solving this special problem: it would have been preferable to have been able to trace the cause of the disease first, and then to follow the path by looking for a suitable treatment. But since it has so happened that we by chance hit upon the wrong end of the right path, shall we undertake to leave it before better alternatives present themselves?… For it should perhaps now enable us to work backwards from it to the nature and cause of schizophrenia itself.
¹⁴

33

Lithium

In 1948 the thirty-seven-year-old Australian John Cade was, by his own description, “an unknown psychiatrist, working alone in a small chronic hospital with no research training, primitive techniques and negligible equipment.”
¹
A survivor of three years in a Japanese prisoner-of-war camp, he emerged with his scientific curiosity intact and took a position at a mental institution in Victoria, Australia, focusing his attention on manic-depressive illness. On the basis of an unsound hypothesis, he conducted tests that led to one of the most significant discoveries in the history of pharmacotherapy, thanks to a chance selection of certain materials for his experiments.

The stereotype of a manic is that of a person talking very fast and becoming euphoric. In milder cases of acute mania, the patient can be easily annoyed and very hostile. There are also so-called mixed states, in which patients have such symptoms and are depressed as well. In more manic stages, thoughts rapidly flow, a surge in creativity is felt, social inhibitions are lost, and schizophrenic-like delusions may occur.

In thinking about the nature of manic-depressive illness, Cade drew an analogy to the behavior of patients afflicted with thyroid disorders. He had observed that extreme hyperactivity of the thyroid gland (thyrotoxicosis) seemed to cause a form of mania, while a marked depletion of thyroid function (myxedema) seemed to trigger depression. Cade asked whether mania might similarly be a state of intoxication produced by a circulating excess of some metabolite, while
depression, where it was associated with mania, might correspondingly be due to its absence or relative lack. He reasoned that the manic patient would be expected to excrete the chemical or its breakdown product in greater magnitude than other categories of patients or normal individuals. Accordingly, he collected urine samples from manic patients, melancholics, and schizophrenics, as well as from normal individuals.

Working single-handedly in a pantry laboratory attached to a psychiatric hospital in Bundoora, a suburb of Melbourne, Cade conducted tests that were relatively crude but nonetheless effective. To test for the presence of a toxic substance, he concentrated the urines and then injected it into guinea pigs. If sufficient urine was injected, the guinea pigs developed severe toxic convulsions, fell unconscious, and died. All the urine samples proved fatal to the animals, but those from some of the manic patients were found to be by far the most toxic. He established that the toxicity was caused, unsurprisingly, by urea (the main substance in urine), but urea was not more abundant in the urine of manics. He postulated that the toxicity of urea might be heightened by the presence of uric acid and that this enhancement might occur to the greatest degree in manic patients.

It was at this point in carrying out tests to measure the toxicity of urea in the presence of varying concentrations of uric acid that Cade ran into difficulties in preparing solutions of the highly insoluble uric acid. The problem was overcome by using its most soluble salt, which was lithium urate. “And,” Cade relates in a disarming admission, “that is how lithium came into the story.”