The Man Who Couldn’t Stop (23 page)

More extraordinarily still, Gage did not seem unduly troubled. There was lots of blood, and his face and arms were burnt, but he was conscious and helpfully told the doctor, who he was taken to see at a nearby inn, what had happened. No need to send my friends in to see me, he said. I shall be back at work in a few days. Infection nearly killed Gage – the doctor who treated him snipped away fungus that sprouted from his head – but he recovered and lived for another decade. He lived, but he seemed a different man, cruder and more impatient. Gage, his friends said, was no longer Gage.

He is remembered partly because his tamping iron landed in the middle of an argument among nineteenth-century scientists over the role of the brain. Some insisted that the whole brain was involved, and so needed, in every mental process. Others said it had distinct regions, each with their own purpose – this part for language, this part for memory and so on. Many of the scientists who favoured this latter approach believed that the size of each of the bits determined personality – so a large brain region responsible for memory would make someone better able to remember things. As it turns out, they were probably on the right lines, but history scorns them because they also believed that brain regions enlarged in this way would show up as bumps on the surface of the skull. (Working backwards, they reasoned that to measure the lumps and bumps of a person's head could reveal their talents and tastes.)

That Gage lost a large portion of his brain, yet was still able to function, indicated that an entirely intact brain was not essential for well-being. Together with studies of animals and Broca's work with people who had survived strokes, it helped to show that certain regions of the brain controlled specific behaviours. This pushed doctors and scientists who worked with severe mental patients at the time towards a startling idea. Could they manipulate these areas to fix people?

The Swiss psychiatrist Gottlieb Burckhardt thought so.

*   *   *

In late December 1888, at a grand asylum on the banks of Lake Neuchâtel, Burckhardt drilled holes in the heads of six mental patients, five of whom would probably today be diagnosed with severe schizophrenia, and gouged out portions of their cerebral cortex. Burckhardt claimed that the surgery improved the condition of three of the patients, but when he presented his results at a scientific meeting in Berlin the following year, shocked colleagues pressured him not to perform the operation again. Perhaps anticipating their hostile response, Burckhardt had concluded his report on the controversial procedure with a defiant line about the direction he thought medicine should take.

Doctors should challenge the classic medical mantra
primum non nocere
(first, do no harm), he said, with an opposing motive:
melius anceps remedium quam nullum
(better an unknown cure than nothing at all). Every path to new victories, he said, must be lined by crosses of the dead, which may be true but it's probably not the motto you would choose for your brain surgeon. Lobotomy had started badly, and would go downhill from there.

*   *   *

July 1935 was warm and sunny in London, so Egas Moniz would have felt very much at home. The Portuguese neurosurgeon, a former ambassador to Spain and minister of foreign affairs in his country's government, had spent the previous fifteen years at the University of Lisbon, where the weather was friendlier than in England.

Moniz had come to London to join fellow brain scientists from around the world for a week-long conference at University College. The event was to prove pivotal for Moniz, who would go on to win a Nobel Prize. Ivan Pavlov was there too, one of his last appearances before his death the following year. So were two scientists from Yale University in the US, John Fulton and Carlyle Jacobsen, who were eager to talk about their work with chimpanzees. In research that wouldn't be allowed in most places these days, Fulton, a physiologist, would sever pathways in the chimps' brains as a way to explore the links between different neural systems. Fulton and Jacobsen told the London meeting how cuts to the frontal lobe areas seemed to make the chimps less anxious. Moniz, in the audience, believed the same could be done to help people with mental illness.

Moniz wanted to use surgery to separate thoughts from emotions, to draw the sting from mental tension. Back in Lisbon, he persuaded a young neurosurgeon called Almedia Lima to operate on twenty psychiatric patients. Lima severed the white matter bundles that connect the frontal lobe regions with the rest of the brain, a procedure called a frontal leucotomy.

The duo went on to perform more than a hundred of these operations – first with injections of ethanol to poison and deactivate the brain tissue, and later with a retractable wire loop on the end of a metal rod to physically destroy it – and though Moniz claimed and celebrated them as successful, he kept few records of what happened to the patients afterwards. Several were quietly returned to asylums. This was the work for which Moniz – still an effective politician – received the 1949 Nobel Prize in Physiology or Medicine. He could not travel to accept the prize, as by then one of his patients had shot and paralysed him.

Moniz wrote positive reports of the surgery, which Walter Freeman, another US scientist, read and was transfixed by. Freeman had also been at the London meeting and he wrote to Moniz in 1936 with a plan to import the procedure to the United States. Freeman's name is mud in medicine now, but at the start he did recognize the risks he was taking, admitting that the scientific basis for the procedure was naïve. He knew that most brain scientists in the US were unimpressed with Moniz's work. One dismissed the whole idea of psychosurgery as burning down a house to roast a pig. But Freeman liked to think of himself as a pragmatist. He had no time for psychodynamics, and he saw how shock cures for mental illness introduced in the 1930s often did more harm than good.

Among these, electroconvulsive therapy (ECT), performed without anaesthetic, led patients to spasm and break bones. Deliberate insulin overdoses put others into terrifying comas for weeks. Meanwhile, the asylums of the United States had long overflowed. In 1937, over 400,000 patients were stuck in some 477 psychiatric institutions across the country. Conditions were dreadful and once a person had been in one for two years, they were unlikely to leave.

Together with the neurosurgeon James Watts, who had the license to operate that Freeman did not, Freeman introduced the Moniz procedure to the USA. Yet when the duo shared the results of their work with colleagues the following year they faced a hostile reaction, just as Burckhardt had done before them. John Fulton – the scientist who had set the ball rolling in London with his research on chimps – defended them (Watts had been one of his students). The work should continue, he said, but as careful clinical trials in the nation's top universities. The work continued, but the trials were never done. It was a pattern that would be repeated.

Fuelled by hype and uncritical reports of patients transformed, lobotomy spread across the country. Neurosurgeons in Florida, Pennsylvania and Massachusetts started to offer the operation. Its profile soared, helped when Freeman and Watts published dramatic accounts in a 1942 book
Psychosurgery
(a tome described by contemporary neurosurgeons as pulp nonfiction).
The New York Times
,
Life
magazine and
Newsweek
all hyped what some surgeons routinely called a miracle cure for America's ills. Joseph Kennedy, the father of John and Robert, took their sister Rosemary to Freeman. An editorial in the medical journal
The Lancet
on 5 July 1941, while cautious, predicted that the prefrontal lobotomy would prove most useful to relieve acute anxiety and obsessions.

At the centre of the firestorm was Freeman, who became high on the fumes. Fed up with Watts denying lobotomies to patients he considered not severe enough, Freeman took matters into his own hands. He picked up an ice pick and started to perform a cruder version of the operation himself. The prefrontal lobotomy became the transorbital lobotomy – the ghastly hammer of the spike through the top of the eye socket followed by the destructive waggle.

Watts, disgusted, walked away. Freeman, disgusting, hit the road. He toured the States in a Winnebago camper van and offered lobotomies to all who wanted them, and many who didn't. When Freeman's lobotomobile rolled into town, mental hospitals saw a way to get long-term patients out of the door. The scientist-turned-surgeon would knock the patient out with ECT, and perform the operation there and then. No sterile conditions. No medical backup. No oversight.

In their decade together, Freeman and Watts recorded 625 operations. In the decade that followed, Freeman alone lobotomized 2,400 people. He managed 225 in less than a fortnight. One in Iowa died when the ice pick slipped as Freeman stopped to take a photograph. He lobotomized children. He lobotomized a 4-year-old. Fulton was aghast. ‘What are these terrible things I hear about you doing lobotomies in your office with an ice pick,' he wrote. ‘Why not use a shotgun?' Lobotomy was much less traumatic than a shotgun, Freeman replied, and almost as quick.

Lobotomy was now divorced from neuroscience. No theory or hypothesis underpinned Freeman's actions. The operations were uncontrolled and the results largely unknown. Some did try to curtail this clinical drift. Surgeons in other countries had also started to perform versions of Moniz's prefrontal leucotomy (there is good evidence that Eva Perón was lobotomized in Argentina towards the end of her life) and in 1945 the UK hospitals board of control started an enquiry. Two years later it published the results of 1,000 cases where the surgery had been performed in England and Wales. Two-thirds of the cases were women. Significant numbers had OCD.

More than two-thirds of the lobotomized obsessional patients, the report claimed, had their problem removed or relieved. One of these was a 33-year-old man who was admitted to the Bristol Mental Hospital in June 1940 as Britain reeled from the fall of Paris to the Nazis and steeled itself for invasion. The man had a compulsive need to get his hair cut. He refused to eat and became severely emaciated. The Bristol psychiatrists diagnosed obsessional neurosis and performed a prefrontal leucotomy. The day after the operation, the man began to eat ravenously and he put on almost four stone in three months. All traces of his obsessions vanished, the doctors claimed. He left hospital, became engaged, obese and found a job as a railway station clerk.

The brain mutilations of what
Time
magazine called the age of ‘mass lobotomies' ended not because of protests and outcry, or due to a crisis of confidence or conscience from Freeman, but with a common allergy medicine. In 1952, a surgeon in Paris, Henri Laborit, noticed the sedative effect of antihistamine drugs and started to use them to calm people anxious before operations. It produced what he called ‘euphoric quietude'. Word reached the psychiatrist Pierre Deniker, who tried an antihistamine called chlorpromazine on his most agitated mental patients. He saw disturbed people who previously had to be restrained transformed and able to mix with others with no supervision. US authorities approved use of chlorpromazine in 1954. Even if there had been widespread demand for lobotomy, there was now no need. The chemical cosh had arrived.

Freeman never accepted that his miracle was redundant. He tracked down former patients and showed off what he claimed were boxes of letters of support from them. He need not have worried. His legacy was secure. Chlorpromazine and subsequent medications such as the SSRI drugs did not work for everyone with OCD and other conditions. Desperate cases remained. And so lobotomy, or a version of it, refused to die.

*   *   *

Mr V in India, the engineer with OCD who could not sign his pension, received an anterior capsulotomy, one of four neurosurgical procedures with their roots in lobotomy that are still performed on people with OCD. The others – cingulotomy, subcaudate tractotomy and limbic leucotomy – take a similar approach but hit slightly different targets. All are designed to disrupt signals in the brain circuits identified as important in the maintenance of obsessions and compulsions.

This kind of more limited psychosurgery first took place in 1947, inspired by the popularity of lobotomy, and it has continued ever since, largely under the public's radar. Collectively, it's called stereotactic surgery. Mr V's operation was stereotactic. So was the rogue attempt to cure the heroin addict in Shanghai. And so was the disastrous operation performed in 1998 on a 58-year-old Kansas woman with OCD called Mary Lou Zimmerman.

A former bookkeeper, Zimmerman had suffered from contamination OCD for thirty years. She wasted several hours a day showering and washing her hands. Drugs and counselling had not helped. When she saw surgery for OCD advertised on the website of the Cleveland Clinic in Ohio, she decided she had little to lose. A surgeon at the clinic gave Zimmerman a combined capsulotomy and cingulotomy. She had four pieces of brain tissue destroyed. But something went horribly wrong. The operation left Zimmerman crippled with brain damage. She developed dementia, became mute and needed full-time care. Her family sued and in June 2002, an Ohio jury awarded Zimmerman and her husband Sherman $7.5 million in damages.

Advocates of stereotactic surgery highlight two differences between it and lobotomy. The volume of brain destroyed is smaller. And the lesion, the damage, is more precisely targeted. The waggle has gone. That's because the surgeons first draw up a three-dimensional map of the brain, which they use to guide the placement of the electrodes. As technology has improved, so has this targeting. In early stereotactic procedures surgeons clamped their patients into crude metal frames and often fatally pierced blood vessels by mistake. Mr V's operation was guided by CAT and MRI scans of his brain's precise anatomy.

Still, just like early lobotomy, stereotactic surgery for OCD has fierce critics. The procedure has certainly had its shameful moments, just like lobotomy. In the late 1960s and early 1970s, scientists in Germany performed ethically dubious stereotactic psychosurgery on sex offenders and homosexuals. The Russian government was forced to ban stereotactic brain surgery for drug addiction in its hospitals in 2002; the Chinese, as we saw, followed in 2004. Scientists in Copenhagen have tried it to cure obesity.