Gracefully Insane

by Alex Beam

  In our own time, it is not so unusual for men and women to discuss their stays in mental hospitals. Although most former patients still feel stigmatized by society at large, they know they are far from alone in their travails. From the high culture of literary memoirs to the low culture of talk shows, tales of life in the “bin” or the “zoo” are part of our cultural landscape.

  But things were different in 1943, when a Boston businessman named Frank Kimball insisted on publishing the affecting story of his eleven-year stay at McLean. A trustee of Boston University, a churchgoer, and successful insurance and investment counselor, Kimball suffered a breakdown during his summer vacation in 1927. By his own account, he had become overwhelmed by his duties on his town’s planning board and by the press of business. In December 1931 he transferred from the Channing Sanitarium in Wellesley, Massachusetts, to McLean.

  Kimball promptly fell into what Abraham Myerson called the “prison stupor” that results when the shock of hospitalization interacts with the instinctual social retreat of the mental patient. Kimball described a “life of semi-automatic activity, in a blue fog of futility.” His family rarely visited him: “What use was it for anyone to see me, when I sat like a wooden Indian? My handshake was cold, my greetings hardly more than dull murmurings.”

  In addition to his depressed state, he started to hear voices, a symptom of deepening schizophrenia.

  One day my nurse happened to move a chair in my room, making a scraping noise. This sounded to me just as if he had said, gruffly, “Get out of here.”

  “What do you mean, telling me to ‘get out of here’?” I complained.

  “What? I never did.”

  Six years into his stay, the doctors started to “push” Kimball into activity. The patient librarian had launched a bimonthly magazine, The McLean Gazette, and asked him to contribute book reviews. He did, and he enjoyed doing it; however, he never spoke with the librarian, choosing to communicate with her only through handwritten notes. Then, in 1942, his doctors recommended electroshock therapy. Although none of the shock regimens turned out to “cure” or even significantly alleviate chronic schizophrenia, they had proved useful in combating depression. Kimball thought it was worth a try: “I don’t remember much about it except for a dim recollection of trips in bathrobe and pajamas by wheelchair to the treatment room. There was little discomfort. I would be given the mild shock about 10:30 A.M., carried back to my room, and the first thing I knew I would awaken around noon, very much refreshed.”

  After three months of treatment, Kimball was encouraged to telephone his wife, Edith.

  Edith was called to the phone.

  “Hello,” said the voice. “This is Frank.”

  “Who?”

  “Frank.”

  “Frank who?” Edith was thinking of the boy who came to do odd jobs.

  The voice, insistently. “It’s Frank, your husband.”

  Edith was flabbergasted; she had not heard my voice on the phone for over fifteen years.

  Kimball went back home to the Boston suburb of Dedham. He returned to his church, he returned to his favorite hobbies—playing the piano and writing letters to the newspapers—and he was invited to rejoin Boston University’s board of trustees. He served as toastmaster for his college class’s fiftieth reunion, he flew in an airplane for the first time, and he even revisited McLean, accompanying his daughter-in-law in a musical revue. He had been saved, and he freely admitted he was not sure how or why:“How can you bear to write so freely about all those bad years?” ask many of my friends. I have to smile. It has been a deep satisfaction right through—not a wink of sleep lost, not a twitch of a nerve from start to finish. Why, that old sourpuss in the story isn’t me anyway! Perhaps never was. I don’t know—I leave it to the psychiatrists to explain.

  Lobotomies posed a classic clinical dilemma to the genteel, Harvard-trained McLean doctors. By the late 1930s, the controversial procedure had attained a certain legitimacy. The Portuguese doctor António Egasmoniz had first invaded a patient’s frontal lobe in 1935, acting on the theory that destruction of the nerve connections behind the forehead broke up the “fixed ideas” that tormented schizophrenics. Almost immediately after reporting success in his first “leucotomies,” Egasmoniz was nominated for a Nobel Prize, which he won in 1949. (Leucotomy, from the Greek word for “white,” refers to the white fibrous material that Egasmoniz scraped from the front of the brain.) A brilliant and ambitious American doctor, Walter Freeman, seized on the Egasmoniz procedure and started performing “lobotomies” in Washington, D.C., in 1936. (Neither Freeman nor Egasmoniz was a surgeon, much less a neurosurgeon, a fact that did not escape their colleagues’ notice.) Freeman and his surgical partner, James Watts, removed more of the frontal lobe than had Egasmoniz, hence the new nomenclature. They did not subscribe to Egasmoniz’s theory that psychosurgery broke up fixed ideas in the patient’s brain. Instead, they argued that lobotomy succeeded in severing contact between the frontal, “thinking” brain and the anterior, “feeling” part.

  The results of the early lobotomies, indeed of all lobotomies, would prove to be equivocal. Eight of Freeman’s first twenty patients had to have second operations. The postoperative reports tended to be vague, and soon enough grisly accounts of scalpel fragments breaking off inside patients’ skulls began to surface. In promoting the procedure, science was the first casualty. Queried at a Boston psychiatric conference as to which kinds of patients were suited for lobotomy, Freeman answered, “The more this procedure is being used, the more indications there are for it.”

  Freeman, who eventually collaborated on more than a thousand lobotomies, was convinced he had struck the psychiatric El Dorado. The doctor in him knew he should be cautious in reporting successes, but Freeman the promoter was unable to restrain his enthusiasms, especially when a reporter’s notebook or tape recorder happened to be nearby. “This woman went back home and in ten days she is cured,” Freeman said of his first patient, a sixty-three-year-old woman from Topeka, Kansas. The woman resisted the surgery when she learned that her hair would have to be cut; Freeman promised her that he would do all he could to save her lovely curls. After the operation, he noted sardonically, “she no longer cared.” His Norman Rockwell-like motto was “Lobotomy gets them home.”

  The media eagerly beat the drum for Freeman’s “surgery of the soul,” psychiatry’s latest silver-bullet cure. “Surgery Used on the Soul-Sick,” read the New York Times headline; “Relief of Obsessions Is Reported.” In smaller type, the newspaper added that “new brain technique is said to have aided 65% of the mentally ill persons on whom it was tried as a last resort, but some leading neurologists are highly skeptical of it.” Similarly enthusiastic reports appeared across the nation in magazines and local newspapers. The lobotomy vogue “hit us like a bomb,” one American neurosurgeon recalled. By 1949, doctors were operating on 5,000 patients each year. Some leading neurologists were in fact skeptical, but as a measure of last resort lobotomy had a certain appeal. Bluntly put, the Freeman-Watts procedure had indeed cleaned some “human salvage” out of the back wards of many hospitals. Why not at McLean?

  McLean doctors like to say they never evinced much enthusiasm for lobotomies, and statistics back them up. Between 1938 and 1941, no more than two patients received the operation each year. At its peak, in 1947, fourteen patients—all women—out of a census of around two hundred were lobotomized. (Two-thirds of McLean’s patients at the time were women, and their average length of stay was much longer than the men’s. Nationwide, doctors lobotomized twice as many women as men.) That peak may be partially explained by the upgrading of McLean’s surgical facilities. Patients no longer had to be driven under guard into downtown Boston for surgery at the Massachusetts General Hospital. Now surgeons were only too happy to avail themselves of McLean’s refurbished operating room. “With surgical fees running as high as $600 an operation,” writes medical historian Jack Pressman, “psychosurgery had become a lucrative side-specialt
y.”

  Pressman obtained access to the case files of all McLean’s lobotomy patients to write his 1998 history, Last Resort: Psychosurgery and the Limits of Medicine. On the one hand, he accepted the prevailing wisdom, articulated by acting psychiatrist-in-chief Paul Howard at a 1950 staff conference, that lobotomies were indeed “a last resort” for those long-term patients who had already failed to respond to less radical treatments. Howard allowed that the surgery may “take away something from the personality” but felt that it also held out the hope of relieving a life of suffering. But Pressman could not help but note how effortlessly the lobotomy option slid into the psychiatrists’ checklist of possible cures. Initially envisaged as an option for patients who had lingered in the wards for more than two and a half years, it soon came to be discussed much earlier in the treatment cycle. “After a preliminary period of observation, electric shock and or insulin shock should be tried,” one doctor noted in the file of a new arrival. “However, the prognosis in either therapy with this patient is not good and she may become a candidate for lobotomy.” Pressman concluded, “For patients whose combination of age, sex, diagnosis, and mental history placed them in the pool of possible candidates, the meter was ticking as to the eventuality of receiving a lobotomy—a race between improving enough to be discharged from the hospital and being brought before a staff conference at which they would be recommended for surgery.” At one such staff conference, a McLean doctor let slip that “we usually do a lobotomy to quiet people down.”

  Here is a transcript of a 1945 staff conference concerning the advisability of lobotomy for a male patient. The doctors’ names have been changed.

  MURPHY: Do you think he should have a lobotomy, Arthur?

  BURDETT: I think it would be interesting to speculate what we would expect it to accomplish.... There is no thinking it is going to make him any worse except it might make him incontinent of urine.

  MURPHY: It might make him dead or have convulsions.

  BURDETT: I don’t think that is very much worse than his present situation. I favor lobotomy, not with great enthusiasm, but I still favor it.

  MURPHY: Dr. Green, what do you say?

  GREEN: I do not feel qualified to express an opinion.

  SWADLEY: I don’t know what lobotomy would accomplish....

  MADDOX: From what I have read about lobotomies, those done on patients with real inner drive are more successful so this man might benefit.

  AVERBUCK: Seems to me the fundamental disorder is not changed and I am opposed unless there is some very urgent need for it. ...

  MURPHY: One argument against the lobotomy is that he does not have a decent personality to go back to.... [On the other hand,] if we do not do a lobotomy the chances are he will just go along on Bowditch in this same state for many years.

  KELLOGG: All the data in this record is on the hopeless side, but I do not have any definite opinion. I am rather against it as the risks are too great and the results too small. I wonder if he could be kept from deteriorating so rapidly by total push means.

  At the end of the conference, the doctors voted not to lobotomize the patient in question.

  At a small, well-staffed hospital like McLean, the doctors knew most of the patients personally. So when a patient like “Sarah Worthington” was lucky enough to make dramatic strides with the help of a lobotomy, every doctor knew about it. Worthington, a housewife and mother in her midforties, had been admitted to McLean in 1947 following a suicide attempt. The initial diagnosis was neurotic depression. At the hospital, she became aggressive and paranoid and again tried to commit suicide. She was given electroshock therapy, which depressed her even more. Five years of intense psychotherapy “might or might not help,” opined one doctor, for “there is nothing to go back to in her case.” About ten months after checking in, Worthington was lobotomized.

  Her improvement was dramatic. She appeared at a rare postoperative staff conference and displayed “pleasure and spark.” “The patient seems to have derived a good deal of protection from the overwhelming accumulation of her depressive feelings,” her doctor noted. “It seems justifiable to say that the lobotomy has given her a chance to solve these problems in a way which no previous therapy had succeeded in doing.” Her IQ was measured at 134—higher than before her surgery—and she was soon discharged home. Worthington found a job demonstrating merchandise to women’s clubs and was promoted to a supervisory job after several years. She continued to meet her doctor for weekly psychotherapy and wrote him a grateful note several years after her surgery: I have been wishing to write to you a note of appreciation, not a sentimental gushing expression of gratitude but an honest expression of how I feel in regard to your work.... When I first came to the hospital I was in a room with no doors, no outlets. My only companions were Fear and Hopelessness. It was grim. Gradually throughout all of this time you have made me see for myself that particular room (which actually seems to have been of my own choosing) has doors. I am the one who must open them. I myself.

  Of course, the doctors drew heart from Worthington’s recovery. But the statistical analysis was less forgiving. Of the first eight women operated on, seven were still in McLean five years after the surgery. At the 1950 staff conference, Paul Howard noted that about half of the sixty patients lobotomized by then had been discharged from the hospital but still needed varying levels of care. Those remaining in the hospital showed some improvement. When I interviewed Howard almost fifty years later, even the distant memory of lobotomies sent a chill up his spine. “It’s a horrible thing to think of, someone reaching into your brain and cutting it with a knife.” He still remembered the approximate range of outcomes. “Our statistics showed that one-third of the patients got a little better—these were people who had been in the hospital for three or four years and probably weren’t going to get out—one-third got much better and one-third remained unchanged.”

  McLean’s flirtation with lobotomies ended in 1954. The newly appointed director, Dr. Alfred Stanton, had a strong psychotherapeutic background and zero interest in psychosurgery. Also, antipsychotic drugs were becoming available to the psychiatric profession. Perhaps more importantly, the operation was developing an unsavory reputation. The irrepressible Walter Freeman had decided to become the Henry Ford of psychosurgery, and he was barnstorming the country to promote his gruesome “ice-pick” lobotomies. Instead of using anesthesia, Freeman, sometimes operating alone in his office in downtown Washington, electroshocked his patients into unconsciousness. Then he hammered an ice pick (initially from the Uline Ice Company; later he used a surgical tool) through the bone above the eye and more or less randomly wiped out frontal lobe tissue. At the 1950 staff conference, Howard related a “probably fictitious story” about patients visiting Freeman’s office for electroshock and emerging with two black eyes resulting from an impromptu lobotomy. Given Freeman’s increasingly erratic conduct, it is possible that the story was true.

  But there is another reason that lobotomies ground to a halt at McLean: Virtually every patient who might qualify for a lobotomy had already received one. Eighty-five percent of the lobotomized patients were discharged within eighteen months of having the operation. The rest hung around, taking up the few remaining beds for chronic sufferers. By 1954, McLean was already trying to admit younger patients, who held out more hope of being cured. “The salvageable deadwood had been logged out,” Jack Pressman explained at the end of his study of psychosurgery at the hospital.

  In a bizarre coda to McLean’s history with lobotomies, Walter Freeman drove his specially outfitted Cortez camper-van onto the property in 1968 and parked it outside of Upham Memorial Hall, then a geriatric ward. Freeman had converted his van into a mobile record room and carried hundreds of his own case files with him. He had even mounted an X-ray viewer inside the Cortez; Freeman was on a cross-country tour, seeking out former patients for the purpose of monitoring their progress and updating his files. (He had stopped performing lobotomies the previous year.) �
��He came on a weekend, and he wanted to be let in and have access to our records,” recalls Dr. Paul Dinsmore, who was running Upham at the time. “I told him he couldn’t just show up there off hours, and expect us to open our files.” Freeman drove off, and did not return.

  Freeman died in 1972, at the age of seventy-six.

  6

  The Talk Cure

  FREUD AND MAN AT MCLEAN

  Great Doctor, are you savant or charlatan?

  Abraham Bijur to Sigmund Freud

  The Boston medical establishment, meaning the Harvard medical establishment, of which McLean was a part, did not leap to embrace Freudianism. This was somewhat ironic, given that Harvard doctors had played a key role in bringing Sigmund Freud’s ideas to the United States. It was philosopher and psychologist (and putative McLean patient) William James who twigged onto Freud’s work and discussed his ideas in his famous Gifford Lectures of 1901-1902, later published as The Varieties of Religious Experience. And McLean historian Silvia Sutton notes that Harvard neurologist James J. Putnam—the same Putnam who admitted Stanley McCormick to McLean—published the first paper in English on the clinical use of psychoanalysis in 1906 and “put Freud on the American psychiatric map.” Like many practitioners dipping their toes into the infant science of psychotherapy, Putnam’s endorsement was tentative at best. His paper concluded “not that the ‘psychoanalytic’ method is useless, for I believe the contrary to be the case, but that it is difficult of application and often less necessary than one might think.”