The Man Who Couldn’t Stop

by David Adam

  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.

  * * *

  Three months after his surgery, Mr V seemed to be doing well – that was all the follow-up that his surgeon reported. But there are concerns about the long-term impact on patients given these kinds of procedures. In a 2003 editorial in the scientific journal Acta Psychiatrica Scandinavia, titled ‘Psychosurgery for Obsessive-Compulsive Disorder – Concerns Remain’, the clinical neuroscientist Susanne Bejerot warned that not enough is known about possible side effects. ‘There is no doubt that neurosurgery can dramatically reduce obsessions and compulsions,’ she wrote. ‘The question is to what price.’ Neurosurgery for mental disorders, she concluded, should only be allowed in controlled research settings – exactly what Fulton had urged in vain for lobotomy.

  In 2008, a group of psychiatrists and neurosurgeons published a rare analysis of the long-term effects of stereotactic surgery for OCD. They tracked down all twenty-five patients (fourteen women and eleven men) who had a capsulotomy at the world-class Karolinska University Hospital in Stockholm between 1988 and 2000. (That is an important difference from lobotomy: the numbers of people involved are much smaller). Nine patients were classed as in remission, but only three of these showed no adverse effects. Ten patients were considered to have significant problems with mental ability or function. The more brain material they had lost in surgery, the worse they were. The team concluded that capsulotomy is an effective way to treat OCD, but carries ‘a substantial risk’ – and one larger than previously assumed.

  Against these risks and warnings, neurosurgeons have to balance the impact on quality of life of OCD left unchecked. Life with a Yale-Brown score in the high 30s is no life at all. OCD may not provoke suicide, but plenty consider it. And some people with OCD who have improved after surgery are keen for others to try it too.

  Gerry Radano was a cheerleader for psychosurgery. A former flight attendant, Radano developed severe contamination OCD when pregnant with her second child. Drugs and therapy did not work. Numerous psychiatrists told her she could not be helped. A decade on, she had lost the career she had wanted since she was a little girl and her husband walked out. Radano was selected by scientists at Brown University in Rhode Island for a new and experimental type of capsulotomy. Rather than physically drill into the skull, the surgeons used technology called gamma knife surgery. These machines – invented in the 1950s and common in the treatment of cancer – use radioactive cobalt to generate 200 beams of gamma radiation.

  Alone, the streams of radiation are harmless, but focused to combine at a specific site in a tumour, or in the brain, they sizzle where they cross and fry surrounding cells. It’s called non-invasive brain surgery, if a technique that burns holes in the brain can ever be non-invasive. In November 1999, Radano was treated for OCD with a gamma knife. She was the first to persuade her medical insurers to meet the $30,000 cost of the surgery. And she was the first to write a book, in which she described what she calls a miraculous recovery. Radano no longer talks publicly about the gamma knife procedure. The Brown University team put its work on hold in 2011 to investigate why several patients developed brain cysts, though it hopes to restart. The procedure is still done elsewhere.

  Just as accidental damage to the brain can trigger OCD, so, in very rare cases, accidental damage can remove it. A 44-year-old woman in Iran was freed of severe obsessions and compulsions she had suffered since a teenager when she banged her head in a car crash. And a Canadian student called George inadvertently cured himself of his OCD when he tried and failed to commit suicide. Driven to desperation by his obsessions, George put a rifle in his mouth and pulled the trigger. The bullet did not kill him but it did give him a successful leucotomy. Do not try this at home.

  * * *

  Functional neurosurgery is not the only treatment of last resort for OCD. Other people have metal wires planted into their brains, attached to a battery that sends through them a powerful electrical current, which changes the way the surrounding neuronal circuits communicate. Called deep brain stimulation, the therapy arrived in the late 1980s, when it was found to reduce tremor in patients with Parkinson’s disease. Electrical stimulation seems to reduce the seizures in epileptic patients too. By the early twenty-first century, electrical wires in the brain were considered a form of reversible capsulotomy, and tried for depression and OCD. They have also been used to tackle obesity, alcoholism, drug addiction, anorexia and Tourette’s.

  Deep brain stimulation has a history as rich and controversial as lobotomy. Electrical modulation of the brain was recommended by Scribonius Largus, court physician to the Roman emperor Claudius, who suggested in AD 46 that a live electric fish be applied to the head of a patient who suffered a headache. It would fall to another former protégé of the lobotomy pioneer John Fulton to show that electricity could do a lot more to the brain than that.

  * * *

  Jose Delgado was born in 1915 in Ronda in the mountains of western Andalusia. He studied medicine at the University of Madrid and worked as a doctor for the Republicans in the Spanish civil war against Franco. In 1946 he won a fellowship to Yale University, and then took a job in the university’s physiology department under John Fulton. Interviewed in 2005, Delgado said he had been determined to undermine his mentor’s work on lobotomy. ‘I thought Fulton and Moniz’s idea of destroying the brain was absolutely horrendous,’ he said. ‘My idea was to avoid lobotomy, with the help of electrodes.’

  Delgado is most famous for a publicity stunt at a bullring in Córdoba, back in Spain.
He wanted to demonstrate the power of what he called his ‘stimoceiver’ – radio-controlled electrodes he placed in the brain that delivered a sharp pulse of electricity at the touch of a button. In one stunning trial of the technology he allowed a fighting bull to charge him until, when it was just a few feet away, he remotely activated the stimoceiver placed in the bull’s caudate nucleus. The bull skidded to a halt and Delgado, unhurt, made the front page of the next day’s New York Times.*

  Delgado experimented with people too. In the early 1950s he placed electrodes into the exposed brains of twenty-five patients at a Rhode Island mental hospital, mainly people with schizophrenia and epilepsy. He showed how electrical stimulation of the motor cortex could make people react with involuntary movements. One patient clenched his fist, even when he tried to resist. ‘I guess doctor, that your electricity is stronger than my will,’ he said.

  Despite Delgado’s intention to offer an alternative to lobotomy, he was dragged into a similar and public controversy. Some of this he courted. He wrote of possible two-way communication between the brain and computers, which would sieve neuronal activity and step in to correct abnormal patterns with electrical pulses. He was talking about detection and treatment of epileptic fits, but his rhetoric frequently strayed into the uncomfortable territory of mind and thought control. In 1969 he published a book called Physical Control of the Mind: Toward a Psychocivilised Society.

  In 1972 any distinction between lobotomy and brain stimulation in the public’s eye dissolved when two Harvard researchers, Frank Ervin and Vernon Mark – one-time collaborators of Delgado – published their own book, Violence and the Brain. The duo provoked a national scandal with their suggestion that both brain stimulation and psychosurgery might help to calm the violent tendencies of rioters in American inner cities. Robert Heath, a neurosurgeon at Tulane University, fanned the flames further when in 1972 he announced he had tried to reverse homosexuality through electrical stimulation of a gay man’s brain while he had sex with a female prostitute.