They called it "Operation Icepick."
During 12 days in August, 1952, Washington neurologist Walter Freeman, America's lobotomy evangelist, performed or supervised 228 of the brain operations on mental patients at five state hospitals in West Virginia.
Strapped to the operating table, each patient was first jolted with three sharp bursts of electricty that produced an anesthetic coma. Then Freeman went to work with two icepick-style surgical knives called leucotomes, placing one under each eyelid and probing into the brain through the bony wall behind the eye socket.
"I was horrified when I saw it," recalls Alan Stone, Harvard University professor of law and psychiatry and president of the American Psychiatric Association. While a medical student at Yale, Stone watched films of Freeman demonstrating the technique known as transorbital lobotomy.
When the ice picks had each been inserted two inches deep into the brain, Freeman gently manuvered them until he was satisfied he had severed the fine nerve fibers connecting the frontal lobes to the thalamus, one of the brain's information centers. Then he slipped the knives out and moved to the next patient.
The operation was built for speed -- "only a litte more dangerous than operating to remove an infected tooth," Freeman told one newspaper reporter -- and it took 10 minutes. There was no time and no money for anything fancier or slower.
"A lobotomy program in a state mental hospital must be considered against a background of shortage of everything but patients," said Freeman, who returned to West Virginia to do 374 additonal lobotomies over the next two years.
The years 1945 to 1954 were the golden age of lobotomy in the United States and Walter Jackson Freeman was its chief prophet and promoter. He imported the operation from Europe, refined it an convinced custodians of mental instituions throughout the country to use it.
Freeman later estimated that of the 40,000 to 50,000 lobotomies done in this country between 1936 and the late 1950s, he had personally performed or directed 4,000 of them in at least 30 hospitals in 15 states. His patients ranged from 7-year-old children to 70-year-old adults suffering from a wide range of mental illness.
The results, he pledged, would be that as many as half the patients would be improved within a year to the point where they could return home. For the rest, "even though the patients must remain in the hospital, they are relieved of their terrific suicidal and homicidal drives and there is a gratifying reduction in the wear and tear on hospital equipment and personnel."
There was, of course, a price to be paid. Freeman later acknowledged in a letter to the American Journal of Psychiatry that lobotomies sometimes produced "disatrous effects."
"Operations that had been done too conservatively were followed by relapses and some suicides; those that had been too extensive ruined the personality."
Still, Freeman contended the operation was not at fault, instead blaming the casualties on doctors who chose poor prospects as patients or cut erratic or overly extensive incisions into the brain. To the end of his life, he believed lobotomy would reemerge as a treatment of choice in coping with mental illness.
"I believe it's due for adoption when the surgeons make up their mind for it," he told a sympathetic interviewer in 1968, four years before his death. ". . . I think they're missing a good bet."
The lobotomy era began, fittingly enough, at Freeman's alma, mater, Yale University, where in the early 1930s a pair of neurological scientists successfully severed the frontal lobes of chimpanzees' brains, rendering the normally frenetic apes docile and relaxed.
The researchers presented their findings at a neurological congress in London in 1935, where Portuguese scientist Egas Moniz heard them and decided that what worked for apes might well work for humans. He returned to Lisbon and that fall drilled holes into skulls and cut the nerve passageways of 20 hopelessly ill mental patients culled from the back wards of one of the city's largest hospitals. Moniz reported the following year that seven of the 20 had "recovered" and seven others "improved."
Freeman, an admirer of Moniz and later instrumental in helping the Portuguese scientist win a 1949 Nobel Prize for his psychosurgical work, read the lobotomy report with great interest.
Amateur poet, outdoorsmen, devoted family man, Philadelphia-born Walter Freeman had the trademark goatee and balding pate of the stereo-typical Freudian psychiatrist. But unlike the Freudians, Freeman strongly believed the most mental illness had physical and biological causes and therefore physical alterations of the body might be necessary to cure it.
As director of laboratories at St. Elizabeths Hospital, Washington's largest repository of the mentally ill, and later as a neurologist and psychiatrist at George Washington University Hospital, Freeman had been deeply troubled by what he saw.
He'd seen patients in St. Elizabeths who'd been there for 40 years and nothing could be done for them," recalls Washington neurosurgeon James W. Watts, Freeman's partner and longtime colleague at GWU Hospital. "He was a passionate man, a doer, and it bothered him greatly."
With Watts' assistance, Freeman set to work. They found a prospective patient in September 1936, a 63-year-old woman, victim of several nervous breakdowns, whom they diagnosed as suffering from "agitated depression."
Watts, now 76, a tall, soft-spoken man with graceful hands and slender fingers, ardently defends the early work he and his partner did. But he admits he had some doubts about its ethics.
"It's one thing to operate on a person whose head is smashed in or to remove a brain tumor when you know the person will die if you don't," says Watts. "But to operate on a normal brain -- one wonders if it'll be right and beneficial for the patient. We were convinced it would be."
Freeman and Watts did the first American lobotomy that September at GWU Hospital. They were amazed at the result.
"In the hospital [before surgery], she showed uncontrollable apprehension, was unable to sleep, laughed and wept hysterically," they later wrote in the landmark 1950 book, "Psychosurgery." The patient had panicked at the sight of the anesthetist and had to be held down while a drug was administered and she passed into unconsciousness.
After the operation, they wrote, "Four hours later after anesthetic had worn off, her face presented a placid expression and she admitted that she felt much better . . .
Question: Do you have any of your old fear?
Q: What were you afraid of?
A: I don't know. I seem to forget.
Q: Do you remember being upset when you came here?
A: Yes, I was quite upset, wasn't I?
Q: what was it all about?
A: I don't know. I seem to have forgotten. It doesn't seem important now."
(This and other quotations reprinted from Freeman and Watts, "Psychosurgery," Charles C. Thomas, with permission.)
Encouraged by the results of their first operation, Freeman and Watts lobotomized six other people that fall and eventually operated on 623 by 1948. As they progressed, they refined their technique, developing more accurate and deeper cuts and scrapping the general anesthetic for a shot of novocaine to the head so that patients were awake during the operation.
Having the patients remain awake made it easier for the two physicians to monitor the results of their cuts. But it meant the patient could hear as the doctors drilled holes into his or her skull above the temple and could feel the movement of the scalpel as it probed into the brain tissue.
As usual, Freeman and Watts took a cool, clinical approach to the subject, writing in "Psychosurgery":
"Apprehension becomes a little more marked when the holes are drilled, probably because of the actual pressure on the skull and the grinding sound that is as distressing, or more so, than the drilling of a tooth. During this part of the procedure the mouth is dry, the heart beats rapidly and the hands are cold, thus betraying an emotional tension of which the patient himself is quite aware."
Freeman and Watts reported no change in a surgical patient when they sliced through the first two or three quarters of the front lobe. But by the fourth cut, the result was dramatic.
"You could see the change right there on the operating table," recalls Watts. "People who were moaning, people crippled with guilt, depression -- their faces eased and tension left -- like that."
Take the case of Frank, a 24-year-old laborer, diagnosed as schizophrenic, who went from agony and panic to calm indifference as the surgeons cut their way through his brain. According to their book:
"Doctor: How do you feel?
Frank: I don't feel anything but they're cutting me now.
D.: You wanted it?
F.: Yes but i didn't think you'd do it awake. Oh gee whiz, I'm dying. Oh doctor. Please stop. Oh God, I'm goin' again, Oh, oh, oh, Ow, (Chisel.) Oh, this is awful. Ow (He grabs my hand and sinks his nails into it.) Oh God, I'm going, please stop."
By 45 minutes later, Frank was a different person:
"Doctor: What's happened to your fear?
D.: Why were you afraid?
F.: I don't know.
D.: Feel okay?
F.: Yes, I feel pretty good right now."
In their book and in countless psychiatric journals, Freeman and Watts reported positive results from their first series of 623 cases. They reported "good" results in 52 percent of the operations, "fair" in 32 percent and "poor" in 13, with 3 percent having died from the surgery.
But some of their alleged successes proved haunting, Lloyd, 36, unmarried draftsman diagnosed as a paranoid schizophrenic, had his first lobotomy in August 1943. For two days, he appeared better but on the third day, his condition deteriorated. According to "Psychosurgery":
"He lies almost immobile, with a fixed expression on his face, a mixture of dreaminess and perplexity. He can hardly be brought out of it by direct questioning, but whenever this is done he gives voice to the same peculiar ideas that he had before."
Two days later, the doctors lobotomized Lloyd again. It did not help. He was discharged from the hospital but, emotionally crippled, eventually lost his job:
"Four years after the operation, his brother reported that he had lost all sense of time, spending 4 to 6 hours a day washing his hands but nevertheless going around with dirty clothes . . . In November 1948, he was admitted to a state mental hospital."
Still, Freeman and Watts depicted Lloyd as something of a triumph. "Fortunately, except for drinking too much, he presents no aggressive misbehavior," they wrote. "It apparently requires some imagination, as well as some emotional driving force, to bring about misbehavior at the legally reprehensible level and this the patient is incapable of."
Cases such as Lloyd have led subsequent researchers to question Freeman and Watts' findings. Some have argued that the two doctors, and the other early lobotomists, were more concerned with making mental patients manageable than making them well.
Neuropsychologist Elliot S. Valenstein of the University of Michigan cites the case of a 6-year-old girl, possibly brain damaged, who was hostile to other children, tore her clothes and used toys as weapons. Freeman and watts lobotomized her twice within eight months until they got the result they sought.
"She has not had one temper tantrum since the operation . . . it is a pleasure to dress her now," they report her mother as saying. Their conclusion: "improved."
The 6-year-old girl was not the only child Freeman and his fellow psychosurgeons lobotomized. He reported to a 1948 conference that "children with uncontrollable states of overactivity either of the schizophrenic type or following cerebral injury or infection are benefited [from lobotomy]."
In 1949, Jonathan M. Williams, a neurosurgery instructor at GWU medical school reported to the school's postgraduate course in psychosurgery that his and Freeman's operations on "wild, destructive" children, which he said numbered less than 30, had been followed with "a somewhat mixed result."
Williams cited the case of 9-year-old R.B., a black male who "smashed his toys, struck his parents and other children, tore his clothes and dived through closed windows." After the lobotomy, reported Williams, "the child was docile . . . obedient, though irresponsible. The mother states that she now has on her hands a child of nine years physical growth but of only three years mental growth."
Williams' conclusion: Lobotomy in children is primarily helpful in making the child more easily controlled."
Occasional bad results did not prevent Freeman from promoting lobotomy throughout the United States. Under the motto "Lobotomy gets them home," he toured the country lecturing on the operation and offering demonstration clinics at GWU Hospital.
"He was a great crusader, a good speaker, almost a ham actor," recalls Watts. "He was so good, people would bring their dates to the clinic to hear him lecture."
One agency that seized upon Freeman's work was the Veterans Administration. Faced with an influx of shell-shocked World War II GIs that flooded its mental wards, the VA issued a directive in 1943 requesting its neurosurgeons to study and use the Freeman and Watts lobotomy technique. By 1951, nearly 3,000 lobotomies had been performed at VA hospitals, according to agency records.
"There are a number of patients now functioning well who wouldn't have been without the operation," says John Ewalt, the current VA director of psychiarty, who notes the agency now has an elaborate set of review procedures that have effectively put a stop to psychosurgery at VA facilities.
Others were not as impressed as the VA. Flushed with success from his first lobotomy series, Freeman in 1937 proposed to William Alanson White, superintendent of St. Elizabeths, that he be allowed to lobotomize the hospital's more difficult mental cases. White's reply, according to Freeman: "It will be a hell of a long time before I let you operate on any of my patients."
But seven years later, after White's death, Freeman and Watts performed lobotomies at St. Elizabeths. They later estimated they did between 45 and 50 operations there.
Freeman and Watts at times appeared all to sanguine about the personality changes their surgery caused. While they conceded that lobotomy "smashes the fantasy life and ruins creative capacity in doing so," they argued that because the other choice was "total disintegration of the personality . . . if creative artistry has to be sacrificed in the process, it is perhaps just as well to have a taxpayer in the lower brackets as a result."
Nonetheless, the restless Freeman eventually soured on the standard lobotomy he and Watts had perfected. He disliked its occasional side effects, such as epileptic convulsions, and the sometimes drastic deadening of personality it caused. More important, it was too slow and expensive a procedure ever to be applied to the masses of people warehoused in state mental institutions.
By 1946, Freeman believed he had found a better alternative -- transorbital lobotomy.
First attempted by a surgeon in Italy in 1937, the transorbital technique scrapped the elaborate drill holes through the skullbone for a simpler entry by a quick thrust of an ice pick-like instrument through the skull's eye cavities. The cut made on the frontal lobe was quicker and less drastic and, Freeman believed, less likely to produce the vegetative side effects of the standard method.
Best of all, according to Freeman, transorbital lobotomy was "safe" to entrust to the psychiatrist" without surgical training. It was thus perfect for the nation's overcrowded and underfunded mental wards.
"One method may require a full day's work by a surgical team to treat a single patient," Freeman wrote in 1959. "Another can be applied to as many as 50 patients in the same period of time."
The "ice Pick" lobotomy gained quick acceptance, especially in the South and Southwest where neurosurgeons were scarce. According to figures compiled by the National Institute of Mental Health, by 199 about one-third of the 5,000 lobotomies performed were transorbitals. In Texas, Oklahoma, Arkansas and Louisiana, the figure was 90 percent.
Freeman spread the gospel of the transorbital lobotomy throughout the country. By 1952, he estimated he had performed 1,100 transorbitals in at least 15 states. But he lost his longtime colleague Watts, who strongly believed the operation should only be done by a qualified surgeon.
"Any procedure involving the cutting of the brain tissue is a major operation and should remain in the hands of the neurological surgeon," Watts wrote. In a recent interview, he added, "I just didn't think somebody could spent a week with us and go home and do lobotomies."
There was another major disagreement over how soon patients should be lobotomized. Watts argued brain surgery should be used only as a last resort on patients for whom other therapies had failed. At first Freeman agreed, but he gradually developed a theory that the longer and more chronic the mental illness, the less successful the lobotomy. He began to push for earlier operations.
"Lobotomy should be considered in a mental patient who fails to improve after six months of conservative therapy," he told a gathering doctors in Richmond in 1951.
Freeman's enthusiasm for the transorbital technique reached the point, Watts recalled, where he learned his partner was performing the operations in the office that they shared on R Street in Washington.
"I knew it was going on because the secretaries told me," says Watts, who around 1959 broke off the partnership in what was an amicable split. While Watts continued to quietly practice and teach neurosurgery. Freeman continued his lobotomy crusade alone.
In the end, the lobotomy era subsided not because of the objections of doctors outraged at abuses, but because a new medical breakthrough -- tranquilizers -- rose to replace it. By the late 1950s, lobotomies entered what Freemam himself called "limbo."
By then, the doctor had retired to California where three of his children lived. He still wrote and dreamed of the day when lobotomies would make their comeback. By the late 1960s, when it appeared the tranquilizer revolution was less that a total success, new and more sophisticated forms of psychosurgery began to emerge. But they faced vehement opposition, in large part a legacy of the excesses of the lobotomy era.
Watts still strongly believes in the work he and Freeman did. He says he and Freeman were highly selective in their patients in their years together, doing only those with absolutely no hope of recovery. As proof, Watts notes he was sued only once, a case he settled out of court for $2,500.
"We were damn careful," says Watts. "I don't think we would have survived if we weren't."
Watts laments present-day restrictions that he says make it nearly impossible to attempt psychosurgery. He recalls seeing a prospective patient a few weeks ago, a woman in her 60s, who reminded him strongly of the first patient he and Freeman lobotomized. He found himself wishing he could operate on her.
"She'd suffered from breakdowns for 13 years, was in the same kind of agitated depression," he says. "That's a miserable way to have to live. I knew I could have helped her, relieved her, I think, permanently."