Blood and Guts: A History of Surgery

CHAPTER 5. OF THE SOUL

THE MAN WHO SHOULD HAVE DIED

Vermont, 13 September 1848


The navvies said that Phineas Gage was the best foreman they'd ever had. The twenty-five-year-old was fair and honest, a good worker and a fine leader. He was employed on the Rutland & Burlington Railroad. The promoters of the railroad hoped it would soon make them rich: winding through the wooded hills of New England, it would link Vermont to the cities of the east coast, bringing trade and creating new markets for the state's agricultural and mineral wealth. It was a fine enterprise indeed, and one well suited to an industrious and practical worker such as Gage.

Gage's work gang had been toiling since early morning near the town of Cavendish. They were building the roadbed – clearing and levelling the land in preparation for the rails. The plans called for a deep cutting, which had to be blasted through the granite hillside. When it was finished, rock would dwarf the trains as they rounded the sharp bend in the track. It would be a proud moment, thought Gage, when the first steam engine – wheels pounding, head lamp blazing – rolled along the track into town. For that to happen there was still much work to do. Gage would make sure it was done, on time and to the highest standards.

As foreman, Gage was highly skilled in the use of explosives, but it was a tricky and dangerous job. First his men would drill a hole in the rock – using a manual drill on solid granite was not an easy task. Gage made sure that the hole was carefully positioned so that the natural fractures in the rock could be used to maximize the effects of the explosion. Next he lowered a measured amount of gunpowder into the shaft and inserted a fuse. He tamped the powder gently with his tamping iron before adding a layer of sand. The sand helped confine the explosion to a small space, focusing the charge into the rock rather than back up through the hole, which was simply a waste of good gunpowder. Finally, Gage tamped the sand good and hard, lit the fuse and stood well back. It was a job he did every day.

Gage was so practised with explosives that he even had his own custom-made tamping iron. The three foot seven inch-long iron bar was an inch and a quarter in diameter. The bar was round, flat at one end – the end he used to pack the explosives and sand – and tapered to a point at the other. It was more than a crowbar; it was styled almost like a javelin. A fine iron bar for an iron-willed man. An unfortunate description given what was about to occur.

It was half past four. They were nearing the end of another hard day and Gage could not wait to get back to the inn where he was staying. Most of his men were looking forward to an evening drink, but Gage rarely touched alcohol himself. They were loading lumps of rock on to a flat car as Gage prepared to blast another section from the hillside.

He lowers the string of the fuse into the hole and pours in the gunpowder. He begins to tap the powder gently with his iron. Distracted by the work going on behind him, he leans forward over the hole. Perhaps he forgets that the sand hasn't yet been poured, or perhaps he slips. But when he tamps the iron again, it goes in too hard and catches on the granite. It ignites a spark.

The gunpowder explodes.

The iron rod shoots out of the hole like a bullet from a gun. It goes straight through Gage's cheek, passes through the floor of his left eye into the front of his brain and tears out of the top of his head. His skull is splayed apart as the iron continues its journey upwards, eventually returning to earth some eighty feet away, smeared with blood and bits of brain. Some of Gage's brain is later found splattered across the rocks where the rod landed.*

* The men who found the iron reported that it was 'covered with blood and brains'. They washed it in a nearby brook, but it still had a 'greasy' appearance and was 'greasy to the touch'.

Gage was knocked on to his back by the force of the explosion. His men ran across to find him twitching on the ground. A few moments later he spoke. Then, to everyone's astonishment, he got up and started to walk towards the road. He was helped on to an ox cart and driven the three-quarters of a mile into the centre of town. When he arrived at the tavern of Joseph Adams, where he was lodging, he walked with only a little assistance and sat in a chair on the veranda. He chatted with some of the men who gathered around and answered questions about his injury. Gage had rarely missed a day's work in his life and said he was keen to get back to the railroad.

When Dr Edward Williams arrived at around five o'clock he could not believe what he seeing. It made no sense – how could this man possibly be alive? Gage remained perfectly lucid, insisting that the bar did indeed pass right through his head. One of the labourers corroborated the story: 'Sure it was so, sir, for the bar is lying in the road below, all blood and brains.'

Despite the burn marks on Gage's cheek, the copious amounts of blood dribbling down the poor man's face and the fragments of bone sticking from his head, Williams was still unable to accept what had happened. It wasn't until Gage started vomiting a large quantity of blood and, as Williams noted, 'about half a teacupful of the brain, which fell upon the floor' that the doctor finally came round to the idea that Gage had survived the firing of an inch and a quarter-wide tamping iron through his head.

Williams was completely flummoxed by the case, and seemed reluctant to administer any treatment. So an hour later, when Dr John Harlow arrived, Gage was still sitting on the veranda answering questions and recounting his dramatic tale; also occasionally vomiting blood, bone and lumps of brain that had dropped through the hole from the top of his head into his mouth. Harlow was impressed with how Gage 'bore his sufferings with the most heroic firmness'. Despite becoming increasingly exhausted from the massive loss of blood, Gage recognized the doctor at once and needed little assistance to make his way up the stairs to his room.

Harlow was much more practical although, unsurprisingly, somewhat taken aback by the mess. 'His person and the bed on which he was laid were literally one gore of blood,' he recalled. However, this didn't stop the doctor passing his fingers completely through the hole. 'I passed in the index finger its whole length, without the least resistance, in the direction of the wound in the cheek, which received the other finger in like manner,' he later reported.

Together the doctors cleaned and dressed Gage's wounds. They shaved his scalp and removed a few bits of bone and a stray piece of brain that was 'hung by a pedicle', as well as bandaging the burns on his hands and arms. Harlow pressed the jigsaw of bones on the top of Gage's skull back into position as best he could and left the man propped up in bed, where his bandages gradually became saturated with blood. A couple of the men volunteered to watch over him.

When Harlow returned at seven the next morning, Gage was still conscious. He had even managed to snatch some sleep during the night. Harlow didn't expect him to live for much longer, and the undertaker was called so that Gage could be measured for his coffin. It seemed the prudent thing to do. As the undertaker took his measurements, Gage's mother arrived to say her last goodbyes.

By 15 September Gage's condition had indeed deteriorated. He was passing in and out of consciousness, he was delirious and incoherent. On the 16th Harlow replaced the dressings but described 'a fetid sero-purulent discharge, with particles of brain intermingled'. That couldn't be good.

Harlow continued to visit his patient every day, and by the 22nd it seemed that the stubborn (and iron-willed) Gage was finally ready to die. He was hardly sleeping at all; he threw his arms and legs about as if he was trying to get out of bed. His body was hot, his wounds fetid. He even told the doctor, 'I shall not live long so.'

One month later Gage was walking up and down the stairs, even into the street. His wounds were healing rapidly and he was eating well. His bowels were described as 'regular' and he had even stopped vomiting globules of brain. By the end of November all the pain had subsided and Gage told the doctor that he was 'feeling better in every respect'. He could walk, talk and eat. There was only one problem: Gage was no longer Gage.

He described it as a 'queer feeling'. Others said the man had completely changed. The accident had radically transformed his personality. The railroad foreman who had once been described as sober, patient and industrious was now vulgar, impatient and impulsive. Gage was rude, they said, and could suddenly break forth into vile profanity. When he reapplied for his position as foreman his employers said the change in his mind was so marked that they refused to take him on. He was described as childlike in his attitude, but 'with the animal passions of a strong man'.

Gage's accident went beyond mere medical curiosity. When the iron bar tore away part of his brain it revealed the inner workings of the mind. It demonstrated that the brain is not some homogeneous grey pudding, but is made up of different parts doing different things. This is a concept known as localization, and would become vitally important for our understanding of the brain and for the first tentative advances in brain surgery.

Most of our personality, our sense of 'self', is contained behind the forehead, in the frontal lobes of the brain. These were the parts that were blasted away by Gage's tamping iron – the parts sprayed on to the rock or those that he later vomited across the floor. The frontal lobes are where we think and plan things. When the rod ripped through Gage's brain it tore away his personality and made him more impulsive. A century later surgeons would employ smaller rods to do much the same thing.

Gage never did return to the railroad. With his tamping iron as his constant companion, he travelled across New England. He eventually ended up in New York, where for a while it is said he became a sideshow in the famous Barnum's American Museum. For a few cents, punters could see a living man with a hole in his head. Although anyone expecting to see something truly gruesome would have been sorely disappointed. They could see (and perhaps if they were lucky, touch) the tamping iron, but the hole was now healed and there was little to show for Gage's trauma. Instead visitors could listen to Gage as he used another skull to regale his dramatic story.

In December 1848 Harlow's account of the case was printed in the Boston Medical and Surgical Journal. It was greeted with scepticism by the medical establishment, most of whom believed Gage's survival to be completely impossible. Surely Harlow must be mistaken? What would a rural doctor like Harlow know about the anatomy of the brain anyway? However, by 1849 Gage's case had attracted the attention of the new professor of surgery at Harvard Medical School, Henry Jacob Bigelow, who compiled a detailed account of the accident and paraded Gage (and his tamping iron) in front of surgical colleagues, suggesting that this was 'the most remarkable history of injury to the brain which has been recorded'. Thanks to Bigelow, Gage's accident would become a medical sensation and one of the most curious incidents in the whole history of surgery.

In the first days after the explosion it had been reported in the local paper as merely a 'Horrible Accident'. Workers died all the time on the railroad; it was hardly big news. But now, as more and more newspapers heard about the case, Gage's fame spread. He could have made a comfortable living on the medical freak show circuit – travelling around the USA from circus to surgical symposium (they often amounted to the same thing). He would be the nineteenth-century equivalent of a daytime chat show guest.

However, Gage's new impulsive nature took him in a different direction. The new Gage discovered that he enjoyed working with animals and went to work at a livery stable. For a while he cared for horses and drove a stagecoach in Chile. But with his health failing, he returned to the United States in 1859, finding employment on a farm in California. Then, in 1860, the accident that should have killed him finally did.

In February 1860, while ploughing a field, he suffered an epileptic fit. During these final few months of his life he started to suffer more and more fits and convulsions. Doctors did the only thing they knew how – which was to bleed him – but the treatment seemed to have little effect. Phineas Gage finally died in May 1860, twelve years after a three foot seven inch-long iron rod passed through his brain.

Although Harlow's treatment of Gage was exemplary, it is one thing to piece back together a fractured skull or even care for major head injuries such as those sustained by Gage, but it is quite another to open up the head and poke around in the brain – to have a crack at brain surgery. As far as most surgeons were concerned, any attempt to go further than repairing a head injury was to be avoided at all costs. Anaesthetics, advances in anatomy and, later, Joseph Lister's antiseptic operating techniques (see Chapter 1) might have transformed nineteenth-century medicine, but the brain was still a mystery, locked away in the sealed casket of the skull. Few surgeons were prepared to open this casket, and those who did usually came quickly to regret it. The only exception to the unwritten 'no operating on the brain' rule was the ancient practice of trepanning.

Trepanning is arguably the world's oldest surgical practice – although amputation is likely to run it a close second. It involves drilling a hole, from half an inch to two inches across, into the skull. The patient would have had their hair and skin scraped away before the prehistoric equivalent of a surgeon started to bore into their head with a sharpened stone or, later, a crude metal drill.

The practice of trepanning was in widespread use from around 10,000 BC, before the invention of reading or writing. The incredible thing is that archaeologists have found skulls with holes drilled in them all over the world. The evidence suggests that trepanning was being practised by many different peoples in completely different locations. These were communities that were segregated by geography. They had no possible way of contacting each other or, indeed, any knowledge of the others' existence. This implies that either many groups developed trepanning separately, or that the practice was passed down from our earliest human ancestors.

The big question is why? Why on earth would you want to drill a hole in someone's head? There could be any number of reasons, which historians can only guess at. In some civilizations, those who were trepanned also show evidence of head injuries, suggesting that trepanning was used as a treatment. It might also have been used to cure headaches, epilepsy or insanity. Perhaps it allowed demons to escape. There is speculation that it might even have given the recipient magical powers – a window, perhaps, to the gods.*

* You might think you need trepanning like a hole in the head, but it is still practised today. Surgeons have to use drills to access the brain, but there are also alternative therapy groups that recommend trepanning for all sorts of mental health conditions. In 2000, for instance, a British woman decided to do her own DIY brain surgery. Twenty-nine-year-old Heather Perry from Gloucester injected herself with a local anaesthetic before drilling a one-inch holein her own skull. Unfortunately, the drill went in too far, damaging a membrane and requiring emergency medical help. Despite the mishap, she told reporters she had no regrets about the procedure.

Back in the nineteenth century there were three major challenges facing budding brain surgeons: the risk of infection, the danger of haemorrhage and the fact that they had very little idea what each bit of the brain did. The issue of infection applied to any major surgery, but infection from operations was gradually being defeated as Lister's reforms were adopted. As for controlling blood loss, this was still a significant problem. The brain has more than four hundred miles of blood vessels and consumes nearly two pints of blood every minute. The scalp, brain and bone are all extremely bloody, so cutting into the skin, skull and membranes surrounding the brain means there is a good chance of a patient bleeding to death on the operating table.

As for understanding how the brain works and the functions of its different areas, these are things that scientists are still grappling with today. Phineas Gage gave surgeons an insight into the role of the frontal lobes, but any sort of accurate map of the mind was still a long way off. All this left surgeons powerless to help people with brain injuries or tumours. Or to find a surgical cure for insanity. Even so, despite limited knowledge and unrefined techniques, some surgeons were still prepared to have a go.

AN OPERATION ON THE BRAIN

Hospital for Epilepsy and Paralysis, London, 1884


Henderson's problems started in about 1880. The Scottish farmer was working in Canada when a piece of timber fell from a house and struck him on the head. The impact knocked him unconscious, but he recovered well and, apart from the occasional headache, returned to health. A year or so later he found that the left side of his mouth had developed a twitch. There was a similar sensation on the left side of his tongue. Within a few months, he was experiencing fits. They began with a 'peculiar feeling in the left side of his face and tongue' before spreading down the left side of his body. They culminated in convulsions and eventually loss of consciousness.

Henderson told the doctors that his symptoms had gradually worsened. He explained how he started to experience the twitching sensation on the left side of his face on a daily basis. The seizures increased in frequency until he was blacking out at least once a month. The twitching spread to his left hand and arm. The limb had weakened until he could no longer move it at all. By August he was unable to use his tools and was forced to give up work. By the autumn the paralysis had spread to his leg. He walked with a noticeable limp. Henderson was admitted to hospital on 3 November, but his condition was deteriorating by the day.

When physician A. Hughes Bennett examined Henderson, the case notes made depressing reading. Bennett had little doubt that a 'fatal termination was not far distant'. Henderson was keeping the rest of the ward awake with his screams; terrible cries from the violent, stabbing pains in his head. The headaches lasted for up to twelve hours at a time. He experienced seizures, attacks of sporadic twitching, violent tremors and uncontrollable vomiting. Bennett prescribed morphine for the pain, but no amount of ice packs or drugs seemed to give poor Henderson any relief. The situation was desperate; a 'fatal termination' seemed inevitable. But Bennett had one final trick up his sleeve.

There was no outward sign on Henderson's skull where the problem might be. Nevertheless, Bennett had studied localization and, without the aid of imaging equipment (no one had yet invented any), the physician diagnosed that Henderson was suffering from a brain tumour. What's more, he was confident he knew where it was: on the right side of the Scotsman's brain – the part that doctors believed controlled movement in the left side of the body.

Bennett decided that the tumour had to be removed, but as he wasn't a surgeon himself he enlisted the help of Rickman Godlee. A nephew of Lister, Godlee was well versed in the latest antiseptic operating techniques. Together he and Bennett planned the first operation to remove a tumour from a living human brain. The procedure would take place on 25 November 1884.

The operating theatre was prepared in the strictest accordance with Lister's methods. The instruments were soaked in carbolic; so too were the bandages and the surgeon's hands. Henderson was carried from the ward and laid out on the operating table, his head propped up on a wooden block. When everyone was ready, a gauze containing chloroform was placed over the patient's face. He was instructed to take deep breaths and gradually slipped into unconsciousness. An assistant started up the carbolic pump and soon a fine mist of antiseptic acid engulfed the area around the patient. They were ready to start.

To work out where to cut, Bennett had drawn a series of lines across Henderson's scalp. It was similar to using triangulation to obtain the position of a location on a map. He had tried to estimate where in his patient's brain the tumour was most likely to be. There were four lines in total and X marked the spot. Bennett indicated to Godlee where to make the first hole.

The drill squeals as Godlee cranks the handle and the bit grinds through the skull, becoming clogged with skin and fragments of bone. He makes sure to apply enough pressure to create the hole, but not too much in case the tool suddenly plunges inwards and gouges the brain. Godlee carefully removes an inch-wide circle of scalp and peers into the hole. An assistant holds an oil lamp over Henderson's head so that they can all get a better look. So far, so good. The outer membranes covering the brain – the meninges – look normal, but when Godlee sticks his knife through them, the brain pulsating beneath appears to bulge.

The doctors decide to proceed with the next hole. Godlee pushes the drill against the skull so that it is slightly overlapping the first hole, and begins to turn the handle. When he has finished drilling, he takes a hammer and chisel and starts to chip away at the jagged corner between the two holes. They can see more of the brain, but, after a quick discussion, they decide to make a third hole. Once Godlee has finished it off with the chisel, they are left with a triangular aperture in the man's head.

Working slowly, Godlee starts to slice through the first layer of the membrane – the dura. He is careful to avoid a large blood vessel. When he lifts the surface of the membrane he can clearly see a transparent solid globule of tissue underneath. He has found the tumour – exactly where Bennett had predicted. Pulling apart the membrane a little further, he is able to wedge a narrow steel spatula between the tumour and the surrounding brain tissue. He slips his finger underneath to try to pull the mass free. He pulls too hard because the upper part of the tumour breaks open.

The operation is getting messy. Blood is oozing out over everything. As soon as Godlee mops it up with a sponge, the triangular opening in Henderson's head wells up again. Struggling to see what he is doing, the surgeon dips in a spoon and begins to scrape away at the remains of the tumour, trying as hard as possible not to remove too much healthy brain in the process. Removing the tumour leaves a hole around one and a half inches deep or, as Bennett puts it, 'a size into which a pigeon's egg would fit'. Later, when they have cleaned it up, they will find the tumour to be 'about the size of a walnut'.

Hands covered in blood, everything else now totally soaked in stinging carbolic from the spray, Godlee starts to close the wound. To do this he employs another recent surgical innovation (a variation of which is still used today): an electrocautery. This is an advance on the old-fashioned cauterizing iron, which has done so much damage during amputations (see Chapter 1). Godlee inserts an electrode into the wound and holds it against the bloody tissue as his assistant throws a switch. The flesh sizzles and the bleeding slows. Satisfied, Godlee stitches together the dura, slipping in a rubber tube to drain any excess fluid, and dresses the wound in gauze. A mixture of blood and spinal fluid drizzles from the tube.

The whole operation has taken two hours. Henderson has remained unconscious throughout, but when he awakes he seems to have suffered no ill effects. Better still, the pain in his head, the convulsions and the twitches have all disappeared. His left side is still partially paralysed, but this is only to be expected. It looks as if Bennett and Godlee have done it. Henderson is cured.

Unfortunately, Henderson did not live long enough to appreciate this remarkable new surgical treatment. Despite Godlee's best efforts, the wound somehow became infected. Bennett speculated that this might have been as a result of the cauterizing apparatus or the sponges (or it could have been because the surgeons had not worn masks or gloves), but once the infection had taken hold, there was little the doctors could do. One month after the operation Henderson, like so many experimental patients in the history of surgery, was dead.

Whether an operation that ultimately leads to the patient's death can be described as successful is debatable. Bennett and Godlee's achievement was nevertheless considerable. They had done everything they could think of to prevent infection, and the technology they used – from the chloroform anaesthetic to the carbolic spray and electrocautery – was Victorian state-of-the-art. Bennett had accurately diagnosed a brain tumour, had identified exactly where it would be, and Godlee had managed to remove it successfully without the patient dying on the operating table. Given that without the operation Henderson would certainly have died in terrible pain, Bennett and Godlee were probably right, on balance, to go ahead and deserved the acclaim they received.* They had made a major advance in neurosurgery, proving that it was possible to open the sealed casket of the skull and operate on the brain. Now it seemed that every other surgeon wanted to have a go.

* Of course, as it turned out, Henderson did die in terrible pain, only it was from meningitis rather than a brain tumour.

Over the next twenty years, thousands of operations were carried out on the brain. In the United States alone more than five hundred surgeons attempted brain surgery between 1886 and 1896. These were all general surgeons who applied the same techniques to excising a brain tumour as they might to removing a diseased appendix. Like Bennett and Godlee, they would categorize operations as successes even though their patients subsequently died. The surgeons consoled themselves with the knowledge that their patients would have died anyway; but this didn't stop them pocketing a healthy fee for the operation.

In 1889 the German surgeon Ernst von Bergmann compiled a review of the mortality rates from brain operations. His study made depressing reading. On average, half the patients undergoing brain surgery died. Some bled to death on the operating table after surgeons accidentally severed a major blood vessel, sending a shower of blood spurting from the wound. Other surgeons managed to remove tumours successfully only to find that they couldn't shove the brain back in again. Lobes of brain tissue would bulge accusingly through the hole in the patient's head. Struggling to force it back in, they would find they could no longer draw together the flaps of dura or get the skull back on. It was like trying to close the lid of an overfilled suitcase, and would almost have appeared comical had it not invariably ended with the patient's death.

If the surgical procedures themselves left a lot to be desired, so did the diagnosis and aftercare. Bennett had got the position of Henderson's tumour absolutely spot on, but other surgeons were not so lucky. The anatomy of the brain was only broadly understood. Surgeons would anaesthetize the patient, drill into their skull and cut into the membranes only to find a perfectly healthy brain underneath – thereby incurring all the risks of surgery without any hope of success.

One of the greatest killers, however, was infection – a problem that had been overcome in most general surgery. Time and again surgeons would operate, remove a tumour and successfully close the wound, only to have the patient die from infection a few weeks later. Even those who, like Bennett and Godlee, employed the very latest antiseptic techniques still seemed to come unstuck at this final hurdle. Soon even the most gung-ho surgeons decided that brain surgery was more trouble than it was worth and gave up neurosurgery altogether. The mortality rate was doing nothing for their reputation. Brain surgery remained in the Dark Ages. It desperately needed someone to make it safe.

THE MAN WITH ONE THOUSAND BRAINS

Peter Bent Brigham Hospital, Boston, 1931


Harvey Cushing was a god among surgeons. And he would often behave like one. Worshipped and feared in equal measure, his patients adored him while his assistants were terrified of him. Cushing was cold to his family and a bully to his friends, but a model of care and tenderness with his patients. Colleagues described him as hard and selfish. He was so focused on his work that when he was told his son had died in a car accident, he carried on with a scheduled operation anyway. When it came to brain surgery, Cushing was a miracle worker – the first true neurosurgeon.

A Cushing operation was an intense affair that could last for anything up to eight hours. He sometimes had another surgeon perform the opening of the skull and the closure at the end, but there was no doubt as to who was in charge. Cushing sat on a stool beside the operating table so that he was level with the patient's head. He worked slowly, methodically, pedantically. Every blood vessel was clamped off until the hole in the patient's scalp was surrounded by dozens of scissor-like clamps. He inserted smaller wire clips and painstakingly cut, scraped and cauterized as he removed tumours. In some cases these growths were massive – a witness reported one to be as 'big as an orange'.

Cushing was a tyrant in the operating theatre. He cursed his assistants if they failed to second-guess his every move, and barked at nurses if the right instrument wasn't placed in his gloved hand. He ordered surgeons out of the room if he thought they were being clumsy, and belittled his colleagues – usually in their presence. He demanded the same high standards from his staff that he expected from himself. But his results were exceptional. Only around one in ten of his patients died. Given that many were seriously ill and that antibiotics had not yet been invented, it was an impressive record.

On 15 April 1931 Cushing carried out his two thousandth tumour operation. His patient was thirty-one-year-old Ida Herskowitz. She had been suffering from debilitating headaches and was rapidly losing her sight. It wasn't a particularly complex operation (in relative terms), and the surgeon managed to remove a tumour successfully and restore Herskowitz's vision.*

* Ida Herskowitz was still alive thirty years later. Even though Cushing sometimes treated his staff abysmally, they were immensely loyal, and on completion of this landmark operation they presented him with a silver cigarette case and an elaborate celebratory cake.

Cushing had first become interested in operating on the brain when he was qualifying as a surgeon in the late 1890s. Despite the terrifying mortality rates associated with brain surgery, he decided that neurosurgery was going to be the next great surgical revolution, and he wanted to be part of it. Indeed, not only part of it – he wanted to lead it. With single-minded determination, he achieved his goal within a few years, and by the 1930s was at the height of his powers. Most of his innovations were relatively small, but together they made brain surgery effective and a good deal safer.

One of Bennett and Godlee's biggest problems had been the amount of blood that sloshed around as they were working. Cushing's first goal was to work out a way of stemming blood flow during an operation. He wanted to see what he was doing while preventing his patients from bleeding to death. His answer was to make small clips from pieces of household wire and clamp them across arteries and veins. He also adapted a pneumatic cuff, originally designed for measuring blood pressure, to act as a tourniquet and reduce blood flow to the scalp.

Cushing was quick to adopt new technology. He was one of the first surgeons to use X-rays for diagnosis, and pioneered the use of an 'electric scalpel'. This device was an advance on the primitive electrocautery probe used by Godlee and Bennett, and allowed the surgeon to cut and seal tissue at the same time. Unfortunately, the electric scalpel could also burn and shock – both the staff and patient – and in one case sent a patient jumping, in the words of a witness 'like a frog', almost off the operating table. Still, when it worked the electric scalpel was a major improvement for controlling bleeding, and particularly useful for excising tumours.

The risk of infection remained a major concern for surgeons, and Cushing operated in conditions of the strictest cleanliness. Everyone in the theatre wore masks and the surgeon operated with gloves. He also appreciated the importance of aftercare. Following operations, patients were nursed around the clock by staff specially trained in dealing with neurosurgery cases. Sometimes patients were even kept in the operating theatre to keep the risk of infection to a minimum. This post-operative treatment was the forerunner of the intensive care units found in modern hospitals.

If Cushing gave every appearance of remaining emotionally detached from his family and colleagues, quite the opposite was true when it came to his patients. It is said the only time he talked of his son's death with any emotion was when he was comforting the parents of a dead child. There is a picture of him holding the hand of a man suffering from acromegaly, a condition caused by an overproduction of growth hormone from the pituitary gland, which results in an abnormal increase in height. Another touching photograph shows him holding a cuddly toy at the bedside of a poorly child whose head is swathed in bandages.

Cushing could not bear to let a patient die, and would do anything he could to help them. Patients spoke of how gentle and kind he was, and told of his sympathy and understanding. Unlike some of the other god-like surgeons around at the time (and since), he was not above helping to clean a patient or deal with their bedpan. And in return for this great care and his undoubted surgical skills, his patients bequeathed him their brains.

The Cushing Tumour Registry comprises a unique collection of photographs, notes, hospital records and brains. Lots and lots of brains. There are around one thousand of them in the Yale archives, collected over more than thirty years. They are arranged on shelves like jars of sweets. Each jar, labelled with details of the case, contains the disembodied brain of one of Cushing's patients. Each one is preserved in fluid, its folds and ridges helping to form a unique record of brain disease.

Cushing's legacy is represented by these jars, but is preserved by the techniques he developed – techniques that are still being used today. He helped train a new generation of neurosurgeons and his work led to future advances in neurosurgery. More than anyone, Cushing made modern brain surgery possible. Now surgeons could operate on brains with every confidence that their patients would survive.

Unfortunately, while Cushing was pushing forward the barriers of modern medicine, others seemed hell-bent on returning it to the Dark Ages.

WALTER FREEMAN, LOBOTOMIST

Washington DC, 1936


There were many reasons why Walter Freeman did what he did. The reasons were lying in the squalid wards of the mental hospitals, staring at the walls, screaming or moaning. The reasons were shouting at invisible demons or lying curled up in the corner of a rubber-walled cell. The patients of mental hospitals were Freeman's reasons; people with no hope.

In 1924, when Walter Freeman was first appointed as laboratory director at St Elizabeths Hospital in Washington DC, he was shocked by what he saw. When he strode through the overcrowded wards of the vast institution he felt a mixture of fear, disgust and shame. Fear of the patients who crowded around him, disgust at the excrement smeared on the walls, and shame that the doctors were powerless to do anything to help these poor people.

Psychiatric hospitals were known as snake pits. They were ware-houses where society dumped the mentally ill; locked people away – often for years, sometimes for a lifetime. They were places of horror and hopelessness. Wards were packed with beds, with hardly any space to move between them. The sheets would be soiled, many of the patients ignored. There were too few staff, and many of those acted more like prison warders than hospital carers.

As he walked through the wards, past the padded cells and through the heavy steel doors, Freeman saw things that would make a lasting impression on anyone. There were young men squirming on the floor, their hands tied so that they could no longer claw at their skin. He saw patients being force-fed, their jaws clamped open by burly orderlies. Some patients would suddenly become violent and abusive, only to be dragged off to a cell. Others would be sitting, just sitting, staring into nothingness, as if their brain had simply shut down.

Although St Elizabeths was one of America's largest mental institutions, it was typical of others around the world. Admissions to psychiatric hospitals were growing by some 80 per cent each year, but the worst thing was that they could offer little in the way of treatment. For the most part, the best the staff could do was keep the patients alive. Those who attempted suicide were restrained or constantly monitored. The only hope was that the mentally ill would recover spontaneously after their period of 'rest' in the hospital. For most patients the stay in hospital had the opposite effect and their condition simply deteriorated.

By the 1940s what treatments there were relied on shocking the brain back to health – sometimes quite literally. Doctors would overdose their schizophrenic patients with injections of insulin to induce convulsions. Others preferred to use a drug called Metrazol to induce seizures. Metrazol convulsions were so violent that patients were contorted in agony, and many suffered fractures to their spine. Patients begged doctors not to put them through this torture but, as some doctors reported that the seizures were resulting in dramatic cures, their pleas usually fell on deaf ears.

The most controversial of all the shock therapies was ECT – electroconvulsive shock therapy. Invented by an Italian who had seen electric shocks used to stun pigs prior to slaughter, it appealed to psychiatrists because it was quick, cheap and easy to use, and was much more controllable than Metrazol. The other advantage of ECT was that it could be used to control the behaviour of patients. There is plenty of good evidence that ECT is effective at treating mental illness, and it is still used today under controlled conditions and with the full consent of the patient. However, in the 1940s, as ECT spread to hospitals across the world, it was quickly adopted as a way of keeping patients subdued.

The procedure was simple enough. Patients would be held down on a bed while electrodes were placed on either side of their head. Some ECT machines employed a Y-shaped electrode, like a catapult, that could be held by the doctor. When the current was turned on the electricity induced a seizure, leaving the victim passive and quiet. Aggressive patients could be given several shocks a day to keep them under control. Patients would be threatened with ECT if they did not behave.

This is the world Dr Walter Freeman was working in – a world he was determined to change. The theory of localization was now widely accepted and Freeman was convinced that mental illness was a result of a physical defect in the brain. It was a view backed by the apparent effectiveness of shock therapies. But rather than fire jolts of electricity through the brain, he wanted to change the whole way it was wired up.

Freeman was determined to get to the root cause of mental illness. In his laboratory he worked tirelessly, examining thousands of brains – slicing them, dissecting them. Day and night he measured the brains of dead mental patients and compared them with 'healthy' brains. Freeman was becoming an expert in brain anatomy, but however much he sliced, diced, measured and dissected, he could find nothing to distinguish the brain of a severely mentally ill patient from the brain of anyone else. It seemed like he had reached a dead end. He had wasted years of his life in pursuit of a physical defect that didn't exist. Then he came across the work of Portuguese surgeon Egas Moniz.

In 1935 Moniz had carried out a radical new operation. He called it a leucotomy. The procedure involved drilling several holes in the front of the patient's skull above the frontal lobes of the brain. Moniz then inserted an instrument he had devised, known as a leucotome. The device acted like an apple corer. When the surgeon pressed down on a plunger and rotated the leucotome, he could extract a brain core one centimetre wide. Usually, he would take about four cores of brain during an operation. Moniz could claim, with some justification, that around one-third of his operations were successful. He never came up with a scientific explanation for why leucotomies worked, but said they made his patients calmer and less agitated; they removed many of the symptoms of anxiety and psychosis. He believed the procedure had no effect on the intelligence of the patients and that it enabled them to lead normal lives once again.*

* In 1949 Moniz received a Nobel prize for his 'discovery of the therapeutic value of leucotomy in certain psychoses'. There have been campaigns to have the prize posthumously taken away from him.

When Freeman learnt of Moniz's research he became wild with excitement. Moniz had proved what Freeman believed all along: surgery was the answer. Freeman became convinced that many types of mental illness were caused by the connections between the thalamus – a small structure deep in the brain – and the frontal lobe. The thalamus, he believed, was the seat of human emotions. If he could only sever the connections in the front of the brain, it would dampen down all these terrible emotions and his patients would be cured.

Freeman became the Portuguese surgeon's biggest fan. He decided that he would adopt Moniz's operation and make it his. He could finally help the patients of St Elizabeths. It could make him famous – his name would be cited alongside other great medical pioneers. He could imagine it now: Walter Freeman – the inventor of the lobotomy.

But Freeman had a problem: he was not a surgeon. So he enlisted the assistance of someone who was – a young neurosurgeon named James Watts. Together they planned the first of Freeman's new lobotomy operations on sixty-three-year-old Alice Hammatt. The woman had been suffering from depression, anxiety and insomnia. She was sometimes suicidal, invariably agitated. Without treatment she would end up being admitted to a mental institution, where she would undoubtedly spend the rest of her life. To Freeman she seemed like the ideal patient. On 14 September 1936 in an operating theatre at George Washington University Hospital in Washington DC, Hammatt was put to sleep.

With Freeman directing the operation from a stool a few feet away, Watts cautiously cut three incisions into Hammatt's shaved scalp. Next he drilled a hole on both sides of her skull – above her ears and behind her forehead – and stuck the leucotome into the left-hand hole. Watts pressed the plunger on the instrument and cut the first core of brain tissue. It was like cutting through butter. Leaning closer, Freeman instructed Watts to take more cores. Eventually, under Freeman's guidance, Watts took a total of twelve cores from the two holes. It was not a particularly precise procedure. At one point Watts managed to get a blood vessel caught in the instrument and blood gurgled from the aperture. Still, the patient seemed OK. Nothing to worry about. An hour or so later the world's first lobotomy operation was over.

Hammatt recovered quickly. She seemed alert but much calmer. Her anxiety had disappeared; in fact she had forgotten what had caused all her problems in the first place. Hammatt could read, could name members of her family and, for the first time in months, was sleeping well. Freeman later reported how Hammatt could now manage 'home and household accounts, enjoys people, attends theatre, drives her own car'. It was wonderful. 'Great improvement,' he concludes. Then, a few months after her operation, Hammatt suffered a convulsion. It was probably related to her surgery. She fell, breaking her wrist and, according to Freeman, became 'indolent' and 'sometimes abusive'. Nevertheless, her anxiety never returned and she lived a relatively normal life.

Freeman declared the operation a great success and rushed off to tell his colleagues. When he published the details of the case, his lobotomy operation won mixed reviews. While some considered it a fine idea, others were outraged that such an untested, extreme operation was even being attempted. But Freeman was completely convinced that a surgical breakthrough had been made. Moreover, he knew how to convince others: he would ignore the medical establishment and take his radical new operation straight to the public.

In a typically long-winded headline (but with the admirable use of a semicolon) the front page of the New York Times proclaimed: 'Surgery Used on the Soul-Sick; Relief of Obsessions Is Reported'. The article referred to Freeman's new surgical technique as 'psychosurgery' and 'surgery of the soul'. His operation could cut away 'sick parts of the human personality' and transform 'wild animals into gentle creatures'. Out of the twenty patients Freeman had treated, the article said, 15 per cent (three) were 'greatly improved', with a further 50 per cent (ten) of them being 'moderately improved'. The article went on to detail two case histories, including Hammatt's, with only passing mention of two deaths following the procedure and unattributed criticism from some 'leading neurologists'.

The New York Times was not alone in trumpeting this new and exciting operation. It was proclaimed a miracle, an incredible cure and even, according to one gushing news report, 'one of the greatest scientific innovations of this generation'. For the first time in history, here was a doctor who could cure madness; heal the mind with surgery.

As ever with these things, the reality did not quite live up to the hype. Many of Freeman's early patients were soon suffering relapses. His answer was to go back and repeat the operation, gouge out more bits of brain. Other patients were suffering terrible side effects. Following their operations they were acting like children: they had to be retaught how to carry out basic functions (such as using a toilet); they were lacking in energy and self-control. It was what had happened to Phineas Gage. They were not the people they had been before the operation.

Over the next five years Freeman and Watts perfected their technique as they conducted more and more lobotomies. Other surgeons took up the procedure, while Freeman worked his way through an ever-increasing list of patients. Soon he and Watts were conducting operations on conscious patients using local anaesthetic. Freeman would have them count or sing a song so that he could tell what effect the leucotome was having. In one instance he is even said to have asked his patient to recite the Lord's Prayer – an unfortunate choice, given the circumstances.

In 1941 Freeman was approached by Joe Kennedy and asked to operate on his daughter Rosemary – the sister of future President John F. Kennedy. Strictly speaking, Rosemary was a poor candidate for a lobotomy. Quiet and beautiful, there is little evidence that there was anything much wrong with her. She might have been suffering from a learning disability, or perhaps depression. People whispered that she was not quite right in the head, and that would not do for an overachieving Kennedy. Joe Kennedy was very persuasive, so Freeman and Watts agreed to go ahead with the surgery.

The procedure was carried out in secret. Joe Kennedy did not even tell his wife. When Rosemary came round from the anaesthetic, she was a very different person. Slow and emotionless, she was hardly able to move or speak. Although she eventually learnt to walk again, she was left permanently disabled and ended up in a residential institution in Wisconsin. If anyone asked, they were told that Rosemary was suffering from a mental illness. Better than saying she had been lobotomized. Freeman never said a word about the case. It was in his best interests not to publish the details of any high-profile failures.

Despite the odd setback, everything was going well for Freeman, but he was not satisfied. Lobotomy operations were taking too long and the asylums were filling up fast. There was no way he was going to get through all the patients that needed this miracle surgery of the soul. To add to Freeman's frustration, the procedure had to be carried out by a qualified neurosurgeon, but he wanted to do it himself. He needed a way to make it simpler and faster. Up until this point he had always made sure to describe the lobotomy as surgery of 'last resort', but this was about to change.

PRODUCTION-LINE LOBOTOMIES

Washington DC, January 1946


Twenty-nine-year-old Ellen Ionesco arrived at Freeman's office accompanied by her husband and daughter. Freeman was their last hope; otherwise they feared that Ellen would have to be admitted to hospital before she killed herself. Over the past few weeks her condition had worsened. She suffered from terrible depression and would lie in bed for days. She was paranoid, suicidal and lapsed into terrifying bouts of violence. At one point Ellen had even attempted to smother her six-year-old child.

Sunlight streamed through the windows as Freeman examined the patient and carefully explained what he was planning to do. It was clear to him that she needed immediate treatment. Of course, any new procedure had its risks, but Freeman was so kind and reassuring that it did not take long for them to agree. Didn't the doctor always know best? Freeman ushered the patient through to a back room, where the equipment was already laid out and asked Ellen to lie down on the examination couch. The operation would not take long, he told her. Before she knew it she would be on her way home. He asked his secretary to order her a taxi.

Freeman slipped a rubber tube between Ellen's teeth and powered up the ECT machine. He fastened a belt containing electrodes around her head. The ECT machine hummed. He asked Mr Ionesco to help hold down his wife. Freeman flicked the switch. The electrodes crackled as Ellen convulsed on the couch, her jaw locked, her head twisting from side to side. Freeman pushed the switch again until his patient was finally rendered unconscious by the electricity. He was ready to begin.

After draping a cloth beneath her eyes, Freeman pulls back one of Ellen's upper eyelids and picks up an ice pick. It is an ordinary ice pick – the type found in many American homes. It looks like a chisel with a wooden handle, a long shaft and a strong, sharp point. It even has the company's name on the side: the Uline Ice Company.

Holding the upper eyelid in his left hand, with his right he inserts the tip of the ice pick into the top of the eye socket. He is careful not to damage her eyeball as he pushes the ice pick diagonally upwards into her tear duct, following the line of her nose.

Steadying the pick, he reaches for a hammer.

Bang, bang.

There is a crunch as the ice pick punches through the thin transorbital bone at the top of her eye socket. Freeman pushes the pick through the bone and into the frontal lobe of the brain. He wiggles the tool from side to side, slicing through the nerve tissue. He pushes it in further, sweeping it across like the blade of a windscreen wiper. After a couple of minutes, he gives the pick a final twist and yanks it out of Ellen's eye socket.

In less than ten minutes, the operation is over and the patient starts to come round. She is helped from the table but can hardly walk. She is disorientated; the eye Freeman operated on is black and blue. She looks as if she has been beaten up.

A week later, Freeman performs a second lobotomy through her other eye. In future he plans to do both eyes at once. After a few days in bed, Ellen is transformed. She is calm, her crazed mind now at peace. She takes up gardening, works in a shop and eventually trains as a nurse. Ellen Ionesco has her life back.

Freeman called his new procedure the transorbital lobotomy. It was quick and easy. It didn't need an anaesthetist, surgeon or operating theatre. There was no faffing around with antiseptics, masks or gloves. As long as he made sure the ice pick was sterilized, that was good enough. The best thing was that the whole operation was so simple that almost anyone could do it. Freeman was tremendously excited. He would be able to transform the lives of thousands of people with mental illness?he could train other doctors?it would be a new era of psychosurgery for the masses! Just as Henry Ford had invented the production-line car, so Freeman had devised the production-line lobotomy.

Dr Freeman jumped into his camper van and set off across the United States to spread the word. During the next few years he crisscrossed the country performing his transorbital lobotomies. He travelled through Europe; he visited clinics and hospitals, operating on one patient after another. As he became more adept, he began to refine the procedure. He would hold the ice pick in his left hand, even though he was right-handed, drive two ice picks in at once, and even carried out operations with a carpenter's mallet. It was wonderfully easy. On one particularly memorable day Freeman got through twenty-five patients. His operations became performances, as doctors, reporters and the occasional interested bystander watched with horrified fascination.

The sight of an ice pick being pushed into a patient's eye socket was bad enough, but the sounds were, if anything, even more gruesome: the buzz of the ECT followed by the thump of the hammer and the crack of bone, the swishing back and forth of the ice picks and the faint plop as Freeman yanked them out. As each disorientated patient staggered from the table, their black eyes smarting, the doctor could notch up another success.

Freeman was getting through an awful lot of patients. He personally performed around three and a half thousand lobotomies, and trained doctors across the world. In total, it is thought that around one hundred thousand people were lobotomized. The results were mixed. Some, like Ellen Ionesco, returned to their families to lead relatively normal lives; Ellen's daughter speaks of Freeman with affection. Other patients were not so fortunate. Following lobotomy their personalities were irrevocably changed; they became docile, placid, mindless; dead to the world around them. A slip of the ice pick left some patients paralysed after the operation. Some died from complications. But Freeman seemed blind to the failures and oblivious to criticism. By the 1960s his notion that lobotomy was a surgery of 'last resort' – to be performed only on the desperately ill – had gone completely out of the window.

THE CASE OF HOWARD DULLY

California, 1960


It was a child's worst nightmare. Howard Dully's mother died when he was five, and she was replaced by a stepmother, Lou, who never loved him; she didn't seem even to like him. She was intolerant and criticized Howard, punishing him for things he didn't do, treating him differently from his brother.

Howard was no angel. He resented his new mother's presence. He could be moody, disrespectful and argumentative, but then so can most young boys. There was nothing particularly unusual about Howard. He was a perfectly healthy boy.

Howard's father was away for long periods of time, and even when he was around, he appeared oblivious to what was going on. As the years progressed, the relationship between Lou and Howard deteriorated further. The boy was getting into trouble at school; his stepmother would yell or hit him for the most petty of reasons, and the boy would yell back. They were constantly arguing, slowly driving each other up the wall. Howard loathed his impostor of a mother, and Lou was fed up with her stepson. Sooner or later something had to give.

Over the years, Lou had consulted doctors, psychologists and psychiatrists (six psychiatrists in 1960 alone) about Howard. All of them assured her there was nothing wrong with him. His behaviour might sometimes be challenging, but he was perfectly normal. Even Howard's father couldn't see anything wrong. Angry, and increasingly frustrated, Lou was eventually referred to Walter Freeman, who had set up his offices in Los Altos, California. Perhaps he would find something wrong with the boy?

Howard's stepmother had her first meeting with Freeman in October 1960. She went alone. Lou told Freeman about Howard's behaviour. Some of it was true, some of it made up. She explained how when she had first seen Howard she thought he was a 'spastic' because of 'a peculiar gait' (the boy was then five and later turned out to be good at sports). She recounted how Howard didn't play with toys, but was destructive with them (much of the time Howard played on his own, so how would she know?). She told Freeman that Howard hated to wash (he was a boy!), she said he daydreamed and scowled if the TV was tuned to some programme other than one he liked, as if this were some sort of damning indictment. Tellingly, Freeman referred to the notes he made of this first meeting as 'the articles of indictment'.

The doctor's notes ran to several pages. He seemed to accept everything he was being told, including Lou's claim that Howard urinated on his bedroom wall or defecated in his trousers. She would make up anything to convince the doctor that Howard was mentally ill, and it seemed to be working. Freeman noted that the indictment was 'sufficiently impressive' and that Howard was suffering from childhood schizophrenia.

Over the coming days, in the manner of some sort of selfappointed judge, Freeman took 'evidence' from Howard's aunt, the school janitor and finally the boy's father. Much of it contradicted what Lou had said. Howard met Freeman for the first time on 26 October and, like many patients before him, felt relaxed in Freeman's presence. The doctor seemed kind and gentle, willing to listen to what the boy had to say.

Taken together, Freeman's notes paint a picture of an eleven-year-old boy living in a dysfunctional family. Today they would probably be offered counselling, but Freeman had other ideas. He told Howard's father that the boy was schizophrenic and that something needed to be done 'pretty promptly'. He offered to change Howard's personality (for a reasonable fee). The decision to operate was made on 30 November 1960 – the date of Howard's twelfth birthday.

Howard Dully was admitted to a small private hospital in San Jose on Thursday 15 December. The next day he was taken into the operating room, where he was given four jolts of electricity from the ECT machine. Freeman noted that he thought it was 'one more than necessary'. Then the doctor stuck in his 'orbitoclasts' (he had moved on from ice picks to these specially designed instruments) and jiggled them around in Howard's brain. He took a picture of the two orbitoclasts protruding from the boy's head before pulling them out again. A small amount of bloodstained fluid oozed from each bruised eye socket.

When Howard's brother saw him shortly after the operation he thought Howard looked like a zombie. The boy was listless and staring. It was as if a fog had settled across his mind. But gradually Howard started to recover. However, the operation that his stepmother had hoped would make him docile and obedient seemed to have the opposite effect. He became increasingly disruptive until his parents could take it no more. Howard was sent away, first to other people's homes, then, even though he had committed no crime, to a juvenile detention centre. Finally, he ended up in a psychiatric institution, the only child in a hospital full of mentally ill adults.

Howard has spent most of his life coming to terms with what happened to him. He suffered problems with work, relationships and money. He drifted in and out of jobs and in and out of jail. Gradually, he was able to piece his life back together. Today he holds down a job as a bus driver. There is absolutely nothing about him to suggest that he has two black holes in his brain. What saved him from going completely off the rails was probably his youth. Howard's young brain was able to rebuild neural pathways and compensate for the damage Freeman had inflicted.

Dr Freeman operated on a total of nineteen children, including a four-year-old. By the time of Howard Dully's operation in 1960, even as surgery of 'last resort' lobotomy should have been confined to the history books. Drugs were available that did much the same thing only without the danger or permanence of surgery. Some drugs were even marketed as 'chemical lobotomies'. These new treatments should have put Freeman out of a job and saved Howard Dully. They almost did. By the mid-1950s the weight of criticism was piling up and Freeman had fallen out of favour in Washington. This prompted his move to California, where he offered his transorbital lobotomies to all-comers, as a quick fix for neurotic housewives or disruptive children. Somewhere between devising the procedure in the 1930s and practising it on children, Freeman had lost sight of the reasons for developing the lobotomy operation in the first place.

Some have described Freeman as a monster, sometimes in those same newspapers that sang the praises of his 'miracle' surgery in the 1930s. Even his own son, who witnessed the terrifying spectacle of one of Freeman's transorbital lobotomies, described the operation as 'diabolical'. But it is difficult to reconcile the image of a monster with the kind and gentle doctor his patients encountered. When the lobotomy was conceived it seemed to provide the only treatment for chronic mental illness. It certainly transformed some people's lives for the better.

But Freeman's greatest failure of judgement was not knowing when to stop. Nor, to be fair, did anyone step in to stop him. Where, for instance, were the authorities who should have prevented the operation on Howard Dully? The fact that Freeman kept performing transorbital lobotomies when the procedure was discredited and opposed by almost the entire medical establishment makes it difficult to forgive him for what he did to so many people. Rosemary Kennedy, Howard Dully and hundreds of others would have had very different lives were it not for Walter Freeman.

Freeman performed his last transorbital lobotomy in 1967. He was seventy-two. His patient suffered a haemorrhage and died three days later. The hospital where he was operating finally decided that enough was enough and stopped him from performing any further lobotomies. It was the end of his career. The lobotomist had lost his purpose in life. But rather than stay at home, he got back in his camper van and headed off for one final road trip.

Over the next few years he covered some fifty thousand miles, tracking down his former patients. It was as if he were seeking redemption. Perhaps he was beginning to have doubts about his treatments and wanted to prove that he had helped people, had improved his patients' lives. He visited homes and hospitals; he saw people who were very sick and those whose lives had undoubtedly been changed for the better.

Walter Freeman died in 1972. The transorbital lobotomy died with him, but to the end of his life he believed in what he had done, and he believed it was right.

Freeman was not completely misguided. Lobotomies are no longer performed, but psychosurgery – using surgery as a treatment for mental illness – is still practised in hospitals around the world. Once again, it has become a treatment of last resort. Although the lobotomy is undoubtedly one of the most disturbing operations in the entire history of surgery, when it comes to matters of the mind it is by no means the only controversial therapy.

CONTROLLING THE MIND

Córdoba, Spain, 1964


Dr José Delgado was brave. There is no doubt about that. Few scientists would attempt to do what he was about to do. Delgado claimed he knew a little bit about bullfighting, and was also reasonably confident that he knew about the workings of the brain. But combining the two? That was a different thing altogether.

The bull is charging across the ring towards Delgado, its nostrils steaming as it kicks up the dirt in the arena. Bred to be aggressive, it is an awfully big, angry bull, its head bowed down as it charges, its horns hard and sharp. If Delgado gets this wrong, there is a good chance he'll be killed.

Delgado concentrates as he grasps the matador's red cape in his right hand. He stands by a wooden barrier that he can duck behind if the experiment goes wrong, but there is no guarantee he will make it in time. In his left hand he holds what looks like a transistor radio – a small box with a long aerial extending from the top. If anything, Delgado is holding this tighter than the cape.

The bull's hoofs pound. Delgado stands his ground. The bull is getting closer. Delgado remains still. Ten feet, five feet. The bull is almost on top of him. Then Delgado presses a button on the box. The bull stops in its tracks, turns round and wanders away. It is an audacious stunt: a demonstration of the power of technology.

The previous day Delgado had anaesthetized the bull and implanted electrodes in its brain. When he pressed the button on the remote control he had been holding, it sent a signal to a receiver on the bull's head. This stimulated the electrodes deep inside the brain, changing the bull's normally violent behaviour. At the flick of a switch, Delgado had control of a ferocious animal.

By the 1960s, developments in electronics and a better scientific understanding of the workings of the brain were making such impressive demonstrations possible. Delgado used an implant device consisting of a sealed capsule about the size of a small watch. This contained the receiver and all the electronics. Wires emerged from the side of the capsule and these were sunk into particular regions of the brain. Thanks to advances in the understanding of brain anatomy and localization, Delgado could surgically implant the electrodes in specific places to get particular responses.

The doctor's other experiments were equally impressive, although somewhat less dangerous. Implants in the brain of a monkey could be stimulated to control the diameter of the pupil in the animal's eye. When the doctor pushed the button on the remote, the pupil would contract and dilate – it was almost like controlling the aperture of a camera. He could get other monkeys to yawn on demand or even perform a complex sequence of movements. He also experimented on cats. He could induce expressions of rage – an electrical stimulation caused them to hiss and bare their teeth. The cats even learnt to turn off the stimulation by rotating a wheel Delgado had installed in their cages.

It was the experiments on groups of animals that revealed the potential of the technology. Delgado discovered that he could use implants to control aggression in monkeys. He could also get other monkeys to do the controlling. In one demonstration he installed electrodes in the brain of Ali, the boss of a small monkey colony. When Ali's brain was stimulated it inhibited his normally aggressive behaviour. Delgado installed a lever in the experimental cage the monkeys lived in. When the lever was pressed, it activated the electrodes. Soon a passive monkey named Elsa learnt that pressing the lever could stop Ali's aggression. She now had control over Ali. Whenever he threatened her, she pushed the lever and Ali stopped. Elsa had become the boss.

It was one thing to operate on bulls, monkeys or cats, but what would happen if electrodes were implanted in human brains? Could human behaviour be controlled in the same way? Delgado hoped to use the technology to help patients suffering from severe mental illness, epilepsy or chronic pain. Rather than change behaviour by removing bits of the brain as the lobotomists had done (Delgado found the idea of lobotomy abhorrent), he planned to insert his devices in the brain instead.

When he tried the technology on humans the results were astonishing. With receivers attached to people's heads, he found he could stimulate a whole range of human emotions from fear through lust, hilarity and rage. One of his researchers is said to have narrowly avoided serious injury during an experiment conducted on a young woman with epilepsy. She was playing the guitar when the device was activated and promptly flew into a rage, throwing her guitar against the wall.

Soon other doctors were taking up Delgado's work. In 1965 psychiatrist Frank Ervin and neurosurgeon Vernon Mark tried out the technology on a sixty-three-year-old man dying of cancer. The patient was in the most terrible pain, and surgeons had run out of treatment options. Injections of morphine were no longer doing the trick, and what remained of his life was a living hell.

After drilling a series of holes in the man's head, Ervin and Mark inserted electrodes into carefully selected sites in his brain. The electrodes were connected to a plug in the patient's scalp, which led to a 'pain box' – a controller that the man carried in his pocket. When the pain got too much, all he had to do was push a button and the agony would go away. If he kept the switch pressed for more than forty-five minutes, the pain subsided for up to eight hours, allowing him to get a good night's sleep for the first time in months. The only side effect was that the device made him feel a little drunk. But then, the patient figured, if you're dying of cancer, that's not such a bad thing.

Few would argue against helping a dying patient, but the development of devices that could change people's behaviour at the flick of a switch had far more sinister implications. Delgado was well aware of the potential of his technology, but downplayed any suggestions that it might be used by sinister forces to control people's minds. In his 1969 book Physical Control of the Mind he dismissed the idea of an evil dictator standing at a master control centre stimulating the minds of an enslaved people. But then he didn't reckon on the CIA.

In the mid-1950s the US intelligence agency had started toying around with the idea of brainwashing individuals, invariably communists. They had looked at using hypnotism or drugs, and investigated the notion of using lobotomy to control antisocial behaviour. A psychiatrist, Henry Laughlin, had even been dispatched to witness some of Walter Freeman's operations. In his report, Laughlin suggested that lobotomy might be used as a 'neutralizing weapon' to 'quench crusading spirits' or 'zealous and fanatic communists'. If lobotomy could do that, just think what brain implants could do.

Following the Detroit riots in 1967 and subsequent civil unrest in deprived inner-city areas across the United States, Ervin and Mark suggested that brain implants might be used to subdue black rioters. In an article in the prestigious Journal of the American Medical Association they proposed that urban riots and other 'acts of senseless violence' could be prevented by surgery.

In 1972 psychiatrist Robert Heath came up with another idea. Why not use brain implants to 'cure' homosexuality? With a long list of ethically dubious research behind him, Heath conducted an experiment on a gay man. The psychiatrist placed electrodes inside the subject's brain and stimulated them while the man had sex with a female prostitute. The aim of the experiment was to condition the subject to want to have sex with women rather than men.

The backlash against using brain stimulation was swift. Delgado was lumped in with Ervin, Mark and Heath, even though their experiments were nothing to do with him. The rise of the implant in science fiction did nothing to help his cause. More and more conspiracy theorists claimed that the government had secretly implanted chips in their brains, and books such as The Terminal Man (see Further Reading) painted a terrifying portrait of a medical experiment gone wrong. That its author, Michael Crichton, was once one of Ervin's students probably did little to help.*

* The reality was that if the government really wanted to control the population through mind control, they would stick drugs in the drinking water, rather than go through the impractical and messy business of implanting chips.

It looked as though it was the end of the line for the brain implant. The research was discredited, ethical approval for brain stimulation experiments became impossible to obtain, and funding for studies simply fizzled out. However, unlike Freeman's transorbital lobotomies, brain implants still held enormous potential.

STUART'S STORY

London, 2006


Sixty-eight-year-old Stuart Carter felt trapped within his own mind. He could think about moving but his body would not move. He could not smile or laugh or frown or cry. He had lost his sense of balance and could barely stand. When he placed his hand down on a table he could no longer lift it up. His face was an expressionless blank. He was a living statue watching life through a mask.

Carter had Parkinson's disease. This degenerative illness affects nerve cells in the brain that coordinate movement. Whereas many people with Parkinson's have uncontrollable tremors, Carter's body froze. He found that his facial muscles would no longer react to emotion and that his body would lock in a particular position. Sometimes it took him an enormous mental effort to get moving again. He knew that without treatment his condition would only get worse, but the drugs he was taking were no longer working. His mind remained sharp, but his body was gradually shutting down.

In 2006 Carter was offered the chance of having electrodes implanted in his brain. In his case, the technology, known as deep brain stimulation, would act as a jamming device. The implants would block the nerve signals in the sick areas of his brain that were causing him so many problems. The operation was not going to be easy – surgeons needed to implant the devices at the base of the brain, in an area called the basal ganglia. As it would be impossible to cut open Carter's brain, the surgeons at the National Hospital for Neurology and Neurosurgery would be operating 'blind'.

With a brace resembling a medieval torture device clamped to his head, Carter lies on the table in the bright glare of the operating theatre lamps. His head is marked with dots, and a large plastic sheet is stretched across his balding scalp. He stares at the ceiling as the final preparations are being made by the androgynous gowned and masked figures around him. In the twenty-first century lying on an operating table is still a nerve-racking experience, made worse if you know you are going to be conscious when a man you barely know starts drilling holes into your head. An injection of local anaesthetic and surgeon Marwan Hariz is ready to start.

Hariz presses a scalpel into the top of Carter's head, slicing deep to the bone. 'No pain, just noise,' explains the surgeon as he holds an oversized dentist's drill to the incision. A thin trickle of blood and tissue is sucked away with a tube as the drill penetrates deeper. A syringe-like device is clamped over the aperture and a wire implant is lowered into Carter's brain. Hariz guides the implant deep through the folds and ridges of his patient's brain, careful to avoid damage.

'You might feel something and you might feel nothing.' This is the moment of truth. 'Whatever you feel, tell us.' The surgeon presses the button to activate the implants. 'No special sensation?' Carter starts to feel a tingling in his left foot. It's working – Hariz has got the implants in the right place. Carter's brain has been electronically enhanced.

Two years later Stuart Carter can walk, laugh and smile. When he puts his hand down on a table he can pick it up again. He is free from the mental trap that Parkinson's imposed. If you look carefully at the top of his head, you can see two small bumps. You can even follow the path of the wire leading away under his skin and down his neck. It terminates in a flat box beneath his shoulder – the stimulator that sends electrical pulses to his brain.

Today there are tens of thousands of people walking around with brain implants. Some, like Carter, have electrodes deep within the brain to stimulate or block nerve signals. Many others have cochlea implants in their ears to cure deafness. Scientists are developing implants to enhance memory, to help the blind to see, or simply to connect our 'wetware' to computer software. Delgado's vision of using electronic devices in the brain to combat disease and disability is finally being realized.

Advances in brain surgery over the past 150 years have come at tremendous human cost. From patients bleeding to death on the operating table to victims of Freeman's crude lobotomies and brain implants to 'cure' homosexuality, the history of brain surgery is full of examples where surgeons have strayed well beyond the bounds of what is morally or ethically acceptable. It is still difficult to read Freeman's notes on Howard Dully without becoming angry, or contemplate Ervin's and Mark's ideas on mind control without feeling utter revulsion.

THEN AND NOW


If you look back through the history of surgery, there are some remarkable individuals: pioneering surgeons, such as Ambroise Paré, Ignaz Semmelweis and Joseph Lister, who helped make operating safe; surgeons such as Dwight Harken, Walter Lillehei and Harold Gillies – brave men who had the courage to fail; but there is also a third group – surgeons such as Walter Freeman and Alexis Carrel – who seemed to operate in their own peculiar moral universe.

Whether these people were brilliant, courageous or misguided, the history of surgery is full of individuals who were prepared to have a go to see what happens. Sometimes they succeeded, sometimes they failed. Some patients lived, many others died. But even in death, they will have helped future patients to live.

Without the surgeons who stole corpses from gibbets, who cut into beating human hearts, or who first attempted to operate on the human brain, modern surgery – from routine procedures to repair a damaged knee to hi-tech operations to implant a device in the brain – would not have been possible.

Nevertheless, despite all the advances, there are still many things that challenge twenty-first-century surgery: artificial hearts are cumbersome, organs still get rejected, reconstructive surgery cannot always restore a face, a brain tumour can still kill. Even the most minor surgery is not without risk: hospital patients still die of major infections; anaesthetics are not 100 per cent reliable; the knife can still slip.

Most of us know people who have gone into hospital for an operation and never come out. Surgeons are remarkable people but, despite the impression some of them might give, they are not gods. There are good surgeons and bad surgeons, but even the best surgeons are fallible. When we submit to an operation we put an immense amount of trust in those who wield the knife. In most cases our trust is fully justified, but the history of surgery suggests that sometimes it is not.

If you need an operation, just be grateful that you are alive today and not 170 years ago – the next patient on Robert Liston's operating schedule.