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The LobotomistReview - The Lobotomist
A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness
by Jack El-Hai
John Wiley, 2004
Review by S. Nassir Ghaemi, MD MPH
Jul 25th 2005 (Volume 9, Issue 30)

How could a man spend most of his life seeking to cure mental illness by cutting off one lobe of the brain and separating it from others? How could those who proposed this treatment win the Nobel Prize? How could lobotomy go from being mainstream in medicine to being a pariah? What does the history of lobotomy tell us about psychiatry as a profession, and about our attitudes as a society to mental illness?

Jack El-Hai has written a biography that gives insights into these questions. El-Hai is a journalist who has written a very readable and well-researched biography of Walter Freeman, the man most associated with lobotomy.

To read a biography of lobotomy is to wince with almost every page. Yet El-Hai performs a bit of a miracle, making Freeman sympathetic. And he does so while being objective.

 

Walter Freeman was the grandson of a famed American physician, Walter Keen, a surgeon famous for his work in support of antisepsis. His grandson was a neurologist who wanted to be a surgeon, judging on his lifelong wish to operate on the brain.

Freeman's brainchild was of course lobotomy. How he came to propose it and push it all his life is the subject of this book.

Freeman began his career as a neuropathologist, and was initially assigned to St. Elizabeth's Hospital, a mental asylum, in Washington DC. Schizophrenia was of course the "graveyard of the pathologists" and Freeman's career was no exception. But Freeman was convinced there was something wrong in the brain of schizophrenics that was eluding his neuropathological skills.

The breakthrough came in the 1930s, when neurophysiologists doing animal studies observed that severing the frontal lobes led to reduction in aggression. When the physiologist John Fulton presented these findings in a 1935 European conference, attendees included Freeman (newly minted as chairman of the department of neurology at the George Washington University in Washington DC) and the Portugese neurologist Egas Moniz (famed for his work on cerebral angiography). Legend has it that lightbulbs simultaneously went off over the heads of both men, and upon his return to Lisbon, after one practice case on a cadaver, Moniz severed the frontal lobes of a few psychotic patients, with beneficial results. For this he would win the Nobel Prize.

Though it is unfair to be irreverent. At the time, the state of mental illness was horrible. Today we know that perhaps one half or more of the chronically psychotic residents of asyla suffered from neurosyphylis. Penicillin, the most effective psychotropic agent ever invented, would in a decade cure them. Two decades later, many of the remaining psychotics would at least have some symptomatic benefit with chlorpromazine. But all that was in the future. In 1937, all one could say is that for time immemorial, mental illness had never been cured or even improved consistently with any intervention (excepting perhaps the recently developed malaria therapy that led to temporary improvement in some persons).

Freeman wanted to empty the asyla; he felt it was worse to live in the squalor of a mental asylum than to suffer the side effects of frontal lobotomy. Up and down for the ensuing 3 decades, when one examines how Freeman defended himself, that was the bottom line. But, in the presence of useful safer treatments, like antipsychotics, Freeman's argument fell flat. He never came to that recognition, and, in 1935, he did not need to.

When Freeman returned to his swanky private practice office on Wisconsin Avenue in Washington, he began communicating with Moniz and they soon became professional friends. Moniz had conducted his first operation in November 1935, reported the results of his first twenty cases in Paris in March 1936, and began corresponding with Freeman in May 1936. Freeman conducted his first operation in September 1936, and had completed six cases by November (with his neurosurgeon colleague James Watts). Their fifth patient suffered seizures as a result of the operation, but the doctors were undaunted. Only a few weeks after their first case, they presented initial results to the District of Columbia Medical Society; perhaps following the medical dictum of fraternity too closely, little reaction ensued. Soon thereafter in November 1936, they presented their first six cases more formally to the Southern Medical Association meeting in Baltimore. Here they elicited immediate opposition from many psychiatrists present, until the dean of American psychiatry, Adolf Meyer, made his famous intervention: "I am not antagonistic to this work, but find it very interesting... ." he said, as he then went on to simply ask for careful and cautious research. "The work should be in the hands of those who are willing and ready to heed the necessary indications for such a responsible step, and to follow up scrupulously the experience with each case... .At the hands of Dr. Freeman and Dr. Watts I know these conditions will be lived up to." Of course, Meyer was not markedly antagonistic to almost any opinion; he had earlier blessed the work of Henry Cotton, which led to thousands of colectomies and teeth extractions as treatment of psychosis. As the father of American eclecticism, Meyer, unfortunately, could not bring any effective critique to bear on dangerous and unproven methods that would soon get out of hand.

In one way, Meyer's comment was to guide Freeman's work for the rest of his life. Freeman, to his credit, did seek to obtain long-term outcomes and follow-up on most of his patients. Yet his methods were rudimentary, partly just because of the state of clinical research in his era. For instance, the concept of randomization had not yet been developed in clinical medicine (the first randomized clinical trial happened in 1948). Thus, Freeman had no way of understanding that he might be biasing his observations by the selection bias of patients who came to him for treatment. Further, he had no concept of the idea that a comparison group needed to be identical in all respects to the lobotomy group except in the fact of lobotomy (such identity is only produced by randomization). He rarely addressed the issue of any comparison groups at all.

Thus, Freeman made some fundamental scientific errors, most of which he shared with most of his colleagues in his era. Enough of his colleagues realized that his treatment was radical enough, though, as to elicit that ultimate Hippocratic protection against excess in an age of ignorance -- the First Do No Harm maxim. Freeman clearly gave up on this ethical safeguard in medicine. (As the famed neurosurgeon Wilder Penfield once said to Freeman in the early years of lobotomy: "Walter, don't you realize that you're doing a very dangerous thing?"). Freeman justified himself as providing a ray of hope as a treatment of last resort.

Freeman was surprisingly unconcerned about the risks he took. The word cowboy would be an understatement for him. For instance, a strong proponent before lobotomy of convulsion therapy, Freeman administered metrazol convulsion treatment on his own aunt in 1937. He frequently used electroconvulsive therapy in the late 1930s. This was before the use of muscle relaxants, and usually his secretary or a relative would hold down the patient while Freeman administered ECT in his private office. Once, when his secretary declined and the relative was too feeble to help, Freeman still administered the ECT, breaking both legs of the patient. The patient sued and Freeman settled out of court. His 10th lobotomy case also sued him due to hemorrhage during the lobotomy, leading to paralysis, leading to another out of court settlement.

Very soon what began as a treatment of last resort became a treatment of any resort. Again unaware of the concept of selection bias, and not having compared his patients to a similar untreated cohort, Freeman observed that patients who were less ill (with depression and anxiety disorders) responded to lobotomy better than the more ill patients with schizophrenia. Of course, the less ill patients would more likely have responded to anything, or recovered by natural history. But Freeman drew the conclusion that lobotomy needed to be used in less ill patients for best effects. He now expanded his lobotomy work and sought a way of making it more amenable to widespread use outside of the narrow confines of neurosurgery. Freeman really had a vision that the mental asyla would be emptied by thousands and thousands of lobotomies leading to good outcomes. To do so, he had to create a method that would be quick and able to be administered by psychiatrists, not surgeons.

He hit upon the transorbital lobotomy; instead of opening the skull and operating directly on the frontal lobes from above, the new method involved putting ice picks into the eye sockets, entering the skull through the transorbital space, and then severing nervous tissue by moving the razor back and forth. Instead of anesthesia, Freeman would initially administer ECT to make the patient temporarily unconscious. The result, 20 minutes later, was two black eyes and a lobotomy, but no anesthesia and no surgery. (Since patients often did not know truly have informed consent, the black eyes could be a problem: "I usually ask the family to provide the patient with sunglasses rather than explanations," Freeman wrote). Watts strongly resisted this adaptation of the lobotomy procedure, arguing for the rest of his life the original position -- that lobotomy should be a rare treatment of last resort conducted as neurosurgery. Freeman was unstoppable. Once in 1950 after a patient had no-showed three times, Freeman located the man in a motel where the police were holding him after a conflict. Obtaining the brother's consent, Freeman drove there, administered ECT, and performed the transorbital lobotomy in less than 10 minutes. He even got Blue Cross to pay for it!

But Freeman went his own way. He had a robust private practice; patients were referred to him from all over the country and from the powerful in DC. (Rosemary Kennedy was his most famous botched case). He was also a chairman at GWU, a leader of mainstream neurology. He reached the peak of his power in the 1940s. He and Watts published the first book on the topic, Psychosurgery, in 1942 (paying, as was common at the time, to have the book published). The book jacket, written by Freeman, stirred an attitude against which Meyer had warned: "Read the last chapter to find out how those treasured frontal lobes, supposed to be man's most precious possession, can bring him to psychosis and suicide!" Elsewhere: "This work reveals how personality can be cut to measure, sounding a note of hope for those who are afflicted with insanity."

By 1950 Freeman had personally conducted 2400 transorbital lobotomies. Worldwide 50,000 lobotomies had been performed. After World War II, while lobotomy was highly prevalent in the West, Germany and the Soviet Union banned it. The 1949 Nobel Prize spurred interest in it. Freeman himself had nominated Moniz and was somewhat influential in the campaign that led to the award. It is quite ironic that in that same year, the Australian psychiatrist John Cade would discover lithium, a truly effective treatment that to this day continues to be probably the most effective psychotropic medication ever (second to lithium); yet after the Moniz fiasco, the Nobel committee apparently has shied away from giving awards for direct treatment of mental illness, and thus the discoverers of lithium, antipsychotics, and antidepressants have never been duly recognized.

Into the early 1950s, Freeman maintained his rapid pace of lobotomies, traveling all across the country to teach it to others in mental asyla, and making special arrangements with certain states, like West Virginia, where especially high rates of lobotomy were performed. He drove indefatigably: "Since 1954 I have averaged nearly 100 miles a day in driving," he later said. "I put 86, 420 miles on my 1954 car, and turned it in August 1956."

But in 1954, the discovery of chlorpromazine, the first antipsychotic, all but rendered lobotomy useless. With all his efforts, Freeman had managed lobotomies in the tens of thousands. In one year, two million patients had received chlorpromazine in the US. Frank Slaughter's bestselling novel, Daybreak, published in 1958, portrayed the public end of lobotomy: the heroine was due to be lobotomized but was saved by her psychiatrist, who gave her chlorpromazine while falling in love with her. Though apparently not pressured, Freeman decided to give up his academic chairmanship at GWU in 1954 and moved West to California, where he had so many times driven in his long camping trips with his family. He went into private practice in the San Francisco area, but was seen by the 1960s as a quaint outsider, never again to have much influence locally or nationally. He persisted in his long-term follow up of old lobotomy patients, sending thousands of Christmas cards, and driving to empty Appalachian hollows in search of old patients. But his attempts to claim long-term success were never convincing, as psychiatry had moved on, first to psychoanalytic ideas, and then to psychopharmacology, leaving psychosurgery behind as a relic.

In the late 1960s, Freeman himself was a living relic, suffering from rectal cancer, driving ceaselessly in search of vindication. In 1972, a few months before he died, he finished a last paper on the sexual lives of his lobotomy patients.

Freeman himself has not been studied enough; what drove the man to dedicate his life to a tenuous lost cause. El-Hai calls it a "tragic quest to rid the world of mental illness." Tragic it was, but one gets the sense that the quest was less about mental illness, and more about Walter Freeman.

It is noteworthy that Freeman's brother was diagnosed with manic-depressive illness. One gets a sense from Freeman's drivenness and recklessness in his work and his play that perhaps he was not totally free from a manic nature. Here was a man -- to focus briefly on his personal life -- who drove endlessly back and forth across the country, who loved to walk long distances in national parks, who would hike in risky locations (leading to the fall and death of his adolescent son), and who also without much concern engaged in extramarital affairs. There might be individual reasons for each of these characteristics, but persons with manic-depressive illness would tend to do them all. Perhaps Freeman too suffered from that mental illness he sought to eradicate.

Perhaps more importantly, Freeman's main downfall came from his motivations: El-Hai paints a picture which persuasively suggests he was more motivated by fame and prestige than anything else. Mental illness, and mentally ill patients, were the means; but the end seemed to be Freeman himself. This may be fine in business (although even there people expect that high quality goods are produced), or in politics (although even there the fate of nations is more important), but in medicine, where the patient is always supposed to be first and foremost, such extreme ambition is, as Penfield put it, simply dangerous. One does not get the sense that Freeman cared enough for the individual human beings he treated in the name of humanity.

 

El-Hai tries to link Freeman to the success of biological psychiatry today, but it would be better said that the ghost of Freeman hovers over biological psychiatry as an object lesson in the danger of medical hubris -- the danger of unprincipled, uncritical, and aggressive biological intervention in psychiatry. Lobotomy was dangerous. And with such dangerous tools, tools that could have been used for harmful purposes (the CIA considered using lobotomy in the fight against communism), one would have hoped for higher ethical standards. Ultimately, that is where lobotomy, and Freeman, foundered.

 

2005 S. Nassir Ghaemi

 

S. Nassir Ghaemi, MD MPH, Director, Bipolar Disorder Research Program, Emory University Dept of Psychiatry, The Emory Clinic. Author of The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness (Johns Hopkins University Press, 2003).


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