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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Decent LifeA Delicate BalanceA Fragile LifeA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Mirror Is for ReflectionA Mirror Is for ReflectionA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Tapestry of ValuesA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst MarriageAgainst 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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
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
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
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).