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WALTER FREEMAN'S PSYCHOSURGERY AND BIOLOGICAL PSYCHIATRY: A CAUTIONARY TALE

Rowland, Lewis P. MD

INFOBYTES: BOOK REVIEW

Dr. Rowland, Editor-in-Chief of Neurology Today, is Professor of Neurology at Columbia University Medical Center.

The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness By Jack El-Hai

368 Pages • John Wiley & Sons 2005

“A side from the Nazi doctor Josef Mengele, Walter Freeman ranks as the most scorned physician of the twentieth century.” So begins Jack El-Hai's laudable attempt to balance the pros and cons of Freeman's contributions – “The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness” – not “to vindicate the doctor but to understand him.”

Freeman was the foremost promoter of frontal lobotomy. The operation rapidly found widespread use because state mental hospitals were deplorably unable to do anything more for psychotic people than keeping them off the streets. “Warehousing” was the term and “snake pit” was a common analogy. In 1936, according to El-Hai, the state hospital population numbered 432,000. There was a serious need for a treatment that would improve patients enough to return them to the community. That was the promise of lobotomy.

As a student at Yale Medical School, I was exposed to John Fulton's attempt to discern the role of the frontal lobes by making lesions in primate brains and evaluating changes in behavior. He lectured about the chimpanzees, Becky and Lucy, who were said to have become docile after frontal lobe resections in Fulton's report to an international Neurology Congress in 1935, which was delivered by his associate, psychologist Carlyle Jacobsen.

Fulton was there and he later wrote that the descriptions of Becky and Lucy impressed and influenced Almeida Lima, a Portuguese neurologist already famous for devising cerebral angiography in 1927. According to El-Hai, however, Lima brushed off that claim, stating he had been thinking of that kind of surgery for years; Lima never gave credit to Fulton. After that meeting, Lima interrupted frontal connections with injections of alcohol and later by surgical sections. Within months, he reported improvement in many patients and was rewarded with a Nobel Prize in 1949, affirming the pressing need for psychiatric treatment, which he called “psychosurgery.”

Freeman immediately took up the procedure. His neurosurgical partner was James Watts, a former student of Fulton's. They did their first lobotomy a few months after Lima's reports. By the end of the four-decade era, about 40,000 procedures had been done and Freeman himself had done nearly 3,500.

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WHO WAS FREEMAN?

Freeman grew up in Philadelphia in a privileged family. His grandfather was the renowned Civil War surgeon, W.W. Keen. Freeman went to Yale College and then to the University of Pennsylvania medical school; there he formulated his life goals – to be as respected and as powerful as William Spiller, the renowned founder of neurology in Philadelphia. It did not work out that way. Spiller rejected Freeman's bid for a position and, instead, Freeman became the first neurologist in Washington DC, starting there in 1924. He saw the despair of patients at St. Elizabeth's Hospital, which inspired in him “a weird mixture of fear, disgust, and shame.” He gained a PhD in neuropathology and became head of neurology at George Washington University. He enlivened his lectures by bringing in patients for dramatic effect.

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Freeman does not come across as an attractive person. According to El-Hai, he visited Italy and “felt fascinated, not repulsed by fascism's rise.” He frequently used the convenient but hazardous cisternal tap, calling it the “jiffy spinal tap.” He immodestly considered a chapter he had written on neurosyphilis “the best in the English language.” After writing that book, he had a “nervous breakdown” and treated himself to a vacation in Europe. He took barbiturates for insomnia, which became a lifelong habit. He was driven by ambition. At meetings, he preferred exhibits to platform papers as a way of becoming “better known.” He carefully arranged his appearance with an eye-catching goatee, cane, and wide-brimmed hat. He “wrote that what the teacher had to say did not have to be important, indeed did not have to be true, but it had to be interesting.”

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FREEMAN IN PRACTICE

He was one of the founders of the American Board of Psychiatry and Neurology; he considered his older colleagues “a rather crabby bunch,” and he was admittedly tough on candidates, especially psychiatrists. He used thorotrast for ventriculography although its radioactive and oncogenic dangers were already known. He never cared much for asepsis when he operated.

Soon after he started doing lobotomies, always the publicist, he had a newspaper writer witness an operation. He had an exhibit at every annual AMA meeting from 1937 to 1946, “sometimes using a clacker to produce a loud sound and shouting like a carnival baker.” He personally gave intravenous metrazol to his depressed 70-year-old aunt. When a patient fractured both legs in electroshock, he later wrote, “I gave her an injection of morphine and left her too soon to see some patients at the hospital. When I returned … the woman was writhing in pain and her husband was outraged.” In another case, cerebral hemorrhage followed lobotomy and caused a right hemiparesis. With humongous chutzpah, Freeman told the woman's husband that it would cost an additional $1,000 to treat the disaster.

Freeman disdained the then-popular psychoanalysis and had long been attracted to physical treatments – cyanide, carbon dioxide, and amytal, as well as insulin or metrazol shock therapy. He was immediately taken with the Moniz procedure and arranged to have the monograph published in the US.

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EARLY DAYS OF LOBOTOMY

Freeman and Watts did their first lobotomy in September 1936. By November, they reported on 20 cases. One had a cerebral hemorrhage and four had second operations. Yet they did more and more procedures, and Freeman was invited to demonstrate the operation throughout the country. At first he considered the operation a procedure “of last resort.” Later he believed it was less helpful in chronic cases and advocated early surgery. He rejected the possibility that improvement could be spontaneous. By 1942 they had operated on 200 patients and published a monograph. Sixty three percent were considered improved, 23 percent unchanged, and 14 percent worse. Among the failures was Rosemary Kennedy, sister of President John F. Kennedy; she was left seriously brain-damaged.

His opponents included well-known psychiatrists such as Smith Ely Jelliffe and William Alanson White, but Adolph Meyer encouraged him. Neurosurgeons Loyal Davis and Wilder Penfield expressed concern and the AMA concluded that “It is inconceivable that any procedure which effectively destroys the function of this portion of the brain could possibly restore the person to a wholly normal state.” But many neurosurgeons followed Freeman's precepts and operations were reported from centers in Europe as well as the US. An international conference in 1948 included reports on 8,000 patients. US Veterans Hospitals did 48 lobotomies a month in 1949.

Freeman became a man on a mission. Not enough procedures were being done, he thought. He did not want to depend on the availability of neurosurgeons. He began to do more operations himself and developed the ice-pick transorbital approach. He used electroshock for anesthesia. He abandoned the operating room in favor of office surgery. He wanted to train psychiatrists to do the operation. All of this was too much for the ever-devoted James Watts and they separated. John Fulton moved from support to opposition. But Freeman continued; in 11 years he personally performed 2,400 transorbital operations and he was a celebrity.

Freeman operated without surgical training. He was uninterested in animal experiments or understanding what was happening in the brain. He never bothered with asepsis, which he called “that germ crap.” He treated emotional disorders by destroying the brain. The operation was blind to the anatomy of the brain and cerebral hemorrhage was a risk. It is doubtful that his procedures met anything like current views on informed consent. He never had controls and continuously modified the operation. More than 10 percent of patients had seizures. Surgical mortality rates were said to be 3 percent but in one of his visits to a state hospital 3 of 25 patients died, a rate of 12 percent.

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ADVERSE EFFECTS ON PERSONALITY

Also, the adverse effects on personality were publicized by famous movies, “Frances” (about Frances Farmer) and “One Flew over the Cuckoo's Nest.” The end of lobotomy came after 1954, with the introduction of chlorpromazine. By the end of the first year, the drug had been used to treat 2 million people and the number of patients in state hospitals began to fall from 559,000 in 1955 by 15,000 each year. Invitations to Freeman for demonstrations also declined and disappeared. His Department of Neurology attracted no applicants for residency training. Freeman, age 57, retired from George Washington University and moved to California for a diminishing private practice.

He never lost his faith in lobotomy and published on 3,000 patients operated in the years 1936–1956. He claimed that 80 percent of his schizophrenic patients and 90 percent of those with depression were out of hospital 6 years after surgery. Nevertheless, a controlled study published by McKenzie and Kaczanowski (Canad MAJ 1961;91:1192–6) found no difference between operated and unoperated groups. His wife turned to alcohol and became demented. He died of colon cancer in 1972 at age 76.

For all the negative aspects of this saga, Freeman had a lasting effect; psychosurgery is still with us. State hospitals may not now be the primary problem, but life-disrupting drug-resistant syndromes persist: obsessive-compulsive disorder, severe anxiety, Tourette syndrome, major depression, self-mutilation, and eating disorders. With growing experience in epilepsy and movement disorders, functional neurosurgery has followed the advent of stereotactic surgery, functional brain imaging, deep brain stimulation, and minimally invasive techniques (Curr Psychiatry Rep 2004;6:355–63).

A PubMed query for the years 2000–2004 brought up 198 references for “psychosurgery” as a keyword. In 2005 the basic science journal Neuron published a paper on deep brain stimulation for treatment-resistant depression (2005; 45: 1–10). (See “Deep Brain Electrical Stimulation Yields Striking Benefit for Treatment-Resistant Depression,” on Page 1.)

El-Hai tells the story well. An eccentric man had a major impact on psychiatric treatment, damaged many people, helped some, and participated in the advent of biological psychiatry, in which psychopharmacology hastened the demise of Walter Freeman's lobotomy, but not the disappearance of psychosurgery.

© 2005 American Academy of Neurology