Tuesday, October 27, 2009

Father of the Lobotomy

I wrote this piece on my mcmanweb site eight or nine years ago, with a minor addition a few years back. This highly macabre piece remains one of the most popular on my site, and in the spirit of Halloween I'm re-running it here. Enjoy ...

The field of mental health suffers no shortage of weird and offbeat and arguably despicable characters, but the Washington Post several years ago outdid itself for its story on Walter Freeman, father of the lobotomy. Sample this lurid paragraph for starters:

"Walter Freeman lifted the patient's eyelid and inserted an ice pick-like instrument called a leucotome through a tear duct. A few taps with a surgical hammer breached the bone. Freeman took a position behind the patient's head, pushed the leucotome about an inch and a half into the frontal lobe of the patient's brain, and moved the sharp tip back and forth. Then he repeated the process with the other eye socket."

Freeman kept records of 3,439 lobotomies he performed over his long career, and he promoted the procedure to more than 55 hospitals in 23 states. At AMA meetings, he set up graphic exhibits and used hand-held clackers to draw audiences.

In all, lobotomies were used on 40,000 to 50,000 Americans between 1936 and the late 1950s. Freeman believed lobotomies worked because the procedure severed connections between the frontal lobes of the brain and the thalamus, thought to be the seat of human emotion, which the mentally ill apparently had in overabundance. Although his theories have been discredited, Freeman was one of the few psychiatrists of his era who believed that mental illness had a physical biological component.

Freeman attended Yale and the University of Pennsylvania School of Medicine, then studied neurology and psychiatry in Europe. Motivated by the tragedy of wasted lives in mental hospitals, he introduced insulin shock therapy and ECT for patients at George Washington University Hospital in Washington DC, where he served on the faculty. He also had a private practice and was director of the laboratories at St Elizabeth's Hospital.

Upon finding out that chimpanzees became subdued when their frontal lobes were damaged, and spurred into action by Portuguese neurologist Egas Moniz' experiments on people, he and colleague James Watts started practicing on brains from the hospital morgue, and in 1936 they were ready for their first patient, a Mrs Hammatt, 63, who suffered from agitated depression and sleeplessness. The technique of entering the frontal lobes through the eye sockets was still far off into the future. Instead, they drilled six holes into the top of her skull.

According to Freeman, Mrs Hammet emerged transformed, able to "go to the theatre and really enjoy the play ... " She lived another five years.

Freeman and Watts claimed 52 percent of their first 623 surgeries yielded "good" results, but they did not offer a clinical yardstick for what constituted an improvement. Patients often had to be retaught how to eat and use the bathroom. Relapses were common, and three percent died from the procedure. The most famous Freeman-Watts failure was JFK's sister, Rosemary Kennedy, who needed full-time care for 64 years (she died in Jan 2005).

Nevertheless, hospitals were willing to put up with lobotomies and all their shortcomings for no other apparent reason than post-operation lethargic patients were easier to care for than pre-operation emotionally-charged ones.

In 1967, Freeman performed a lobotomy on one of his original patients in Berkeley, California. He severed a blood vessel, and the patient died three days later. This effectively brought his career full circle. During the last five years of his life, he performed no more lobotomies. He died from cancer in 1972, age 76.

Today, according to the Washington Post, there are probably fewer than 20 brain operations a year (not lobotomies) in the US to treat psychiatric disorders, part of the negative legacy of Freeman that has scared away researchers and funders. [Update 10/27/09: Last year the FDA approved deep brain stimulation for OCD in rare instances and the procedure is being experimentally used for depression.]

In 1949, at Freeman’s urging, Moniz received the Nobel Prize. As S Nassir Ghaemi MD of Emory University in a review comments:

“It is quite ironic that in that same year, the Australian psychiatrist John Cade would discover 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.”

One day that may change. But first the ghost of Freeman needs to be thoroughly lobotomized.


Adelaide Dupont said...

But for the majority of OCD and depression, it still isn't a first-line treatment, is it?

(There was a friend of late New Zealand author Janet Frame's: Audrey Scrivener, who had an 'obsessional neurosis' and so was treated with a leuctomony when Janet Frame wasn't. It turned out to have some nasty consequences).

So the Nobel committee has shied away from direct treatments of mental illness?

Anonymous said...


Macabre indeed, you should see the Gothic facility on the mountain in Montreal where this and other very reprehensible (CIA sponsored) procedures took place during the Cold War Era. Yes, that’s right, the CIA in Canada. Disgraceful.

Yet, recently I was offered a referral to a Neurologist as a candidate for “Deep Brain Stimulation”. Other events have since dramatically improved my health. But, lobotomy history or no, I may seriously consider the procedure at some future time.

John McManamy said...

Hi, Adelaide. DBS looks very promising for depression, and its application was pioneered in Canada by Helen Mayberg, who is now at Emory University. The procedure has been successfully used for years on patients with Parkinsons and is being tested on patients with epilepsy. If approved by the FDA for depression, there will be stringent restrictions to its use, only as a last ditch effort on desperate populations such as those in depression years on end who failed just about every available treatment. The OCD application has a whole host of restrictions like this.

Just to clear up any possible misconceptions - no holes are drilled through the brain lobes. No surgical lesions (cuts) are made. No part of the brain is severed from another part in any way.

DBS for OCD would replace capsulotomies and cingulotomies that did involve surgical lesions.

Instead, an electrical lead is inserted between the folds in the brain. The patient can remain awake - no anesthesia is required. Thus, if the surgery fails, it is reversible, unlike procedures that require a surgical lesion.

Again - we are talking miniscule numbers, such as maybe ten a year. Perhaps in the future say a few hundred a year. In other words, an extremely rare procedure.

In the decades ahead, as we better learn to pinpoint brain activity, it is possible that surgical procedures will become more common -but that is way in the future and a mere speculation at this stage.

herb said...

Hi John,

I’d like to point out that one should not be cavalier in considering DBS or for that matter any treatment. Please make no mistake about the facts. DBS is surgery and therefore invasive by nature with all its inherent potential side-effects.

Aside from the surgical implanting of the pulse generator and leads, holes are drilled in the skull and fine electrodes are introduced through the brain. In addition the surgery requires a frame placed on the patients head so as to precisely position the introduction of the electrodes into the exact position and location.

Infection, headaches, bleeds, strokes are possible side-effects amongst others and incorrect positioning can and may potentially lead to brain damage and dysfunction. Surgery is no cake-walk if you’re the one encountering the side-effect(s).

The most important fact of all to consider while DBS for Depression at the moment is still being studied and is not FDA approved is that like all other treatments for Major Depression there is no guarantee of efficacy or means to establish who will or will not be a responder. The therapy also comes with restrictive warnings for certain diagnostic procedures.

In the case of DBS for Epilepsy there are also reported side-effects of mood disturbances such as impulsivity as well as elevated mood states.

There is no panacea other than what I have for four decades referred to as the “Trial and Error Approach to Wellness.”

Once again, lets not be cavalier in our thoughts about most therapies for serious mood disorders.


John McManamy said...

Hey, Herb, clarification: There is no way I was being cavalier about DBS. I was responding to Adelaide's concern that DBS might be somehow related to lobotomies. The antipsychiatry movement would love to make that kind of link. I repeatedly emphasized that unlike earlier types of psychiatric surgeries, there are no surgical lesions. This is no minor technical matter. This is a major advance that changes the whole conversation.

All surgeries - particularly on the brain - are invasive and carry risks. And, like any treatment, there is no guarantee of success. But the bottom line is the future may bring a new option for people who have not responded to other treatments. As our knowledge improves and techniques become more refined, DBS and other innovations may offer hope to a group of patients who have written off hope.

Adelaide Dupont said...

John and Herb:

I do now realise that a DBS is something like a pacemaker to the brain.

Holes in the head and damage to the brain (lesions) are different.

I appreciate the information about DBS for depression and epilepsy. I had never heard about capsultomies and cignultomies before.

herb said...

Dear Adelaide,

If by some chance you’re also not aware please let me introduce TMS (Transcranial Magnetic Stimulation), MST (Magnetic Seizure Therapy), TDCS (Transcranial Direct Current Stimulation) and VNS (Vagus Nerve Stimulation) amongst newer treatment modalities where the former three therapies are non-invasive and the latter being invasive.


Anonymous said...

I have been recommended for a cingulotomy as a means to stop my pervasive cycling. I have tried many kinds of pharmacotherapy and failed them all. TMS has no established success in treating bipolar depression or cycling and I haven't looked into deep brain stimulation or vagus nerve stimulation. I think people like me who have pervasive cycling with little to no euthymic mood should be able to explore whatever means are available to ameliorate or end this problem. Since insurance companies do not pay for any of the abovementioned treatments, it makes more affordable and more effacious means all the more attractive: the firearm, bottle of pills and the noose. I'm in favor of reopening consideration for and research using both invasive and non-invasive techniques to benefit those of us who continue to defy standard treatments. Every intervention has risks but lack of intervention carries certainty of a bad outcome for some of us.

Anonymous said...


I have been a patient in a dbs research study for treatment resistant depression. As mentioned with any surgery, their are risk. My depression was so severe that ultimately, I the prospect of not trying one more thing to help depsite the risk was not an option. The mental anguish or mental pain was such that I felt I could not continue without some relief. It is hard for anyone who has not experienced major depression to understand someone choosing
an invasive brain surgergy. For me, it has been the right decesion, and in my case, the surgery did not even register on the difficult scale as compared to how difficult it had been living day to day with the horrible mental pain of depression. It have had some struggles along the path back to feeling better since dbs as my life had been so delayed, or somewhat behind in my aspects from lack of normal functioning. The dbs for me seems to keep me from spiraling down to a point of not returning as I had in the past. For people that have criticized the procedure as turning up the electrodes to feel good or "up", this was so not the case for me. It it no way made or makes me feel "up", it is more about the pain that that seemed to be taken away, so that I lost pain, but didn't feel "up" or "high" at all. I am grateful to have had the opportunity.

John McManamy said...

Many thanks for sharing your story of DBS, Anonymous. So glad you are on your way to winning back your life. Please keep us informed.