Dr. Freeman liked routine and efficiency. He was upset when a patient missed three office appointments in a row, and he was not going to tolerate this behavior. When Freeman learned that police had apprehended his mentally unstable patient in a motel room, he drove to the scene with some essential tools from his office. Upon his arrival, the police forced the patient to the ground, and the doctor, armed with a sharp tool and an electroshock machine, started his work. He pulled up the unconscious patient’s eyelid and pushed the ice pick-like metal object into the tear duct. After hammering the tool further, he reached the front of the brain, and made the necessary incisions. In fewer than ten minutes, he had finished his psychiatric treatment (1).
Jack El-Hai depicts this scene in his recent book, The Lobotomist, which chronicles the life of Dr. Walter Freeman, the American psychiatrist who coined the term “lobotomy” and performed thousands of these procedures from the late 1930s to the early 1950s. Freeman was not the first person to attempt to cure psychiatric phenomena with brain surgery; however, through experiments with cadavers, he learned how to speed up the procedure by using the eye orbit as an entry point instead of drilling into the skull (2). The procedure is unsettling, and El-Hai’s book is made horrifying by his accounts of Freeman’s cavalier attitude towards decontamination and his almost theatrical approach to lobotomies (3).
Although Freeman’s lobotomy revolution was short-lived, this procedure is still used in extreme circumstances today, within a branch of medicine called psychosurgery. While Freeman’s gratuitious use of lobotomies is now considered a shameful and infamous part of 20th century medicine, his determination to treat psychiatric symptoms with biological approaches is impressive given the limited knowledge of the neurological basis for psychiatric disorders during his time. Today, with the advent of non-invasive brain imaging, scientists and physicians are finding more correlations between behavior and specific areas of the brain. As a result, we may be on the verge of another wave of psychosurgery fanaticism. Popular Science questions whether a relatively new procedure, called Deep Brain Stimulation (DBS), could be the new lobotomy (4). What is the role of psychosurgery in modern medicine? What factors in the 1930s set the stage for Freeman’s development of transorbital lobotomies? How have we advanced surgically and ethically since the time of Freeman and his ice pick?
Early Attempts at Psychosurgery
The origins of psychosurgery may date as far back as the Stone Age. Kurt W. Alt and colleagues published a study in Nature that found evidence of a procedure called trepanation within a Neolithic burial site more than 7,000 years old (5). Trepanation is the process of introducing holes into the skull of an individual, and it was used for a variety of purposes, including treatment of epilepsy and spiritual therapy (5). However, the 20th century interest in psychosurgery is generally not traced to these ancient origins. In a scientific review on psychosurgery, Dr. George Mashour of Harvard University and his colleagues attribute its beginnings to the rise in scientific examination of the “brain-behavior correlation” (6).
Currently, with new brain studies and anti-depressant medications being discussed on the news almost daily, it is easy to forget that scientists have only recently made strides in understanding how the biology and chemistry of the brain affect moods, behaviors, and emotions. According to Mashour, scientists began to understand the connection between brain damage and cognitive functions, such as language, by examining the brains of deceased patients who had shown cognitive impairments (6). During this early era of psychological discoveries, Dr. Gottlieb Burckhardt attempted to cure the psychiatric ailments of six of his patients by cutting out small portions of the frontal, parietal, and temporal brain lobes (6). It was the year 1888, and Burckhardt deemed three of the six cases successful. Although Burckhardt could be considered the first modern psychosurgeon, his work was short-lived, since, as Mashour reports, his research was not well-regarded by his scientific community (6). Hesitance to accept such a radical procedure seems logical to us today; however, it is worth questioning: what were the alternatives?
There were very few treatment options for the mentally ill at that time. In his book Great and Desperate Cures, Elliot Valenstein explains that classification and diagnosis, let alone treatment, of mental disease was poor at the turn of the century. Psychological treatments involving extensive rest and sleep therapy were popular at the time, as were water bath techniques. As Valenstein explains, “in this therapeutic and theoretical vacuum, almost any treatment was tried” (7). In the midst of this vacuum, Portuguese scientist Egas Moniz invented the predecessor to the lobotomy, a feat which won him the Nobel Prize for Medicine in 1949 (8).
From Moniz to Freeman
By the 1930s, more promising psychiatric treatments emerged, including electric convulsive therapy, and a new potential for psychosurgery was introduced at a conference in London during 1935. According to the Nobel Prize Organization, Jacobsen and Fulton’s presentation on psychosurgery in chimpanzees inspired Egas Moniz to experiment with a procedure called the prefrontal leukotomy (8). Operating on the frontal lobes of the brain, Moniz treated patients with different varieties of depression and schizophrenia. Although Moniz observed little progress in his schizophrenic patients, his overall mortality rate was low, and he achieved global recognition (8). However, the greater impact of Moniz’s work involves its influence on physicians around the world, including Walter Freeman.
Inspired by Moniz’s work in the field, Freeman and his partner James Watts started practicing the procedure in the United States. Watts, a neurosurgeon, and Freeman, a psychiatrist, both performed operations from the beginning of their partnership (9). Although Freeman’s surgical work was not permitted under hospital regulations, he was not specifically prohibited or punished for overstepping his medical boundaries, a point frequently made in El-Hai’s book. Given the current zeal for prosecuting malpractice cases, it is hard to believe that there was ever a time when medicine was so unregulated. While this unsettling level of medical freedom contributed to the rise of Freeman’s lobotomy, there was another societal factor that had a much greater effect: World War II (10).
Institutions for the mentally ill received a large influx of patients who had developed psychological problems during the war. El-Hai explains that in 1948, the American Psychiatric Association stated that institutions were overloaded with 50 percent more people than the maximum available space could hold (11). Freeman was convinced that psychosurgeries were the best possible treatments for the individuals crowding institutions, yet he knew that his lobotomy procedure, modeled after Moniz’s, was not efficient enough. Creating a hole in the skull in order to reach the brain was a difficult step in his experimental lobotomies. Further, at this point in their careers, Freeman and Watts had observed massive personality transformations in their patients, and they began to use lobotomy only as a last resort in psychiatric treatment. But Freeman saw almost limitless potential in the surgery. He refined the technique in order to make it faster, easier, and more effective (10). As El-Hai describes, Freeman’s work on cadavers led him to a solution: entering the brain through the eye orbit. He began to experiment with a new, non-surgical tool: an Uline Ice Company ice pick (12).
Freeman’s Approach
According to El-Hai, once Freeman had created the transorbital lobotomy, he believed that it was only a matter of time before he would revolutionize the field of psychosurgery. His overwhelming confidence in his new method led him on trips across the country, visiting institutions in what This magazine calls his “lobotomobile” (13). In only two weeks, he completed 228 transorbital lobotomies, operating on 25 women in the span of one day (14). If the sheer numbers aren’t disturbing enough, Freeman’s approach to each lobotomy is even more horrendous. Efficiency was his ultimate goal, and his concern for it was reflected in every part of his routine. Sterile dressing, gloves, gown, mask, expensive medical tools – why bother? A sterile surgical pick was all he needed. A carpenter’s hammer was just as good as one from any medical brand, and why waste time worrying about sterilized clothing if he wasn’t even exposing the skull? One of his colleagues even said that Freeman constantly ranted about “all that germ crap,”
and disregarded modern sterilization techniques (15) .
El-Hai demonstrates that, ironically, the one thing Freeman seemed to waste time on was documenting and exaggerating the ease of his procedure. A student nurse named Patricia Derian observed a lobotomy in which Freeman operated on both eye orbits at the same time (an unnecessary approach done entirely for show), and explained in El-Hai’s The Lobotomist, “He looked up at us, smiling. I thought I was seeing a circus act. He moved both hands back and forth in unison, cutting the brain identically behind each eye. It astonished me that he was so gay, so high, so ‘up’” (16).
The Results
Despite his egregious approach to surgery, Freeman did improve the lives of some lobotomy patients. One of Freeman’s earlier patients, Ellen Ionoesco, suffered from manic and suicidal behavior, and the lobotomy eliminated these symptoms. Although she never functioned at a high level of mental cognition, she did manage to hold a job and raise a family (17). Freeman’s patients often suffered from extremely debilitating behavior, including violent, manic, or obsessive impulses, and the lobotomies generally made them much more manageable and compliant (18).
But tractability often came at the cost of personality – people were transformed into living zombies or often were rendered too childlike to function independently. In other cases, the goals of the surgery backfired entirely, and the patients became aggressive, according to This magazine (13). In addition, El-Hai notes that sometimes, Freeman accidentally cut blood vessels in the brains of the patients, causing hemorrhaging and even death (19).
Psychosurgery: Post-Freeman
During the 1950s the advent of new drugs for psychiatric treatment helped eradicate the medical use of lobotomy. However, as Valenstein explains in his book Great and Desperate Cures, the medical community saw another resurgence of lobotomies in the 1970s. Neurosurgeons attempted new methods of destroying brain tissue with radioactive chemicals and freezing (20). At this time, interest in lobotomy surfaced in psychosurgery as a mode to control violent behavior and in surgery to control criminal minds. These ideas were expressed by physicians Vernon Mark and Frank Ervin in the contentious book Violence and the Brain. Simultaneously, the growing activism in social justice during this era helped spawn an “anti-psychiatry” movement, which espoused the idea that psychiatry was a form of mind control by the government (20). The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created during the mid-1970s and certain states, including California and Oregon, imposed legal restrictions on psychosurgery (21). This once again brought psychosurgery to a virtual standstill (22).
Today, psychosurgery is limited to a handful of operations that are used when other therapies have been exhausted and after the prospective patient is carefully reviewed for candidacy. Obsessive Compulsive Disorder (OCD), characterized by excessive thoughts and worries that may manifest into symptoms such as compulsive praying, hand washing, and other repetitive rituals is one of the disorders that can be remedied with modern psychosurgery. The Stanford School of Medicine reports that there is a communication loop in the orbitofrontal cortex that passes through several structures en route to the thalamus and then passes back to the frontal cortex (23). Further, the Stanford School of Medicine interprets a theory by Dr. Lewis Baxter and his colleagues at UCLA: in short, OCD patients have “worry” commands from the frontal cortex that are sent through this communication loop, and a misfiring of the loop allows these commands to cycle continuously (23). One contemporary psychosurgery, known as Anterior Capsulotomy, is used to treat OCD. It involves lesioning of the internal capsule, an area of the brain next to the thalamus that is implicated in this information loop (23).
New methods of psychosurgery aside, what has happened to the standard lobotomy? Brazilian researcher Dr. Delcir Antonio de Costa published a study reporting the benefits of frontal lobotomy (24). He noted improvement in patients who received lobotomies, and states, “Despite its controversial nature, there is no clear evidence contraindicating the use of psychosurgery for the treatment of patients with schizophrenia” (24).
Deep Brain Stimulation (DBS)
Surgically inserting an electrode into the brain seems like a horrifying combination of Freeman’s anesthetic electric shock and his destructive lobotomy. However, these steps are the basis of a recent innovation in psychosurgery called deep brain stimulation (DBS). This technique appeared in the 1990s for treatment of Parkinson’s Disease, a disorder affecting motor control (4). Currently, it is being tested in clinical trials for depression treatment, bridging the gap between mind and body, and thus, entering the field of psychosurgery. The electrode is implanted into the center of the brain and stimulated to send electrical pulses into the basal ganglion, a structure deep within the brain involved in motor control (4). Mashour’s review clarifies that deep brain stimulation can be classified as psychosurgery because it hinders the behavior of brain structures: “‘Stimulation’ ultimately results in inhibition of neural activity, and thus is the functional equivalent of lesioning” (6). However, in contrast to Freeman’s lobotomies, deep brain stimulation can be reversed.
Should it be used to treat depression? It is still unclear precisely how DBS alleviates depression (4); doctors have simply seen some convincing results. Popular Science described a chilling scene of a DBS patient receiving a brain scan. As the doctors monitor her brain activation, they turn the electrode on and off to see how electricity influences her underlying brain regions. She smiles and frowns in-sync with the activity of the electrode. A doctor in an adjacent room was in essence turning her happiness on and off. What if the person holding the voltage controls were not a doctor? What are the ethical implications of the power to electrically manipulate the emotions of others? In addition, although the procedure is reversible, it has the potential to cause permanent damage (4). The electrode’s level of current can be adjusted, and if turned up too high, it could, frankly, fry the patient’s brain.
An additional concern is that this procedure is usually performed on patients with Parkinson’s Disease in the last two decades of their lives. If this procedure is used for treatment of depression, it is likely that some patients will receive deep brain stimulation in their 20s and 30. We have no current knowledge of how 50 years of applied electricity could affect the brain (4). On the other hand, the effects of depression are often so devastating that some patients are willing to take virtually any risk to achieve relief. A person who has exhausted all options of treatment may view brain surgery as a potential miracle cure.
What Can We Learn from Freeman?
In the past 100 years, progress in brain sciences has been phenomenal. At the turn of the century, issues of the mind could not be linked with any neural underpinnings, yet today, brain imaging data is all over the news and drug companies advertise Selective Serotonin Reuptake Inhibitors, a class of antidepressants, as though they were the new aspirin. However, it is too easy to draw clear lines between past and present, ethical and unethical, safe and dangerous. In dismissing the work of Freeman and detaching modern advancements from earlier practices, we may be giving ourselves a false sense of security.
While medicine has changed enormously in the past 100 years, it is still a science that involves trial and error. We are equipped with new procedures and technologies, but that does not guarantee the humane practice of medicine. Further, psychiatry and neurology are in some ways still shrouded in as much mystery as they were in the times of Freeman. We have a better understanding of how brain processes affect our thoughts, personality, and mental health, yet we have not cracked the neural code. We have theories to explain the symptoms of OCD and depression, but there is much left to be discovered about the mechanisms of neurological disease.
In some ways, we are more vulnerable to the practice of faulty medicine than we were in the times of Freeman. Our increasingly fast-paced culture is constantly searching for a quick fix, which often includes surgery. We can lose sight of the fact that these procedures have serious risks. In the same vein, when we give our children pills to calm their hyperactivity, we sometimes forget that we are radically tampering with childhood brain chemistry. Popping a pill is much faster than behavior therapy, and going under the knife for cosmetic surgery is quicker than finding peace with the appearance of one’s body. Our quest for easy solutions mirrors Freeman’s obsession with efficiency. Shouldn’t we strive for methods that are not just the most efficient, but instead, the most effective and ethical? In order to learn from Freeman, it is not enough to be critical of our techniques. We must scrutinize our research and the implementation of our findings in order to ensure that modern day psychosurgery avoids the ethical malpractice of earlier days.
References:
1. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), pp. 191-192.
2. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), p. 182.
3. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), p. 245.
4. G. Mone, “Happiness is a Warm Electrode” (2007). Popular Science. Available at http://www.popsci.com/scitech/article/2007-09/happiness-warm-electrode (24 January 2008).
5. K.W. Alt, et al., Nature 387, 6631 (1997).
6. G.A. Mashour, et al., Brain Research Reviews 48, 409 (2005).
7. E. Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books, New York, 1986), p. 34.
8. B. Jansson, Controversial Psychosurgery Resulted in a Nobel Prize (1998). Available at http://nobelprize.org/nobel_prizes/medicine/articles/moniz/index.html (24 January 2008).
9. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), pp. 88-122.
10. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), pp. 178-185.
11. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), p. 179.
12. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), p. 183.
13. D. Egan, Magical Mystery Cure (2005). Available at http://www.thismagazine.ca/issues/2005/01/magicalmystery.php (24 January 2008).
14. National Public Radio. “My Lobotomy: Howard Dully’s Journey” (2005). Available at http://www.npr.org/templates/story/story.php?storyId=5014080 (24 January 2008).
15. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), p. 186.
16. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), p. 245.
17. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), p. 188.
18. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), pp. 166-199.
19. J. El-Hai, The Lobotomist (John Wiley & Sons, New Jersey, 2005), pp. 171-172.
20. E. Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books, NewYork, 1986), pp. 284-290.
21. E. Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books, NewYork, 1986), p. 288.
22. E. Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books, NewYork, 1986), p. 289.
23. Stanford University School of Medicine, Understanding Obsessive-Compulsive and Related Disorders (2008). Available at http://ocd.stanford.edu/about/understanding.html (24 January 2008).
24. D. A. Costa. Schizophrenia Research 28, 223 (1997).