A monster or a medical genius?

Walter FREEMAN was a hard man to like. Most of his contemporaries found him abrasive, arrogant and egotistical, and so he was. Subsequent generations have identified him as the premier lobotomist of the 20th century, and so he was.

He did not invent this supposed cure for psychosis. As Jack El-Hai points out in “The Lobotomist,” his powerful biography of Freeman, that dubious honor belongs to the Portuguese neurologist Egas Moniz, who pioneered the operation in the mid-1930s and received the Nobel Prize in physiology or medicine in 1949 as a reward for his accomplishment. But it was Freeman, in collaboration with the comparatively shy and retiring neurosurgeon James Watts, who fostered the operation in the United States.

And it was Freeman who popularized an alternative way of performing the surgery -- the transorbital lobotomy, which involved inserting ice picks under the eyelids and pushing them through the orbital plate into the brain’s frontal lobes -- and announced that the procedure was so simple that with a little practice it could be performed by the most witless of state hospital psychiatrists. He also announced, and repeatedly demonstrated, that it could be done on an outpatient basis, using two or three electroshocks to the brain as anesthetic. He insisted that the newly lobotomized patient could return home within hours of the surgery, taking only the simple precaution of wearing sunglasses to cover the black eyes that were evidence of the slicing and dicing of her brain. (It was usually “her” brain.) Freeman, moreover, was willing (indeed, eager) to lobotomize children as young as 4 years old and adults whose neuroses were of recent origin. He warned that unless such patients were treated promptly, their personalities would deteriorate and they would spend the rest of their lives as chronic lunatics on the back wards of state hospitals, a fate surely worse than death.

Children’s brains, he pointed out, were more resilient than those of adults. Just as well, because he also insisted that in pediatric cases, “maximal operation” -- a particularly extensive standard lobotomy -- “is the only effective procedure and necessarily leads to a rather vegetative condition.” For adults he preferred the transorbital operation, because it was so much simpler and quicker. Whereas a standard lobotomy might take several hours, the operation via the eye sockets took less than six minutes, including time out to photograph the ice picks in place. El-Hai notes that Freeman delighted in demonstrating his prowess before an audience. Wearing no gown, mask or gloves, he treated the occasion almost as a circus act, spearing the brain and twisting his hands back and forth to make identical cuts behind each eye. He once managed to perform 228 of these procedures in the space of only 12 days, courtesy of the superintendents of the West Virginia state hospitals, who gave him unlimited access to their charges.

His posthumous reward was to be branded an outcast, rather than the hero he was in his own eyes. Freeman saw himself as having almost single-handedly pioneered a surgical treatment that would rescue hundreds of thousands of psychotics from the snake pit, not as a heartless barbarian worthy of mention in the same breath as the infamous Nazi doctor Josef Mengele. But in popular culture his operation came to be seen as a crude device for repressing the rebellious and nonconformist, silencing, for example, the intractable Randle McMurphy in Ken Kesey’s “One Flew Over the Cuckoo’s Nest.” In the 1982 biopic “Frances,” Hollywood starlet Frances Farmer’s transorbital lobotomy is performed by the bearded Freeman himself. (El-Hai suggests that the Farmer/Freeman encounter is apocryphal; regardless of whether he is right, the scene certainly reinforces Freeman’s status as lobotomist sans pareil.)

Though the lobotomy’s reputation still horrifies the public, both it and Freeman have been all but erased from memory among the psychiatric profession, consigned to the oblivion of its Dark Ages, removed from sight like a demented aunt in a Victorian attic. El-Hai acknowledges that when he began working on Freeman’s biography, he shared that repugnance. Over the years, however, as he repeatedly interviewed Freeman’s three surviving children and read the reams of published and unpublished prose set down by the man he came to regard as “a maverick medical genius,” El-Hai’s opinions subtly evolved. Freeman began to seem less like a monster and more like a driven man desperately seeking to subdue the demons of mental disorder, someone who cared for his patients (and who in fact spent many of his declining years motoring around the United States to check on their welfare). El-Hai suggests that Freeman deserves better than the condescension and condemnation of posterity; indeed, he goes further, noting that new forms of psychosurgery may yet serve “to wipe out many of the symptoms of the most recalcitrant forms of obsessive-compulsive disorder and some varieties of depression.”

This tendency to view lobotomy through rose-tinted spectacles is one that El-Hai shares with the late Jack Pressman, author of “Last Resort” (1998), so far the most thorough academic treatment of the history of psychosurgery. It is a plausible but, I think, deeply wrongheaded perspective. Yet because their research is scrupulous and intelligent, one needs to understand why they came to adopt such a position.

Central to this revisionist view are several interrelated claims: that conditions in mental hospitals in the 1940s and ‘50s were so awful and the prospects for schizophrenic patients so dismal and desperate that the most extreme remedies were justifiable if they produced a measure of improvement; that the results of damaging people’s frontal lobes were not as uniformly dire as we suppose; that it is wrong to impose our contemporary moral and scientific standards on the past; and that people like Freeman were sincere, well-intentioned scientists whose motives we should respect. None of these assertions is spurious. Individually and collectively, however, they are a grossly inadequate defense of Freeman and the operation he did so much to promote.

Conditions in postwar American mental hospitals approximated our worst gothic nightmares about madhouses. Patients (at least those with some residual grip on reality) and their families were indeed desperate for some alternative to life on the back wards and thus often eager to secure Freeman’s services. And psychiatry was largely helpless in the face of the misery of psychosis. But to offer a profession’s therapeutic impotence as mitigation for inflicting massive damage on top of an illness that one cannot cure strikes me as bizarre. Attention to the ancient Hippocratic injunction to “First do no harm” would surely have been a preferable response.

What of the fact that some lobotomized patients resumed something approaching a normal life -- in one instance as a classical violinist, in another as a physician, in a third, ironically enough, as a psychiatrist? Such examples certainly existed but, as El-Hai admits, they were far from the norm. More numerous were the patients with blunted affect and initiative -- indolent and tactless, yet capable of functioning outside the hospital walls as housewives or in occupations requiring limited skills and independence. Weighed in the balance, are not their outcomes an improvement over what otherwise might have been, and an offset to those other lobotomized patients who were (as even Freeman sometimes acknowledged) reduced to human vegetables? I think not.

As the attentive reader of El-Hai’s book will discover, lobotomies were generally not performed on schizophrenics on the back wards, save as a means to make violent and disruptive patients more manageable. Very early, Freeman concluded that such patients exhibited a poor response to his ministrations, often ending up in a worse state than before. His preferred targets were still-functioning neurotics, obsessives and depressives -- people who were relatively whole, if miserable and appallingly difficult to live with. Increasingly, as the years passed, Freeman sought to visit his surgery on the mildly, not the seriously, disturbed. The argument as to whether schizophrenics were better off with intact brains in a back ward or with brains damaged sufficiently to allow their release to family care is moot, for these alternatives were not offered.

To suggest that ethical or scientific objections to lobotomy rest on an anachronistic application of contemporary standards is likewise a mistake. Such critiques have certainly been made, and El-Hai is right to find them wanting. But plenty of psychiatrists and physicians in the 1940s fought the use of lobotomy, objecting that too little was known of brain function, or of the type of damage inflicted, to justify the surgery, and that it was wrong to respond to what might be temporary mental disturbances by permanently injuring the brain. They also argued that substituting a straitened mental and emotional life for psychic pain, even extreme psychic pain, was a poor bargain, given the irreversibility and uncertainty of the outcome. That these objections often came from Freudians, most of whose views contemporary biological psychiatry has consigned to the scrap heap, does not make them any less compelling.

El-Hai may well convince his readers of Freeman’s sincerity. But does Freeman’s sincerity matter? His conviction of his own rightness is one of Freeman’s more disturbing qualities, because it helped make him impervious to his critics. Still, one of the many virtues of El-Hai’s text is the rich detail he provides about Freeman’s life and ideas. His readers will thus be able to judge Walter Freeman for themselves and decide whether he is, as El-Hai would have it, “a maverick medical genius” or, as others have concluded, a moral monster. *