Barron Lerner: Review of Jack El-Hai's The Lobotomist: A Maverick Medical Genius and his Tragic Quest to Rid the World of Mental Illness (Wiley, 2005)

Barron Lerner, in the New England Journal of Medicine (7-14-05):

Dr. Lerner, the Angelica Berrie-Arnold P. Gold Foundation associate professor of medicine and public health at the Columbia University Medical Center, is the author, most recently of The Breast Cancer Wars ( Oxford, 2003).

Desperate times call for desperate measures. So thought Walter J. Freeman, a neurologist who became the United States's staunchest advocate of the lobotomy between the 1930s and the 1970s.

A new book, The Lobotomist by journalist Jack El-Hai, chronicles Freeman's advocacy of a procedure that was viewed by many, and continues to be viewed, as barbaric. In exploring the ways in which lobotomy became part of common medical practice, El-Hai raises questions not only about how we should judge the procedure in retrospect, but also about what lobotomy teaches us about last-ditch medical interventions.

In the early 1900s, relatives frequently committed their loved ones to long stays in understaffed, overcrowded, and often filthy mental institutions. The therapeutic options for people with severe mental illness were quite limited.

One option, the lobotomy, also known as leucotomy, was devised in 1935 by Portuguese neurologist Egas Moniz. It involved drilling holes in the skull and then using a blade to sever nerve fibers running from the frontal lobes to the rest of the brain. Moniz believed that psychiatric symptoms were caused by faulty nerve connections established over a period of years. If these nerves were severed and new connections were allowed to form, he postulated, patients' symptoms would improve. Lobotomies were originally used to treat patients with depression but were later often performed to treat schizophrenic patients suffering from agitation and paranoid delusions.

The principal U.S. proponent of lobotomy was Freeman, of George Washington University Medical School. In June 1937, at the annual meeting of the American Medical Association, Freeman and his colleague James W. Watts, a neurosurgeon, presented data on 20 patients who had undergone lobotomy.1 Their paper launched a fierce debate over the procedure. On the one hand, certain members of the medical profession consistently condemned it as brutal, unscientific, and harmful. This appears to have been the case with the 1941 lobotomy performed on Rosemary Kennedy, the mildly retarded sister of john F. Kennedy, whose cognitive functions were severely worsened by the operation. The negative image of the lobotomy entered the popular culture through Ken Kesey's 1962 novel One Flew Over the Cuckoo's Nest and the movie based on it, in which the rebellious hero becomes nearly catatonic after undergoing the operation.

On the other hand, Freeman's data painted quite a different picture. The condition of 13 of the 20 patients, he and Watts claimed, had improved. In one case, a 63-year-old housewife who had had increasing anxiety and agitation for a year, they said, "now manages home and household accounts, enjoys people, attends theater, drives her own car."

Bolstered by such results, which were confirmed by later studies, Freeman's enthusiasm for lobotomy increased. In 1946, he devised the so-called transorbital lobotomy, in which he actually used a mallet to pound an ice pick through the patient's eye socket into the brain, then moved the pick around blindly in order to sever the nerve fibers. He traveled the world promoting his new procedure....