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Question: When Doctor Walter Freeman performed the lobotomy with his method, was the entire frontal lobe severed from the brain or was only part of the frontal lobe severed? Also, how did Doctor Freeman determine how far and deep he needed to insert his ice picks to sever the frontal lobe and not protrude into the other parts of the brain? -W.T.H., Falls Church, VA

Answered by Elliot S. Valenstein:
Walter Freeman performed two types of lobotomies. Originally, he performed what came to be called the standard Freeman-Watts lobotomy which enters the brain from the side of the frontal lobes. The transorbital lobotomy was what you referred to as the "ice pick" lobotomy and the instrument entered the brain through the orbit above the eyeball. In both cases, he tried to sever particular connections between the medial thalamus and the ventromedial part of the frontal lobes. The ventromedial part of the frontal lobes and the medial part of the thalamus were (and still are to a certain extent) believed to play a part in emotions. The entire frontal lobe was not disconnected from the rest of the brain.

Question: I really enjoyed reading Mr. El-Hai's book. Not a topic that you'd think would be a real page-turner, but it was.

From a cultural standpoint what is it about the practice of lobotomy, as opposed to other medical practices that are no longer considered acceptable, that so fascinates us? Books, PBS specials, songs, playground taunts, etc. Why? -Barry Gisser, Omaha, NE

Answered by Jack El-Hai:
You've asked a good question. You're absolutely right that thinking about lobotomy affects us differently than thinking about discarded treatments for such diseases as, say, whooping cough or polio.

We all have a lot of fear built into our response to lobotomy -- fear of tampering with the brain, fear of altering our personalities and souls, and fear of everything that we fail to understand about mental illnesses. In some people the fear makes them shrink, but in others (including me) it produces an attraction that makes them want to look more closely, like at a highway accident. Then there are others who try to channel the fear into affected indifference or ridicule (many of the song lyricists and schoolchildren).

Another cause of lobotomy's fascination is the mystery surrounding the treatment: Why would anyone propose such a treatment, go through it, or condone it? Those were some of the questions that led me to write my book, and I found answers in the contexts of mid-twentieth-century medical practices and in Freeman's own life. The American Experience documentary raises its own wonderful questions, as well.

Question: Why did the doctor not experiment on animals before operating on humans and be published and reviewed by his peers? How and when did that change? I assume that such a thing could not happen today not just because doctors are not afraid to criticize other doctors in public now. Also at the end of the program it said that the operation is still done today. Where and why? -K.P., Portland, OR

Answered by Robert Whitaker:
This surgery did, in fact, arise out of a long line of research, including research on animals. The research involved studying the function of the frontal lobes (which were the part of the brain destroyed or disconnected in a lobotomy), and what change resulted from damaging the frontal lobes.

In 1861, the French neurologist Pierre Paul Broca observed that the frontal lobes were much more pronounced in humans than in other animals, and concluded that it was this region of the brain that gave rise to the "superior faculties" of humans. Next, in 1871, England's David Ferrier reported that destroying this brain region in monkeys and apes markedly reduced their intelligence. The animals became "apathetic or dull or dozed off to sleep, responding only to the sensations or impressions of the moment." Italian neurologist Leonardo Bianchi conducted similar experiments in the 1920s with dogs, foxes, and monkeys, and he concluded that the human intelligence responsible for creating civilization could be found in the frontal lobes.

At the same time, many soldiers in World War I suffered frontal lobe injuries, and this led to a number of clinical reports that people with damaged frontal lobes became childish, apathetic, lost their capacity to plan ahead, and could not make sound judgments. Their emotions seemed flattened or out of sync with events. Frontal-lobe injuries led to a recognizable syndrome, dubbed Witzelsucht, that was characterized by childish behavior.

The next step in this line of research came from Carlyle Jacobsen at Yale University. In a study with two chimps, Becky and Lucy, he showed that once their frontal lobes were removed, they lost the capacity to solve simple problems. The frontal lobes, Jacobsen concluded, were responsible for an organism's adjustment to its environment. Jacobsen wrote that this region of the brain synthesized information, including memories formed from recent events, and it was this process that produced intelligent action.

In 1935, neurologists from Europe and the U.S. gathered in London for a congress that included an all-day symposium on frontal-lobe function. Neurologists presented case histories of their patients who had suffered frontal lobe injuries, and Jacobsen presented the results from his chimp studies. Walter Freeman (the lobotomist in the documentary) attended the symposium, and after listening to these presentations, he concluded: "The audience was impressed by the seriously harmful effects of injury to the frontal lobes and came away from the symposium reinforced in their idea that here was the seat of the personality and that any damage to the frontal lobes would inevitably be followed by grave repercussions upon the whole personality."

Now Portuguese neurologist Egas Moniz was also at the meeting. But he was inspired by one other message that was delivered at the meeting. Jacobsen, in his report on Becky and Lucy, noted that the surgery produced a marked emotional change in Becky. Before the surgery, Becky would go into a rage if she couldn't solve a problem (and thus obtain the food that was the reward). She'd roll on the floor, defecate, and otherwise show signs of extreme emotional distress. But after having her frontal lobes removed, Becky wasn't the least bit bothered when she couldn't solve a problem. It was as though she had joined a "happiness cult," or placed her "burdens on the Lord," Jacobsen said. Moniz seized on this kernel of information. This operation, he reasoned, could remove the anguish of mentally ill patients, and he figured that the intellectual deficits produced by destroying the frontal lobes wouldn't be that extreme. He said that humans who had suffered injuries to this region of the brain could "still understand simple elements of intellectual material," and thus concluded that "even after the extirpation of the two frontal lobes, there remains a psychic life which, although deficient, is nevertheless appreciably better than that of the majority of the insane."

So we can see in this history there was a great deal of research that was done prior to this surgery being tried, and it revealed what surgeons could expect from doing it on humans. There would be a diminishment of intellectual faculties, and a diminishment of the person's emotional engagement with the world. That was all very well understood. However, Moniz -- and many others who followed in his footsteps -- concluded that this was a change that would benefit the "mentally ill."

Now while there certainly were doctors and surgeons who worried about doing this surgery, and approached it very cautiously, nearly all of those who initially tried it reported good results, and published their findings in medical journals. Indeed, in 1943, a researcher tallied up the results of 618 lobotomies performed at 18 different sites in the United States and Canada, and concluded that 518 patients were "improved" or "recovered," and that only eight had been made worse by the surgery. The researcher concluded: "We have known for a long time that man may get on with one lung or one kidney, or part of the liver. Perhaps he may get on, and somewhat differently, with fewer frontal fiber tracts in the brain."

Thus, lobotomy arose out of a scientific process. First there was animal research done, and there were discussions about what frontal lobe injury did to people, and then the doctors who tried the surgery reported their results in medical journals, and they said it worked. And it did work, in the sense that it changed people in the expected ways. People operated on did become childish, less emotional, and intellectually dulled. The surgery did what scientists said it did; the question is why did they judge this to be a good thing for those said to be mentally ill? It was that evaluation process that provided a context for Freeman and others to do the surgery.

So, could something like this happen today? Could psychiatry -- or some other branch of medicine -- adopt a form of care that we would later come to see as harmful? The history of medicine certainly warns us that doctors can be deluded about the merits of their therapies, and today that whole decision-making process is greatly influenced by pharmaceutical companies' money, which only increases the possibility of medicine going astray. The lobotomy story really should remind us of that possibility.

In terms of whether the surgery is still being done today, surgeons will occasionally do a bilateral cingulotomy. The cingulate gyrus is a small area in the brain that connects the limbic system to the frontal lobes, and the surgery targets that structure. In the sense that a lobotomy disconnected the frontal lobes from other regions of the brain, there is a certain similarity between the two operations, but obviously this is a much more focused surgery, and it is, I believe, used sparingly as a "last resort," after other treatments have failed.

Question: What are the side effects of Thorazine and are there any effects to the brain after the medication is no longer being used? -V.C., Albuquerque, NM

Answered by Anand Pandya:
As with most medications that require a prescription many, many side effects are reported for Thorazine (also known as Chlorpromazine) but only a few are common enough to warrant discussion. Among the most common side effects of Thorazine are sedation (feeling tired or sleepy), dry mouth, constipation and blurred vision. These are side effects that are usually visible very early in treatment so if these do not occur in the first few days, they are less likely to occur. Some people are able to get used to these side effects so sometimes it is worth waiting to see if the medication becomes easier to tolerate with time. Other side effects include feeling restless (known asakathisia), rigidity (people report that they either feel "stiff" or appear "stiff") and a shuffling gait. These side effects can be treated so it is important to let your doctor know if you have any of these side effects. Some patients experience writhing or jutting movements. These are sometimes described as "spasms" and can be quite unnerving because it may feel as if you have momentarily lost control over part of your body. You should contact your doctor immediately, if these side effects occur. There may be medications that can address this side effect or it may require you to change medications. Finally, in the longer run, some people gain weight on Thorazine.

Almost all of these side effects are reversible with two exceptions. One type of jutting/writhing movement caused by Thorazine may become irreversible if it is not addressed promptly. This is relatively rare but it is one of the reasons why it is important to tell your doctor right away if you are having any unusual movements on Thorazine. Also, as we all know, it is usually easier to gain weight than to lose it so people who gain weight on Thorazine may need some time (and a lot of motivation) to shed any extra pounds.

Question: For Angelene Forester: Do you think the lobotomy was a positive operation and would you have agreed to havingyour mother undergo the operation if it was up to you? -A. M., McLean, VA

Answered by Angelene Forester:
Yes, if it was in the same time period, with the same facilities available and the technology and medicine of the time, unequivocally, yes. If it was today, no! I wouldn't because we have other things today, we have medicine. Many of the ailments that Dr. Freeman was fixing to cure, we now know are chemical. Many of the ailments, not only in my mother, but that other people had in the show, are being treated today chemically quite successfully. My mother was treated successfully at the end, with chemicals. So, yes, if it had saved time, I would have done it. Today, with technological enhancements and medicine, no.

There is one other thing. The electro-convulsive therapy that she was subjected to is used today very, very successfully to treat suicidal depression, which is one of the biggest things they took her to Dr. Freeman for, and it did cure that. She was never depressed or suicidal again. So, they would probably still treat her with the electro-convulsive therapy. But for the other problems ... my mother, over the years, had been under the care of a psychiatrist all that time. She was schizophrenic, paranoid, delusional, and she suffered from auditory and olfactory hallucinations. The medicine they put her on stopped them completely. She was like the mother I always wanted. And it was very successful, with the medical treatment we have today. It just shows how far we've come, and I'm glad she lived so long to be able to take advantage of the medicine and become my mother.

Question: What percentage of the lobotomized people were able to live relatively normal lives (gainfully working, marrying, having family, managing their finances ...)? What percentage of those who prior to the operation were rather hopelessly detained in mental institutions? -Svato Schutzner, Washington, D.C.

Answered by Walter Freeman III:
My father's statistics showed that one third of lobotomy patients returned to normal lives, one third returned to living with their families, and one third remained institutionalized for the remainder of their lives. There was a dramatic decrease in the incidence of suicide among lobotomized patients compared with untreated patients. The likelihood of discharge from state mental hospitals without lobotomy prior to the introduction of drugs and the use of lobotomy was under 5%. And the likelihood of mental anguish continuing for years with agitated depression and self-inflicted violence was very high, until eventual burnout. The images shown in The Lobotomist of the overcrowded state hospitals showed the results of abandonment of the patients by their families, as they "closed ranks" in my father's phrase and moved on. One of his great pioneering achievements was to introduce a psychiatric ward in a community hospital, so that acutely ill patients could be treated close to their homes and returned there in order to avoid being warehoused in the state institutions.

Question: In this century where MRI and new tools are available, has any physician or medical school tried to understand what were the positive and negative effects of lobotomy? What was really happening to the brains of these people?

Answered by Robert Whitaker:

An MRI or other modern imaging tool couldn't really provide any new insight into the surgery. Freeman and others knew with some precision what fibers they were cutting in the brain, and had a good sense of the importance of frontal lobe function to the human intellect. The frontal lobes, in fact, were often said to be the seat of human consciousness, the very part of the brain that gave rise to the faculties that separated us from our primate cousins.

Indeed, the "positive" effects of lobotomy could be fairly easily described back in the 1940s -- the surgery did make people less emotionally engaged, and that enabled some people to leave mental hospitals and go home. It often did reduce their psychic pain. However, that loss of emotional engagement with life could also be described as a negative effect. And then you had other negative effects as well -- the childish behavior, the apathy, the dulling of the intellect. Thus, modern imaging tools can't help us decide whether the surgery should be remembered as beneficial or harmful; the question is really one that goes to moral values. Was this a good change for the mentally ill or not? And before you answer that question today, you need to ask: What chance of recovery do the seriously mentally ill have in the absence of such aggressive treatments? The answer may surprise many, given that we are told that people with schizophrenia have a biological illness and are pretty much doomed to become chronically ill. In fact, many people with schizophrenia and other serious mental illnesses can and do recover over time. Freeman and others reasoned that lobotomy was justified because the mentally ill were doomed to be ill forever, that they really had no hope of getting better. But that is not true, and so you have to factor that possibility of recovery into any moral equation of this sort.

We should note that this same question arises for our society today. As the documentary noted, when Thorazine was introduced in 1955, it was hailed for producing a "chemical lobotomy." Antipsychotic drugs can make people less emotionally engaged, more apathetic, and intellectually dulled. But the drugs are said to be worthwhile because they are said to reduce psychotic symptoms. They remove distressing symptoms, much like the operation did, but at a significant cost. And while our society is convinced that antipsychotic drugs are good for the seriously mentally ill, many who are asked to take them do not share that sentiment. They complain about how the drugs make them feel like zombies, etc. So the moral dilemma that is at the heart of the lobotomy story hasn't really gone away.

Question: I notice the show didn't mention it, but do you think that the closing of so many state hospitals over the past 15-20 years has had a negative effect on many mentally ill? For example, the large numbers of mentally ill in prison or homeless who don't get any treatment, etc. What would Dr. Freeman think of the nation's deinstitutionalization? -P. C., Gary, IN

Answered by Franklin Freeman:
I know there's been a lot of criticism about closing the big hospitals and so on. But they were horrible places. During the late 1940s, most state legislatures budgeted $2 a day per patient for room, board, medical treatment, staff salary and so on. There was very little left over for treating the patients. And of course, psychiatry from the early 20s to the 1950s and beyond was dominated by the psychoanalysts, and psychoanalysts could not deal with these intractable cases. So these patients were just confined to the back wards where they got precious little treatment if at all, and they simply deteriorated. And that's a known fact.

So, at the same time, beginning in the late 1930s, the idea of community psychiatry came on board. Dad [Dr. Freeman] was one of the first in Washington to treat patients in the local community hospital -- mostly electroshock therapy, that sort of thing. Gradually the thing grew. Dad was involved in the building of the El Camino Hospital in Santa Clara, California. It was one of the finest psychiatric facilities in the state. My brother Paul and I stopped in there one time. Nice courtyard with flowers, obviously very well kept. So the idea was to close those terrible places and put them in the care of local hospitals and local psychiatrists.

Now, some of these people, they get away and they just don't take their medication, they end up committing crimes, they have committed suicide by threatening a police officer with a knife or something like that, and surprise, surprise: they're shot. So we still have that sort of thing, but on the whole, psychiatry has come a very long, long way since those terrible days.

Question: My grandfather, Charles Armstrong, received a double frontal lobotomy from Dr. Freeman in 1948 or 1949 which was a total success in treating his depression. He went back to work and lived to the age of 95 still reading the Harvard Classics daily. He had no negative effects from the treatment. How many other positive cases were there among Freeman's patients? -Brian Armstrong, Millstone Township, NJ

Answered by Andrew Scull:
Let me begin by saying that your grandfather was a very, very fortunate man. Stories like this one do exist, and they undoubtedly helped Freeman and those who emulated him convince themselves that lobotomies had merit. But they were rare, and far from the norm.

A few points to consider: the human brain is a phenomenally complex organ, at once very delicate and yet surprisingly resilient. To grasp this in another context, think of people who suffer serious strokes. Many incur brain damage so severe that they never recover vital motor and mental functions. In others, even with extensive pathology, the brain learns to adapt, and function is gradually restored. Lobotomies were extremely crude operations that inflicted quite varied patterns of damage on individual patients. Some people were relatively fortunate, and were able to compensate for the resulting deficits. Many more were left with permanent problems initiating action, a crippling lack of inhibitions, an inability to plan for even short-term goals, incontinent, and so forth. No one can tell you how many "good" results Freeman obtained, for the simple reason that no systematic data of this sort were collected, and such information as does exist was mostly gathered by Freeman himself, and is thoroughly unreliable.

As a general matter, the assessment of medical treatments is enormously difficult and complex, and fraught with the possibility of bias creeping into the evaluations. The complex protocols that govern clinical trials, and the insistence among most researchers on double blind controlled trials are both symptomatic of these problems, and represent an attempt to minimize their effects. These difficulties are compounded with respect to psychiatric treatments, where one is concerned with making a comprehensive assessment of patients' mental and social functioning across an extraordinary array of dimensions. These days psychopharmacologists attempting to test drug effects often rely on rating scales to try to measure outcomes. While providing a more systematic way of measuring improvement or its absence than anything that was used to evaluate lobotomy, these rating scales are not without their own flaws and problems, and often gloss over or ignore important issues that are difficult to measure but of crucial importance.

Finally, one should beware the tendency to rely on an individual piece of anecdotal evidence (or even a handful of such examples) when assessing whether a treatment "works." Lobotomy was a mutilating and irreversible operation that possessed little or no scientific warrant, and was used in remarkably careless ways on patients who either had no say in the matter, or who were gulled by ruthless enthusiasts like Walter Freeman, who fed them grossly inaccurate information about what was being done to them. Many operations were done on people whose problems were relatively minor and transient, and these less disturbed individuals undoubtedly provided the majority of Freeman's successes. (Note the passages in the program where Freeman is performing the operation on outpatients, or people like poor Rosemary Kennedy.) Lobotomy was presented as a last resort operation to be used on burned out schizophrenics on whom everything else had been tried. Some patients of this sort, particularly those who posed major management problems, were indeed operated on. But Freeman himself conceded that results in such cases were almost always poor. Instead, he preferred to seek out the depressed, the obsessive-compulsive cases, the neurotic, and even children like Howard Dully, whom you saw on the program. These patients suffered from conditions which were sometimes persistent, but often saw spontaneous remissions (i.e., they simply got better over time, unless their treatment made them worse). Perhaps that helps explain Freeman's eagerness to extend the "benefits" of psychosurgery to these forms of mental disturbance.

Question: Very good and interesting show. Dr. Freeman's procedure and attitude does seem rather cavalier. It seemed that the judgments of the value of this procedure were colored by the horrific nature of the procedure and supported with anecdotal data. Has there been any quantitative follow-up ever done on the side effects and benefits of this procedure? -N. S., Linden, NJ

Answered by Barak Goodman:
The quantitative analysis of lobotomy was meager. The obstacles to a good study of lobotomy were numerous: the patients were often abandoned in mental hospitals and therefore hard to access; controlled studies were of course impossible; and no two patients got the same operation (Freeman's operation was truly "a stab in the dark"). The stigma attached to the operation made it a less than desirable area of research and study. Perhaps the most thorough analysis was done by Freeman himself, who kept in touch with hundreds of his patients and tried to assemble data to support lobotomy's efficacy. I think we have to regard that data as suspect.

Question: When travesties such as these are uncovered, what, if anything, is ever done to rectify the damage that's been done or does everyone just walk away shaking their heads? -Howard Dully, San Jose, CA

Answered by Andrew Scull:

Dear Mr. Dully,
Sadly, I think the answer is often even worse than the alternatives you offer. Those who attempt to blow the whistle on these sorts of things are often ostracized or punished by their fellow professionals, who prefer to sweep professional misdeeds under the rug. Here are two examples:

At about the same time that Freeman was experimenting with lobotomy, a substantial number of psychiatrists, here and in Europe, were putting schizophrenics into extended comas by injecting them with insulin. They claimed 70 to 80 per cent cures. The procedure was dangerous, and its inventor claimed it "worked" by starving the brain of oxygen. In 1953, a young British psychiatrist, Harold Bourne, published a paper in The Lancet on "The Insulin Myth," arguing that the treatment was a sham and a failure. His reward, in the weeks that followed, was to be denounced in vituperative terms in the press and in professional journals by the leading lights of British psychiatry. Five years later, an extensive controlled trial demonstrated that Bourne was right. I am not aware that he (or those who had been put into the comas) ever received an apology, public or private.

A decade and a half before lobotomy, the superintendent of the Trenton State Hospital, Henry Cotton, had claimed to cure 85 per cent of his patients by removing the infections that he claimed caused all forms of mental illness. In pursuit of his goals, he removed teeth, tonsils, stomachs, spleens, colons, and uteri, virtually eviscerating many of his patients, and killing almost half of those he subjected to abdominal surgery. Thousands of others were left mutilated by his depredations. (He was every bit as sincere as Freeman, pulling his wife and his children's teeth in an attempt to prevent their going mad -- both his sons subsequently killed themselves -- and arranging to have his own teeth pulled when he himself had a mental breakdown. After which he was allowed to return to Trenton and to operate on many more patients.) America's leading psychiatrist, Adolf Meyer, who had sent one of his protégées, Phyllis Greenacre, to investigate these claims, suppressed her report documenting these disasters, and when Cotton died six years later, wrote an obituary in the American Journal of Psychiatry lamenting Cotton's premature death, and the cutting short of his grand experiment! (The whole travesty is recounted in my book Madhouse for those who are interested.)

Occasionally, after the fact, lawsuits are launched attempting to secure damages for the victims. This occurred in Canada, for instance, after the death of Ewen Cameron, former president of the American, Canadian, and World Psychiatric Associations, and a member of the Nuremberg medical tribunal which had investigated Nazi doctors. Cameron, practicing at McGill University, had experimented with "depatterning" and "psychic driving," extraordinary experiments where, inter alia, he wiped out patients' memories with repeated electroshocks designed to reduce those subjected to them to the status of helpless, incontinent "infants," whose psyches he then purported to rebuild. Cameron at his death was a highly respected figure in his profession. Only after it emerged that much of this work had been secretly supported by the CIA were lawsuits brought, some of which were successful in securing monetary damages for his victims and/or their families. Whether money could ever adequately compensate for what has been done, for suicides and ruined lives, is very doubtful, as I'm sure you would agree. But the legal acknowledgement of the depth of the wrong that has been wrought is, of course, worth something.

Remarkably, scholars writing about such episodes in recent years have adopted a more benign view of these human experiments. They have urged that these doctors' actions have to be seen in the context of their times, and the depth of the dilemmas they confronted. There is merit to these contentions to a point, but I fear they can easily topple over into apologetics. Freeman, Cotton, and Meyer were, in my view, moral monsters -- a judgment that requires more extended analysis than I can give it here. One needs, to be sure, to understand how they came to do what they did, and how they were able to persuade their fellow-professionals of the merits of the approaches they championed. But to understand is not to excuse, and I believe it is important to say so loudly and clearly.

Question: I'm wondering if Franklin Freeman might care to comment further on the E! Mysteries and Scandals broadcast where he states that his father lobotomized Frances Farmer, now that I have provided the source of the picture he states was of Farmer being operated on (it's actually a 1949 Seattle P-I series where the patient's face is seen in another photo) and also retrieved the complete lobotomy logs from Western State Hospital, which show all lobotomies Dr. Freeman (and those he trained) performed. Frances was not the patient in the photo nor is she in the lobotomy logs (or any surgery logs, for that matter). Thank you for your time. -Jeffrey Kauffman, Portland, OR

Answered by Franklin Freeman:

Many years ago Frances Farmer's file disappeared from the patient's records at Western State Hospital.

Question: Do you approve or disapprove of your father's work? -A. R., McLean, VA

Answered by Walter Freeman III:

I strongly approve my father's work developing, applying, and proving the value of surgical intervention to relieve the suffering from otherwise incurable mental disease leading to physical and emotional devastation and often suicide. I also approve the transorbital procedure, because its rates of mortality and postoperative epilepsy are one third those of standard procedures. I strongly disapprove the use of lobotomy to ease the control of aggressive and unruly patients, as appears to have occurred in the cases, under parental pressure, of Rosemary Kennedy and Howard Dully. I disapprove equally strongly the use of this valuable surgical procedure to reduce the cost of mental health care, by my father and by anyone else.

Question: How was Dr. Freeman able to perform all of these lobotomies without consent from patients or family members? -A.D., Waukesha, WI

Answered by Jack El-Hai:

Walter Freeman did secure legal consent for most of the lobotomies he performed, at least by the standards of the time. Many of his patients were wards of the state, institutionalized in government psychiatric hospitals. If the hospital administration decided that such patients would benefit from a lobotomy, they got one. In other cases, Freeman obtained consent from patients themselves (if they seemed competent to give it) or from family members and next of kin. In the early years of lobotomy, Freeman was quite scrupulous in gaining familial consent, because he believed that the families had to be on board to provide the extensive recovery care at home that most patients required.

As one anti-lobotomy psychiatrist pointed out in the 1940s, however, families could have mixed motives for approving a patient's operation. Some desperately hoped for a miraculous recovery, but others may have unconsciously wanted to end a patient's burdensome existence. Some chronically ill patients later confessed that they had wanted to die as a result of their lobotomy -- a passive form of suicide.

Question: Is there any way one can find out for sure if a lobotomy had been performed on him/her as a youth, some fifty years ago? Thank you. -S. Smith, Lake Tahoe, NV

Answered by Barak Goodman:

I would recommend you contact the George Washington University library, where Freeman's papers are kept. If you are a family member of one of Freeman's patients, it's possible you can gain access to his records. beyond this, it may be difficult to find out for certain if a lobotomy has been performed for it leaves no visible physical trace.

Question: Did having a father who was noticed in the public eye, positively and negatively, have an impact in your life? -Nguyen MyAnh, McLean, VA

Answered by Walter Freeman III:

Unless the parent is a president, governor, or superstar in cinema, sports or music, very little of public fame spills over to the spouse or offspring. In my experience the effect of having a parent who was greatly admired by some and detested by others was limited to the adoption of an attitude toward me that was colored by enhanced friendliness or overt avoidance in social encounters. As far as I can tell, the fame did not carry over to overt preferential treatment in admission to schools or openings for jobs. To the contrary, I was impressed that people who had a negative attitude toward my father were more likely to be scrupulous in visiting that anathema on my head.

Question: If the chemical treatment Thorazine had not come into use, would lobotomy still be considered an acceptable form of treatment? -Thomas Kohlbrenner, McLean, VA

Answered by Anand Pandya:

Aside from the discovery of Thorazine, there are several other treatments that were developed or refined around the same time and those treatments also have many advantages over frontal lobotomies. These include Lithium, tricyclic antidepressants and electroconvulsive therapy as well as the development of psychosocial interventions such as clubhouses and residential models that empower patients, and cognitive and behavioral therapy. Together, these interventions would likely have displaced frontal lobotomy.

In addition, starting in the sixties, we have had a revolution in society's attitudes about the rights of people with mental illness. It is not acceptable (and, of course, it never should have been acceptable) to ignore the preferences of the person with the illness and their family. Nor is it acceptable to engage in such invasive procedures without offering the patient and their family information about the risks, benefits and alternatives. I believe that these reforms would have reduced the practice of frontal lobotomies even if we didn't develop better treatments. The documentary The Lobotomist vividly shows that lobotomies may have been helpful for some people and were clearly not appropriate for others. I believe that if we did not have modern treatments, we would have at least learned not to use frontal lobotomies only on carefully selected cases. In fact, psychosurgery is still performed on patients with severe cases of OCD but such patients are carefully selected and there is a process for informed consent.

Your question acknowledges that most frontal lobotomies were acts of desperation in a time before medication. In the centuries before frontal lobotomies, there were even more dangerous attempts to treat mental illness such as bleeding. Like bleeding, frontal lobotomies could calm a patient temporarily. When you look back over the course of history, you realize that frontal lobotomies seem like just a step on a long path. Our modern medications are probably just another step. They are far better than a frontal lobotomy but I believe that someday we will have treatments that are far better still.

This doesn't mean that everything is always getting better. The lives of people with mental illness can and has become much worse at times when society is not willing to treat all people with dignity. Hopefully, we can learn this lesson from the tragedies of frontal lobotomies.

Question: Why is it exactly that many of the surgery patients suffered through negative consequences? Did Dr. Freeman cut the wrong nerve connections? If so, what part of the brain causes mental illnesses? -Manaswi Sangraula, McLean, VA

Answered by Walter Freeman III:

There are no exact answers to your questions, because there is no one part of the brain that causes mental illnesses, and there is no one connection to cure them.

My father was aiming to disconnect the thalamus from the frontal cortex. The most eminent neurophysiologist of the 1920s and 1930s, John Fulton at Yale School of Medicine, found in two chimpanzees, Becky and Lucy, that cutting the nerve connections between thalamus and frontal cortex greatly reduced the emotional behaviors of the chimps. He presented his findings to an international meeting in 1934. Egas Moniz went home to Portugal and operated on 12 chronically institutionalized patients. He showed that four were able to return to work, four were able to live at home, and four were no better or worse. He reported his work to a congress in London in 1935. My father learned from talking with Moniz, not just from reading.

The positive consequences of cutting between thalamus and frontal cortex were loss of fear and anxiety. The negative consequences of cutting were loss of social inhibition (loss of guilt, shame, fear of disapproval) and loss of the ability to think ahead (no ambition, eating to excess, inability to read the minds of others).

This same Hobson's choice holds for so-called "chemical lobotomy." People who start taking Prozac, Miltown, or other tranquilizers no longer suffer anxiety and fear of the future, but they lose ambition, libido, and the capacity for deep feelings. That is the cost of treatment. Neither surgery nor drugs cure the mental illness. They only relieve the suffering, and the cost is high. Most patients who are not suffering too much prefer to continue to suffer than to accept the loss. Other patients suffer so intensely that they kill themselves rather than continue living. For them, lobotomy offers a one in three chance at returning to a normal life. But if the operation fails, they still get relief from their demons, though they may no longer care.

Answered by Anand Pandya:

Unfortunately, we do not completely understand what causes mental illness but it is clear that rather than a problem in one part of the brain, most mental illnesses are caused by a complex interaction between different parts of the brain. Today, neurosurgeons are able to figure out fairly precisely where they want to intervene within the brain based on a variety of tests and the use of CT scans and MRIs. These were not used in lobotomies and thus it is likely that each lobotomy affected many different parts of the frontal lobes (the front part of the brain responsible for a variety of things including planning and executing certain behaviors). It is likely that they frequently cut the "wrong nerve" (although we would technically call these "neurons" rather than "nerves").

More importantly, this documentary makes it clear that the treatment was tried on a broad variety of patients with a broad variety of problems. It is likely that for some of these patients there was no "right nerve" to cut in their frontal lobes. Thus, one of the lessons from this tragedy is that we need to be very careful -- both careful in the way we do our treatments and careful in matching the right treatment to the right patient.

Question: When I watched the program and heard about the children that had had lobotomies, I had to wonder if anything has really changed. There are many children today being treated with antipsychotics, and some are very young. From what I can tell many of these children are in foster care, and are drugged to keep them under control. Are there not any rules, regulations or oversight into the "chemical lobotomizing" of our children? Are there likely to be adverse effects from treating people with these drugs when they are not truly mentally ill? -M. W., Tomball, TX

Answered by Andrew Scull:

Thank you for your excellent question. The issue of drugging children with such things as Ritalin, antipsychotics and antidepressants is a complex one. I am not one of those who believes, as does the psychiatrist Peter Breggin, that all psychopharmacological agents are toxic, and their use never defensible. For some children (and for some adults), when used with care, drug treatments have their place. It is important, however, to understand the limits of drug treatments for psychiatric disorders. Even in the best of circumstances, they are not psychiatric penicillin. They alleviate symptoms, sometimes and for some people. They do not cure. That limited success is nonetheless a worthwhile accomplishment when they work, which is far from universally.

There is still another set of problems that need to be acknowledged: when the lay person hears that something represents a significant improvement as a treatment, the natural tendency is to believe that "significant" means that it represents a "major" improvement. What it really means is that it meets a statistical test of significance, often a very low threshold. The improvement the treatment offers may be marginal, or even a product of the particular rating scale that was devised to measure the drug effect. That rating scale may ignore or overlook other impacts of the drug, and may indeed have been very precisely tailored to "prove" that the drug works. Enormous sums of money are at stake here. Pharmaceutical companies invest many millions of dollars to bring a new drug to market, and stands to make billions if a new medication with broad applications is approved. Outside the realm of psychiatry, the recent revelations about the manipulation of data on the safety of Vioxx illustrate how these market incentives can influence the behavior of the pharmaceutical industry, to the detriment of patients.

One should harbor no illusions. Contemporary psychiatry is largely in thrall to the big drug companies, and the classification of diseases in contemporary psychiatry is essentially driven by the impact of those companies, as refracted through the academic community. One symptom of this is the explosion in the range of behaviors which are pathologized and "psychiatrized," something you can readily see for yourself by getting hold of successive editions of the American Psychiatric Association's "bible," the Diagnostic and Statistical Manual. This expansion of the psychiatric universe has entailed the redefinition of all sorts of problems in living as medical diseases, for which, conveniently, the drug companies have a suitable pill to sell. (For an excellent and sophisticated discussion of these issues, I recommend you read a book by the British psychiatrist David Healy, called The Anti-Depressant Era. It is published by Harvard University Press.)

Nowhere has this dubious expansion of psychiatric labels been more common than with children. Howard Dully, whom you saw in the program, was treated with a lobotomy. His contemporary equivalents are treated with pills. Is this an improvement? On the whole, yes. For the most part, even if the drugs don't work, they don't inflict the lasting and grave damage that a lobotomy did. But that is not the whole story. For on occasion, these drugs have devastating effects. After years of denial, and suppression of the relevant clinical trial data, drug companies have finally been forced to acknowledge that certain antidepressants carry with them an increased risk of suicide among children and adolescents. Antipsychotic drugs often dull the mental faculties, and they carry risks of serious iatrogenic consequences, many of which are masked as long as the patient remains on the pills, but then surface and are essentially untreatable. For twenty years after the introduction of Thorazine, psychiatry denied that its use was associated with the risk of permanent disabling and stigmatizing tics and grimaces -- a disorder called tardive dyskinesia. This is now a recognized risk of using these drugs. It almost certainly reflects neurological damage attributable to the drugs, and it remains something we cannot reverse and very often cannot effectively mitigate. On another level, treating what are often behavioral and maturational issues through drugs is a terrible evasion of the underlying issues, and illegitimately redefines what are often as much social and psychological problems as biological -- among other things, a dreadful lesson to teach our children.

Question: For Angelene Forester: How did your mother do long-term after her lobotomy? Did she ever need further treatment for depression or mental illness? Was she dependent and childlike, in need of support, like some patients were? -M. H., Woodstock, GA

Answered by Angelene Forester:

My mother never needed any further treatment for depression, and she never showed any sign of depression after the treatments; however, she had other medical problems as far as mental illness goes and she did require treatment. At the time they were developing new pharmaceuticals, and she was on them for the rest of her life. She did quite well on them. She did not develop any of the side effects that some people did. She was not childlike in any way. She was an adult; she was able to hold a job, she became an L.P.N. She worked, she was a nanny. She had a normal life after that. I never looked upon her as childlike at all. She lived by herself after my father died and she did quite well. She shopped, she had friends, she went out. There were no other problems at all with the medication and the treatment. She didn't become hampered at all like some of the other patients I've heard of. She was a full human being, and was in full faculty.

Question: This was one of the most difficult episodes of a historical documentary I have ever viewed. I have a Tivo and had to stop after just a few minutes and watch the show in its entirety at a later time. It was very difficult to watch. I missed the information in this episode about the consequences of a lobotomy. What is the range of capabilities a patient can hope to experience after this procedure? Are they committed to an institution for life or can they interact with others in a meaningful way? The documentary (or is it just the procedure itself) seems horrific for the patient. What are the benefits?

History that evokes an emotional response like the story of Dr. Freeman is worth watching. Thanks for telling this story despite how difficult it is to watch. -John Powell, Austin, TX

Answered by Barak Goodman:

One of the difficulties in assessing the lobotomy -- then and now -- is the fact that results varied so widely. No two patients received the same operation -- it truly was "a stab in the dark." Furthermore, Freeman operated on such a wide range of patients -- from the profoundly mentally ill to the merely badly behaved -- that any real scientific understanding of the effects of lobotomy was truly impossible. Finally, there were very few real studies of the procedure. By the time such studies were commonly undertaken in the 1950s, lobotomy was already on its way out. That said, it is possible to state some generalities. Freeman himself followed up with his patients very closely and published results in his own books. In gross terms, he said, a third of lobotomy patients were helped, a third were largely unaffected, and a third got worse. Not great results. Even for those who were "helped," there might be an alleviation of the symptoms of their illness, but that came with a cost. Patients were often permanently impaired. They lost all initiative, had little or no ambition or drive, lost their ability to make social judgments or decisions. They were childlike in their naiveté about the world and the impression they made on others. A few lucky ones had no noticeable side effects at all. For them, lobotomy might have been the greatest thing that ever happened. There seemed to have been very few of these patients.

Question: Was Dr. Freeman ever sued by any of his patients' families, or disciplined by the medical profession? -C. D., Lorton, VA

Answered by Jack El-Hai:

The short answer is no -- an indication of an earlier age's distaste for litigation and reluctance to apply professional oversight.

A patient once did take legal action against Freeman, not for lobotomy, but for injuries she sustained as a result of electroconvulsive therapy (ECT) he administered. Back before drugs could prevent ECT convulsions, Freeman was short of help and tried to restrain the patient single-handedly during the treatment. He failed, and the patient broke a limb. He and the patient eventually settled out of court. Freeman ruefully remarked that he should have known that the patient was better suited for lobotomy than for ECT.

I have heard secondhand that a lobotomy patient's lawsuit against Freeman was in the works during the early 1970s, but that the patient abandoned it upon Freeman's death in 1972.

Except for the hospitals that withdrew his surgical privileges when lobotomy fell from popularity at the end of his career, no medical body ever disciplined or penalized Freeman. In fact, Freeman long served in the leadership of several medical organizations, including the Medical Society of the District of Columbia, which he is credited with racially integrating during the 1950s.

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