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Day 2:
January 22, 2008
If it were up to you, would you have agreed to having your mother undergo a lobotomy?
What percentage of lobotomized people were able to live relatively normal lives?
What would Dr. Freeman think of the nation's deinstitutionalization?
How many positive cases were there among Freeman's patients?
Question:
For Angelene Forester: Do you think the lobotomy was a positive operation and would you have agreed to having your 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.
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