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Day 4:
January 24, 2008
Did Dr. Freeman cut the wrong nerve connections?
Are there no regulations governing the "chemical lobotomizing" of our children?
Was your mother dependent and childlike, as some patients were?
What is the range of capabilities a patient can hope to experience after this procedure?
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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