Reviews Book

The Lobotomist: A Maverick Medical Genius and his Tragic Quest to Rid the World of Mental Illness

BMJ 2005; 330 doi: (Published 26 May 2005) Cite this as: BMJ 2005;330:1275
  1. Raj Persaud, Gresham professor for public understanding of psychiatry and consultant psychiatrist1
  1. 1 Maudsley Hospital, London

    Aside from the Nazi doctor Josef Mengele, the US neurosurgeon Walter Freeman ranks as the most scorned physician of the 20th century. The operation Freeman refined and promoted, the lobotomy, still maintains a uniquely infamous position in the public mind nearly 70 years after its introduction and a quarter of a century after its disappearance.

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    Jack El-Hai

    Wiley, £19.99/€24.30/$27.95, pp 368 ISBN 0 471 23292 0

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    At the Santa Marta Hospital in Lisbon on 12 November 1935 Egas Moniz and Almeida Lima began the first neurosurgical attempts to attack the frontal lobes as a psychiatric treatment. They published impressive results of their initial series of 20 leucotomies within just four months of the first operation: they claimed improvements in two thirds of the patients and complete cure in a third. This rush to publication ensured no proper follow-up beyond the first few weeks of surgery. Of course, if you read the fine print of the neurosurgeons' claims you will see that Moniz maintained that although the operation did not in fact eliminate his patients' delusions and hallucinations, it did diminish their emotional responses to psychotic symptoms.

    But back in 1936, when Freeman performed his first leucotomy, the only alternative treatment for severe mental illness was prolonged institutionalisation, and the procedure did seem to liberate many patients from this fate. How else to explain why, in the United States alone, more than 40 000 such procedures would be carried out over the next few decades, and why it remained in use well into the 1970s?

    Yet the popular media view of psychosurgery, reinforced by its portrayal in Ken Kesey's film One Flew Over the Cuckoo's Nest and Frances, the 1982 biopic about the life of the rebellious movie and stage actress Frances Farmer, is that doctors chose particular patients to operate on precisely because they wanted to crush their spirit. A disturbing scene in Frances shows a balding and goateed psychiatrist, who closely resembled Walter Freeman, performing an “ice pick” lobotomy at Western State Hospital on the supine heroine. The film turned Frances Farmer into a well known symbol of the excesses of the procedure—a patient supposedly selected for her nonconformist political opinions and who was operated on only with the consent of her vindictive mother, who colluded with doctors in using the procedure to vanquish her soul and spirit.

    But as Jack El-Hai points out in this meticulously researched account, it's extremely unlikely that Frances was an accurate portrayal of the psychiatric treatment Farmer actually received. The author can find no reliable record in the hospital's accounts of its operations that anyone fitting Farmer's description ever received the procedure. Also, given Farmer's personal accomplishments after her release from the institution—marrying, regularly hosting a TV programme in Indianapolis, and appearing on This is Your Life—combined with Freeman's compulsive pursuit of his patients to accumulate evidence of the benefits of his controversial procedure, it seems odd that the neurosurgeon would neglect to record or mention what would have been his most celebrated success story.

    Freeman himself was assiduous in his own follow-up of his patients, crisscrossing the United States long into his retirement, driving alone and living in a camper van, obsessively pursuing the evidence in his former patients' subsequent lives that the procedure was worth performing.

    For example, two years after no contact from one ex-serviceman on whom Freeman had operated in 1946, the man suddenly appeared in Freeman's office bearing a long narrow box, which he handed to the physician. “Take this, Doc,” he told Freeman, “I've decided not to kill myself.” After he left Freeman opened the box and found a rifle and a supply of ammunition. Oddly enough, in the light of modern psychiatric practice, Freeman, as with all his other patients, pursued this one over many years to keep track of how the patient was doing, but Freeman also kept trying to return the gun to him. The patient refused to have it back.

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    Frances Farmer: a symbol of the excesses of lobotomy


    Although he was an enthusiast for his procedure, Freeman could be quite circumspect. For example, he always declined to operate on people in prison, despite pressure from attorneys keen to claim that the procedure had removed their clients' “criminal tendencies,” so rendering them ready for release. A habitual burglar, Millard Wright, with no history of violence underwent the procedure in 1947 as part of his lawyer's plan to secure his release from prison, but tragically the judge with whom this initial agreement had been hatched died before Wright could return to court to be re-evaluated. Despite the fact that the press now reported him to be a “new man… cheerful, sociable, relaxed,” the new judge refused to cooperate with the lawyer's plan and, despite Wright having had the lobotomy, sentenced him to between two and 10 years of prison. Wright used his eyeglasses to slash an arm and then hanged himself while in custody.

    This incident was followed in 1950 by the slaying of a Yale University psychiatrist, Lewis Thorne, by a former patient who had received a lobotomy several years earlier.

    The violence and suicide associated with extremely disturbed states of mind claim victims on both sides of the therapeutic fence, doctors as well as patients. This extremely sympathetic account of Walter Freeman reminds us that doctors have, at the very least, courage in such attempts to engage with difficult and dangerous conditions—which the popular media, in their rush to condemn, fail to appreciate.


    • Items reviewed are rated on a 4 star scale (4=excellent)

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