Frank Freeman remembers hiking with his father in the woods, going fishing with him, and setting off on cross-country driving trips that could last for weeks. He also recalls one occasion in 1952 when he helped his father perform a trans-orbital lobotomy on a patient.
The procedure, which his father, Walter J. Freeman, popularized and perfected, involved first knocking the patient unconscious with two or three jolts of electricity from an electroshock therapy machine. "I was there to hold the person's legs down," Frank Freeman says. "We all went for a ride when he threw the switch."
After the convulsions subsided and the patient lay insensate, Walter Freeman lifted the patient's eyelid and inserted an ice pick-like instrument called a leucotome through a tear duct. A few taps with a surgical hammer breached the bone. Freeman took a position behind the patient's head, pushed the leucotome about an inch and a half into the frontal lobe of the patient's brain, and moved the sharp tip back and forth. Then he repeated the process with the other eye socket.
"I was kind of impressed," Frank Freeman recalls. "He made it look so easy."
For Walter Freeman, a neurologist and psychiatrist who practiced in Washington for 28 years, it was easy. He kept record of 3,439 lobotomies he performed during his career. His technique of trans-orbital lobotomy was such a breeze that he could teach it in a day or two to state-hospital psychiatrists who, like himself, had no certification in surgery. Freeman gave lobotomies to children, adults, old people, and people with depression, manic-depression, schizophrenia, obsessive-compulsive disorder and a variety of undiagnosed psychiatric illnesses. He believed in lobotomy, defended it, promoted it and demonstrated it during psychosurgical road trips he took to more than 55 hospitals in 23 states. He felt certain that lobotomy could return psychologically disabled people, many of whom had no other prospect of effective medical treatment and who lived in oppressive psychiatric wards, to useful lives.
"Lobotomy gets them home" was his motto.
Freeman's enthusiasm for lobotomy, which developed through his work with his colleague James Watts at George Washington University Hospital, began a wave of psychiatric surgery that was used on 40,000 to 50,000 Americans between 1936 and the late 1950s. It is difficult to say how many benefited. Few controlled studies were ever conducted, and Freeman's own summaries of his results were difficult for others to interpret.
By the time Freeman died in 1972, his theory that mental illness could be cured by physically attacking the brain's frontal lobes had been discredited. While things have not exactly come full circle since then, there is much in today's neuropsychiatric climate that Freeman would recognize.
Many psychiatrists no longer practice "talk" therapy and instead treat their patients' brains. In 1999 Surgeon General David Satcher issued a 450-page report on mental health making the case that many psychiatric illnesses are actually brain disorders, and that often the most effective treatments affect the transmission of messages in the brain's neuro-pathways.
Freeman would fully agree. He believed that lobotomy succeeded because it severed neural connections between the frontal lobes of the brain and the thalamus, which he characterized as the seat of human emotion. Mentally ill people were too self-aware, he maintained, and their overactive emotions caused them to obsess about their problems. Sixty years ago few of Freeman's colleagues, especially psychiatrists for whom psychotherapy was the preferred treatment for psychiatric disorders, believed that brain disorders caused mental illness. Now we live in an era in which a biological and brain-centered view of mental illness reigns supreme.
But do today's neuroscientists celebrate Freeman as a pioneer, far ahead of his time in his focus on the brain in treating psychiatric disorders? Far from it. Researchers investigating new methods of surgically treating the brain for mental illnesses find his legacy a hindrance to the public's understanding and acceptance of their research.
Why, 34 years after his final lobotomy, does Walter Freeman continue to cast a shadow over psychiatric surgery? The answer lies in the complex tangle of Freeman's personality and motivations, and in the public's fear of past abuses.
When Freeman arrived in Washington in 1924 to direct the laboratories at St. Elizabeths Hospital -- one of the nation's preeminent institutions for the insane -- he carried with him more baggage than medical textbooks and instruments. He also shouldered a load of high expectations, courtesy of his family. Born and reared in Philadelphia, Freeman belonged to a prominent and hard-working medical clan.
His maternal grandfather, William W. Keen, served as a surgeon during the Civil War, removed a tumor from the jaw of President Grover Cleveland, experimented with an early form of cardiopulmonary resuscitation, and was a president of the American Medical Association. Freeman's father was an otolaryngologist with a practice of modest attainments.
Freeman himself attended Yale and the University of Pennsylvania School of Medicine before studying neurology and psychiatry in Europe. Initially, he regarded mental hospitals with what he called in his unpublished memoirs "a rather weird mixture of fear, disgust, and shame." These feelings soon were transformed into indignation: "I looked around me at the hundreds of patients and thought what a waste of manpower and womanpower." Freeman thought the idleness and confinement of vast numbers of patients a great social tragedy, and he wanted to do something about it.
He set about -- ultimately unsuccessfully -- to discover measurable differences between normal brains and those of schizophrenics. While working at St. Elizabeths, Freeman opened a private practice and joined the medical faculty of George Washington University as a professor of neurology. By the mid-1930s he had introduced several new therapies for mental patients at GW Hospital: insulin shock therapy, metrazol shock therapy and electroconvulsive therapy. All of these treatments were intended to fight psychiatric disease by subjecting patients to chemicals or jolts of electricity that might disrupt unhealthy neural activity in the brain.
It's easy to imagine Freeman -- his high forehead, steel-rimmed glasses and goatee making him look the part of the consummate 1930s mental doctor -- convincing seriously ill patients and their desperate families that these experimental treatments held the only hope for recovery. For many Americans with psychiatric diseases, hospitals could offer little else except the agonies of cold-water therapy and long-term storage in facilities that echoed with the screams and moans of the hopeless.
In 1935 Freeman caught his first glimpse of yet another treatment that could join his arsenal. At a London conference, he attended a presentation by a Yale researcher on the behavioral effects of surgical damage to the frontal lobes of chimpanzees. The animals became subdued and inactive. Rather impulsively, another conference attendee, a Portuguese neurologist named Egas Moniz, rushed home and began performing similar operations on mentally ill people. Moniz's subsequent reports on these experiments crossed the Atlantic and further intrigued Freeman.
To him, the intoxicating thing about psychosurgery -- Moniz's coined term for psychiatric surgery -- was its potential to sever the links between the over-excited emotions of an unhealthy thalamus and the behavioral functions of the prefrontal lobes of the brain. If it worked, the destruction of these nerve fibers would prevent the thalamus from poisoning patients' thinking.
He absorbed the details of Moniz's work and, with GW neurosurgeon Watts, began figuring out how to adapt the Portuguese physician's techniques. Freeman and Watts used brains from the hospital morgue to practice the coring of sections of the prefrontal lobes with a leucotome. By the summer of 1936 they were ready for a live patient: a Mrs. Hammatt from Topeka, Kan.
Sixty-three years old and suffering from agitated depression, she came to Washington with her husband, desperate for an improvement to her sleepless and hysteria-filled life. Freeman explained to her that without a lobotomy -- the name he and Watts gave for their surgery -- she faced an indefinite stay in a mental hospital. She decided to take her chances with this new operation, which was scheduled for September 14, 1936.
When the day arrived, Mrs. Hammatt tried to change her mind when she found out that her head had to be shaved. Freeman and Watts promised to spare as much of her hair as they could, before forcibly anesthetizing her. Later, Freeman recorded that her last words before surgery were, "Who is that man? What does he want here? What's he going to do to me? Tell him to go away. Oh, I don't want to see him," followed by a scream.
Freeman and Watts then performed America's first lobotomy. They drilled six holes into the top of Mrs. Hammatt's skull and inserted a leucotome into each. The two physicians shared the task of lesioning the brain, as they did for all of the approximately 1,000 lobotomies they performed together. They rinsed the openings with saline solution and sutured the wounds.
By Freeman's account, Mrs. Hammatt emerged a transformed woman. She felt a great relief of her anxiety. After a hemorrhage scare on the third day of recovery, she was discharged from GW Hospital about a week later. "She survived five years, according to Mr. Hammatt the happiest years of her life," Freeman noted in his autobiography. "As she expressed it, she could go to the theatre and really enjoy the play without thinking what her back hair looked like or whether her shoes pinched."
Thus encouraged, Freeman and Watts went on to perform more operations and further refine their technique. They replaced Moniz's coring leucotome with one resembling a butter knife and moved the entry holes to the sides of the skull. They developed a "radical" procedure that made more cuts into the brain. Some patients needed multiple lobotomies; others died. They operated on an alcoholic lawyer and Rhodes scholar who escaped from the hospital on Christmas Eve and was found, drunk, in a downtown Washington bar.
Freeman and Watts headquartered their increasingly lucrative private practice in a house at 2014 R St. SW. Watts occupied an office at ground level, their assistant manned the first floor, and Freeman worked upstairs. Lobotomy Patient No. 157 once returned to threaten their lives and two others pulled guns on Freeman when he recommended psychosurgery.
As much as some of Freeman's colleagues lamented the practice of damaging healthy brain tissue in order to treat mental illness and the absence of scientific evidence that lobotomy actually worked, doctors were even more critical of Freeman's hunger for public recognition. More than once, AMA members tried to censure him for advertising his services, which was then considered an unethical practice for physicians. The suspect advertising appeared, his accusers said, in the colorful lobotomy exhibits Freeman set up every year from 1939 through the early '40s at the annual AMA convention. Freeman targeted his displays not at other doctors, but at the press.
"I found the technique of getting noticed in the papers," he later acknowledged. "It was to arrive a day or two ahead of the opening [of the convention] and install the exhibit in the most graphic manner and then be alert for prowling newsmen." Playing the role of barker, entertainer and scientist, Freeman used hand-held clackers to draw reporters and frequently displayed a lobotomized animal.
The results were immediate. Freeman described what happened after journalists viewed the exhibit in 1939: "That night our monkey died but Watts and I made the headlines even though we did not get an award." A photo of Freeman and Watts in the operating room appeared in Time magazine in November 1942, and many other magazines and newspapers published laudatory accounts of the Freeman-Watts operation.
By his own reckoning, 52 percent of their first 623 surgeries yielded "good" results, 32 percent "fair," and 13 percent "poor." Three percent died during or after surgery. At first glance, those results seemed miraculous, given that few other treatments held much promise for hard-core cases of depression, agitation and obsessive behavior. But Freeman and Watts often did not define what they considered improvement to be. Relapses frequently occurred. In addition, a certain number of these cases were bound to get better on their own. And the aftereffects of lobotomy, separate from the symptoms of mental illness, often crippled the emotions, inhibitions and personalities of patients.
Nurses who cared for Freeman-Watts patients immediately after the operations grew accustomed to dealing with people who needed to be retaught how to eat and use the bathroom. The patients often made clumsy passes at their caregivers, urinated on their shoes, sat unmoving for hours, stubbornly refused to follow instructions and behaved childishly. Nurses learned that spanking and tickling could reliably distract patients from delusions and perceived threats. The most famous failure of Freeman and Watts from this period is Rosemary Kennedy (JFK's sister), who was probably the first mentally retarded person to receive a lobotomy and who has needed full-time care for the past 60 years.
Freeman believed that many of these changes were not only acceptable, but also therapeutic. He saw laziness, indifference and dullness as signs that the overcharged emotional impulses of the thalamus had successfully been derailed. The less that patients paid attention to their own troubles, the better.
Officials at state mental hospitals and veterans hospitals across the country also found the trade-offs acceptable. (An exception was William Alanson White, superintendent of Freeman's own St. Elizabeths, who never allowed lobotomies in the hospital during his tenure.) Lobotomy arrived on the scene at a time when these institutions overflowed with patients, many of them servicemen who developed mental illnesses during World War II, with no reliable courses of treatment ahead of them. Mental health practitioners desperately needed new therapies.
By 1945, however, Freeman was starting to doubt the effectiveness of his standard lobotomy procedure. The damage it caused was undeniable. Its cost and requirement of a skilled neurosurgeon limited its application. Freeman was also rethinking the standard wisdom that lobotomy should be the therapy of last resort. He suspected that people who had been seriously disordered for more than five years were usually too far gone to be helped, and that lobotomy might work best for patients in the early stages of psychiatric illness.
His research led him to the work of Amarro Fiamberti, an Italian psychosurgeon who eliminated the need for boring holes into the skull by breaking through the easily accessible bone at the rear of the eye socket and injecting alcohol or formalin into the brain. Again practicing on cadavers, Freeman altered this technique by replacing the injection with the cuts of a sharp instrument -- first an ice pick from his kitchen whose handle bore the name of the Uline Ice Company and later a type of leucotome that he designed and always carried with him in a felt-lined case.
Freeman kept his new trans-orbital technique a secret from Watts. In January 1946, he performed the first such operation in his R Street office on a patient named Ellen Ionesco. Eight more followed in quick succession. He often sent patients home in a taxi an hour after the operation. Freeman later wrote that during his 10th trans-orbital surgery, he called Watts to his office to assess the operation. Watts later claimed, however, that he entered Freeman's office unsummoned and found Freeman pushing an ice pick in the eye socket of an unconscious man. Freeman audaciously asked Watts to hold the ice pick so that Freeman could take a photograph. Whichever account is true, no one disputes the result of this encounter: Watts threatened to break off their partnership if Freeman persisted in performing lobotomies himself and treating them as office procedures done without surgical gloves or sterile draping. For the remainder of his association with Watts, Freeman did these operations outside the office.
For the next 21 years, Freeman performed trans-orbital lobotomies almost exclusively. One of his earliest setbacks came at the end of 1947 in the case of a Washington-area police officer who hemorrhaged on both sides of the brain after the operation and was left seriously disabled, "never able to do more than the simplest tasks around the house," Freeman wrote. He later wielded his leucotome and hammer in state hospitals in South Dakota and Washington state, and from there to half of the other states. In the late 1940s at Western State Hospital in Steilacoom, Wash., Freemen met the movie actress Frances Farmer, according to Farmer's biographer William Arnold.
Farmer had been a patient there for five years, the victim of her family's intolerance of her unconventional and wild behavior. Whether Freeman lobotomized her remains unclear, though Arnold says he did. Farmer's relatives and Western State's staff psychiatrist at the time said it never happened, but Frank Freeman says his father verified Farmer's operation and identified her as the patient shown in the world's most famous lobotomy photograph, an oft-reproduced shot showing Freeman using his hairy and muscular arms to hammer the leucotome into a woman's eye at Western State as a crowd watched. Filmed interviews of Farmer made after her discharge from the hospital show a detached and flatly demeanored (though clearly intelligent) woman, an outcome consistent with lobotomy.
Walter Freeman's championship of trans-orbital lobotomy revealed many of his worst qualities. Shocking his colleagues, for instance, grew into a great source of pleasure. Once, during a lobotomy demonstration at a nursing home in Baltimore before a group of surgeons, he replaced his surgical hammer with a carpenter's mallet. He delighted in reporting how other lobotomy demonstrations made a Columbia University professor emeritus of neurology weaken with faintness, sickened students in England, and so outraged a German neurologist that Freeman said, "I almost had to push him out of the way in order to perform the operation." Several times he showed off his virtuosity with the leucotome by performing two-handed lobotomies, working on both eye sockets simultaneously.
His cross-country trips in pursuit of lobotomy patients and his self-appointment as the trans-orbital procedure's international ambassador only heightened Freeman's sense of professional solitude -- and caused him to commit serious errors of judgment. More than once he worked the leucotome forcefully enough to break it inside a patient's brain. At Cherokee State Hospital in Iowa, he accidentally killed a patient when he stepped back to take a photo during the surgery and allowed the leucotome to sink deep into the patient's midbrain.
Freeman had completed 400 trans-
orbital lobotomies by 1949, and maintained a brisk pace of work for the next five years. He had already alienated psychiatrists by insisting that psychoses were actually organic brain disorders, and now he invaded the turf of neurosurgeons by performing brain operations and training other doctors lacking surgical certification to do so. The superintendents of state hospitals continued welcoming Freeman to their institutions, though, because some lobotomized patients went home and many of the others were easier to manage. "The noise level of the ward went down, 'incidents' were fewer, cooperation improved, and the ward could be brightened when curtains and flowerpots were no longer in danger of being used as weapons," Freeman wrote.
By the mid-1950s, new tranquilizers such as chlorpromazine had replaced trans-orbital lobotomy as the treatment of choice in many of these same hospitals. Meanwhile, Freeman's partnership with Watts had fallen apart. It was a good time for a change of scenery. In 1954, Freeman abandoned Washington -- whose summers he hated -- in favor of Los Altos, Calif. For the next 18 years, California remained his home base as he continued performing a steady trickle of lobotomies in his office and in state hospitals, and indulged his passion for hiking and cross-country driving.
When the occasional opportunity presented itself, Freeman grabbed the chance to further refine trans-orbital lobotomy. In a 1964 letter to a Japanese colleague, he described an experiment he had tried on 14 "disturbed mental defectives, mostly young schizophrenics," confined in a Delaware hospital. In these cases, he followed the lobotomy with an injection of hot water into the brain. "I was prepared to accept two fatalities," he wrote, "but fortunately all the patients survived, and I have been invited to return next May. I don't see how any of these patients could improve but at least one can now be cared for at home."
Any physician today using a therapy with an expected fatality rate of 14 percent and offering no hope for improvement would probably end up in court if not in prison. (Freeman was never sued for lobotomy malpractice, although a suit was in preparation when he died.)
In 1967, Freeman received a visit from Helen Mortensen, a woman who had been one of his first 10 trans-orbital patients in Washington in 1946. She suffered a relapse of her psychiatric symptoms in 1956 and Freeman gave her a second operation. Now, after several more years of working productively, Mortensen wanted a third lobotomy.
Freeman did the surgery at Herrick Memorial Hospital in Berkeley, Calif., and severed a blood vessel in Mortensen's brain. Three days later, Mortensen died. The hospital revoked Freeman's surgical privileges. During the last five years of his life, he performed no more lobotomies. Freeman died from cancer on May 31, 1972, at the age of 76.
Freeman has been dead for 28 years, and most of the lobotomy patients who survived his treatment have followed him to the grave. Probably fewer than 20 brain operations are now conducted annually in the United States to treat psychiatric disorders. These procedures are not lobotomies; they most often use lasers or radiation to produce tiny lesions in the cingulate gyrus region of the brain, which has been connected with the development of obsessive-compulsive disorder (OCD). (Other operations that destroy parts of the brain are done to help reduce or eliminate tremors in Parkinson's patients.)
Nevertheless, Walter Freeman weighs heavily on the minds of a new generation of neuroscientists. They think about his promotion of lobotomy to treat a variety of unrelated disorders, his lack of interest in scientific verification of lobotomy's effectiveness, his patients' permanently altered personalities and emotional lives, and his recklessness, pride and craving for public attention.
Joseph Fins, a medical ethicist at Weill Medical College of Cornell University, holds Freeman partly responsible for the "therapeutic nihilism" that has existed until recently -- a reluctance of researchers to investigate new surgical treatments for psychiatric disorders and brain injuries. "One reason is the consequences of lobotomy and [surgically] destroying brain tissue. That didn't work, and people were horrified," he says.
But the tide may be turning. In the past two years a few neuroscientists have planned or carried out research into an entirely new form of psychiatric surgery, one that uses an implanted "pacemaker" and small electrodes to stimulate an area of the brain that might house the circuitry responsible for OCD and some forms of depression. (Ironically, Freeman's grandfather Keen used primitive electrical stimulation more than 100 years ago to treat behavioral disorders.) The region of the brain frequently targeted is the thalamus, the same area that Freeman held responsible for the emotional over-excitement that he theorized was a cause of mental illness.
Today's researchers view the thalamus differently. They see it as a coordinator and regulator of neural activities in the cerebral cortex, the part of the brain that accomplishes many of our highest mental functions. We can move, speak and plan our lives because of intricate teamwork between the thalamus and the cerebral cortex. If neurons in small regions of the thalamus shut down, current neuroscientific theory holds, the corresponding parts of the cerebral cortex run uncontrolled, producing Parkinson's disease, OCD and other problems. Electrically stimulating those neurons can restore them to wakefulness and rein in the cerebral cortex.
The surgery required to implant the electrodes is not dangerous, but researchers believe the public is frightened of it. "I definitely believe that there is a very important public stigma attached to surgical treatments for psychiatric disorders, and that this is for good reasons," says Bart Nuttin, a researcher at the Laboratory of Experimental Neurosurgery and Neuroanatomy, Catholic University of Leuven in Belgium. "I am convinced that in the past this kind of surgery has been abused."
Nuttin and his colleagues surgically installed electrodes in the brains of four patients with cases of OCD that did not respond to standard treatments. Three experienced relief of their symptoms when the electrical current was on. One of these patients, a 39-year-old woman with a long history of untreatable OCD, felt "an almost instantaneous feeling of being relieved of anxiety and obsessive thinking," the team reported in the British medical journal the Lancet in 1999. About 90 percent of her symptoms vanished.
Because brain stimulation, which the Food and Drug Administration recently approved as a treatment for Parkinsonian tremors, causes no permanent changes in the brain and can easily be shut off, Nuttin says it is in some ways similar to drug therapy. Yet this is a form of brain surgery, and Freeman's lapses of the past have left their mark. An ethics committee oversees the use of brain stimulation, to ensure that patients are not taken advantage of and subjected to unsafe therapy. "My greatest fear is that some surgeons would start using this technique in a less controlled way than we have," Nuttin says. "There remains a need for strict official control of this kind of treatment."
Belgium's Catholic University is one of a handful of research centers that have investigated brain stimulation as a treatment for psychiatric disorders, or plan to. Another is the Cleveland Clinic. Ali Rezai, who heads the section of stereotactic and functional neurosurgery at the Cleveland Clinic, has mixed feelings about Freeman. "In some ways he was a pioneer, but in others he did a disservice and slowed the pace of development by being too much of a cowboy and acting too exuberantly without scientific foundation," he says.
Freeman also spooks federal funding for this kind of research. The National Institute of Mental Health does not currently fund any research on psychiatric surgery and hasn't for many years. Although a spokeswoman for NIMH says that psychiatric surgery is not barred from funding consideration, Elliot S. Valenstein, a University of Michigan neuro-psychologist and author of the psychosurgery history Great and Desperate Cures, believes there is a political bias at work. "I think they're really concerned about the reaction to the [perceived] notion that the government is supporting brain operations and that there may be a resurgence of lobotomies in this country," he says.
Rezai hopes that his institution's brain stimulation research, set to begin this year, will win NIMH funding. He emphasizes that this therapy, if it works, will be best suited as a last resort for a small number of OCD patients: those for whom all other treatments have failed. But it also holds future promise for people with untreatable depression, speech disorders, multiple sclerosis and chronic pain.
Lobotomy also raised high hopes in its day. During the late 1950s, when the new tranquilizing drugs had grown popular in state hospitals, Freeman wrote letters to his psychosurgical colleagues around the world, praying for a time when brain operations would again gain wide favor in the battle against mental illness. It didn't happen in his lifetime.
Now that it might happen in ours, Freeman's presence is unwelcome. He flits around, a pesky spirit looking for the recognition he believes he is due, an unwanted ghost causing sighs and regret.