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J R Soc Med. 2005 August; 98(8): 381–382.
PMCID: PMC1181846

The Lobotomist

Reviewed by Erlick A C Pereira

Jack El-Hai
368 pp Price £19.99 ISBN 0-471-23292-0
London: John Wiley.

Among surgical operations, only castration can compete with lobotomy for emotive impact. No procedure is as notorious as the now defunct operation comprising the freehand severing of neural connections between the prefrontal cortex and the rest of the brain.

It was for conceiving the prefrontal lobotomy that the suave Portuguese neurologist Antônio Egas Moniz won a 1949 Nobel Prize. Around that time an American neurologist, Walter Freeman, had just popularized an outpatient version of it using an implement passed through the orbit. His invention of the quick and crude 'ice-pick procedure' led within just two decades to 10 000 lobotomies in Britain and 60 000 in the USA, over 3000 of them by his own hand. It is Freeman who is the subject of Jack El-Hai's biography The Lobotomista Maverick Medical Genius and his Tragic Quest to Rid the World of Mental Illness.

El-Hai finds Freeman a 'biographer's dream: an engaging writer with a substantial ego' who 'never feared setting down his professional speculations, no matter how out-rageous or controversial'. The author uses his rich sources to convey myriad influences upon a complex character. We are taken first to Freeman's illustrious medical ancestry—his grandfather W W Keen pioneered colostomies and did the first brain tumour excision in the USA. After an aloof childhood, average scholastic achievement then colourful beginnings in neurology, Freeman's clinical practice and academic stature become transformed by his expertise in lobotomy. His opportunism and exhibitionism at first gain him admiration among colleagues, then notoriety and rejection, and ambivalent affection from many patients.

The foundations of psychosurgery form a unique and intriguing chapter in medical history involving an alliance of clinical specialists, generalists and scientists, all trying to help a desperate group of patients. The medical climate that led to its application should be considered against the background of social, ethical, and political conditions and controversies that surrounded its practice. Deconstruction of its chief protagonists gives insight into the intellectual status of clinical science and the personal influences on the uptake of medical innovations.

Psychosurgery has been extensively chronicled and most accounts portray it as an exemplar of medical malpractice. Such narratives depict overzealous physicians instigating a catastrophe and are used to underline the importance of effective regulation. A stark picture is painted of evil doctors forcing abhorrent treatments upon hapless victims, One Flew Over the Cuckoo's Nest being but one example. El-Hai admits that he held similar preconceptions before he read Freeman's considerable writings. However, such a perspective lobotomizes psychosurgery's history of its richness. It might be argued that Freeman and his 'lobotomist' colleagues differed from other doctors of the time because science and circumstances uniquely exposed and eclipsed their medical practice. Our understanding of psychiatric disorders, the mechanisms underlying them and our means of assessing them underwent a revolution between lobotomy's beginnings in the 1930s—against a background of ineffective alternatives such as insulin-induced comas and lifelong institutionalization—and the advent of the first effective antipsychotics in the 1950s.

El-Hai's book illustrates the sometimes uneasy relationship, reciprocal legitimation, between science and the clinic. Moreover, it is a lively biography of a much maligned and misunderstood practitioner. Freeman's dogged crusade to engineer the prominent place of lobotomy in the minds of doctors and lay people alike is at times sobering but is fascinating to the end and mercifully devoid of stereotypes and clichés. Of Freeman's own rise and demise, El-Hai declares that he 'deserves, at the very least, the kind of all-inclusive scrutiny he hoped to give to others'. El-Hai suggests that Freeman was 'the most scorned physician of the twentieth century' after the Nazi Josef Mengele. But was he a cowboy or a pioneer? Functional neurosurgery is currently performed for debilitating psychiatric illnesses refractory to other therapies, including obsessive-compulsive disorder and depression. Stereotactically guided lesioning is undertaken at the Massachusetts General Hospital in the USA, and reversible deep brain stimulation with indwelling electrodes is performed in Canada and mainland Europe. Despite the gaps in the underlying theory and the complete dearth of double-blinded randomised controlled clinical trials, it has matured to multi-disciplinary regulation and evaluation. Many of those who perform such operations may, in private, express some admiration for Freeman, but they are pragmatic enough to realize that the stigma of the pariah who once performed 25 lobotomies in a day and occasionally performed bilateral lobotomies simultaneously—operating on one side with his non-dominant hand alone—does them and their patients more harm than good. In public they are rightly keen to distance their own safe and successful treatments from his. Yet, as El-Hai concludes, 'we should not allow Walter Freeman's ghost to flicker unnoticed in the shadows'. With The Lobotomist he has performed a spectacular and worthy exorcism.

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press