January 2007 | Back to Table of Contents

Book Review

Brilliance or Brutality?

By Charles R. Meyer, M.D.

Two stories of 20th century physicians who thought they could surgically rid their patients of mental illness.

The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness, Jack El-Hai, John Wiley, 2005

Madhouse: A Tragic Tale of Megalomania and Modern Medicine, Andrew Scull, Yale, 2005

Innovators in science take chances. They risk reputation, income, and sometimes their own safety to pursue their ideas. Innovators in medicine may chance all of these, but they may also gamble with their patients’ lives. Where medical innovation ends and carelessness or even criminality begin is the subject of two recent biographies: The Lobotomist: A Maverick Medical Genius and HisTragic Quest to Rid the World of Mental Illness, the story of Walter Freeman, M.D., by Minnesota writer Jack El-Hai, and Madhouse: A Tragic Tale of Megalomania and Modern Medicine, the biography of Henry Cotton, M.D., who translated the theory of focal infection to mental illness, by Andrew Scull. In each, we glimpse the imperfect science of American psychiatry in the first half of the 20th century and how Freeman and Cotton pursued their dreams of curing mental illness with radical, sometimes brutal, procedures.

Psychiatry at the turn of the 20th century was a collage of theories in search of a science. Freud’s psychoanalytic approach seemed inappropriate for the hoards of hardcore mentally ill who populated state hospitals. The prevailing approach for these unfortunates was housing rather than therapy, what Scull, a University of California sociology professor, calls a “counsel of despair … by declaring that the mad were degenerates and defectives, tainted creatures whose blighted minds were but a reflection of their hopeless heredity.” State hospitals for the mentally ill were prisons where patients were, at best, untreated and, more likely, mistreated.

To the Trenton State Hospital in 1907 came psychiatrist Henry Cotton, who had been trained by Adolf Meyer, M.D., the godfather of American psychiatry at the time. Meyer had fostered a culture of actively treating the mentally ill at Worcester State Hospital in Massachusetts. Dubbing Freud as a “fraud” and comparing psychoanalysis to Christian Science, Cotton found the state hospital in “deplorable condition,” with guards wielding unchecked violence and brutality on patients. Cotton dispensed with most restraints and taught attending physicians that they should not just write off patients as “crazy.”

Cotton assumed his post at Trenton just as medicine was emerging from a flurry of discoveries in infectious disease with the identification of organisms causing typhoid, cholera, tuberculosis, malaria, and diphtheria. Suddenly, it seemed as though all human disease was caused by infection and “the practical payoffs of the bacteriological revolution seemed limitless.” Quickly, the bacterial paradigm spread to all areas of medicine. At Chicago’s Rush Medical College, Frank Billings, M.D., trumpeted the “etiological relationship of focal infection to systematic diseases” and created the Memorial Institute for Infectious Disease and the Sprague Memorial Institute at St. Luke’s Free Hospital. Edward Rosenow, M.D., brought the theory of focal infection and systemic illness to Mayo Clinic, and a new concept of “surgical bacteriology” suggested that “chronic intestinal stasis … flooding the circulation with filthy material” caused autointoxication. Cure required surgically removing the infection.

Cotton applied the theory of focal infection to the illnesses of his Trenton patients, stating that psychosis was a “symptom … of long continued chronic sepsis,” and started attempting to surgically rid them of infection. He found rampant dental infection and removed so many teeth that Trenton was dubbed the “Mecca of exodontias.” Tonsils were excised, gallbladders removed, and parts of or entire colons resected. The proof of infection in the offending organs was slim even by early 20th century standards. The toll of lives lost was staggering with mortality rates for colectomy approaching 50 percent. And the documentation of resolved psychiatric illness was paltry.

Cotton’s practices were challenged by an exhaustive study of his records by fellow Adolf Meyer trainee Phyllis Greenacre, M.D., prompting an investigation by a New Jersey legislative committee. Cotton weathered these challenges and his own mental breakdown and, despite a demotion to “emeritus” superintendent at Trenton, continued to promote his theories until his death in 1933. Sepsis continued to be a focus of therapy at Trenton State Hospital until the late 1940s when it was supplanted by lobotomies.

The godfather of lobotomies in the United States was Walter Freeman, M.D., the subject of El-Hai’s book. Trained as a psychiatrist at the University of Pennsylvania and St. Elizabeths Hospital in Washington, D.C., Freeman, like Cotton, disdained psychoanalysis, believed that mental illness was physical, and spent hours in neuroanatomical dissection looking for connections between anatomy and behavior. When he heard a 1935 presentation by Portuguese neurologist Egaz Moniz describing a new technique that utilized a trocar to remove cores of the frontal lobe of mental patients, Freeman was sure he had found the physical treatment for mental illness he had long suspected existed. He exulted, “Here was something tangible, something that an organicist like myself could understand and appreciate.” Partnering with neurosurgeon James Winston Watts, Freeman started performing lobotomies on patients at St. Elizabeths and reported his first results in 1937, prompting the headline in the New York Times “Surgery Used on the Soul-Sick.”

From 1937 until 1967, Freeman operated on thousands of mentally ill patients, mostly schizophrenics, using first the trocar instrument championed by Moniz and finally settling on a common ice pick inserted through the upper orbital plate into the frontal lobe. Meticulously following his patients postoperatively, Freeman’s reports of his results were almost universally favorable, citing 80 percent of previously institutionalized schizophrenics living outside of mental facilities six years after their operation. The price for their “cure” was a perpetual infantile state with sometimes wild impulsiveness.

From today’s perspective, frontal lobotomy seems an aberration of medical experimentation. Yet it was a mainstay of legitimate psychiatric therapy in the 1940s and ’50s. In 1949, 49 lobotomies each month were performed at VA hospitals. Prominent Minneapolis surgeon Harold Buchstein, M.D., performed a total of 46 lobotomies at the Willmar State Hospital. Mayo Clinic surgeon J. Grafton Love, M.D., performed 46 at the Rochester State Hospital. In the four years after Moniz won the 1949 Nobel prize in medicine for his work in surgical psychiatry, 20,000 lobotomies were performed in the United States. Some commentators speculate that lobotomies lost favor only because effective antipsychotic medicines, such as chlorpromazine, were developed.

Were Freeman and Cotton careless surgical cowboys, risking patients’ lives while tilting at scientific windmills? Or were they well-intentioned physicians, trying to advance their science and treat patients with devastating disease? El-Hai and Scull portray their subjects as dedicated doctors who believed that their ministrations would help. But both authors also depict crusaders in monomaniacal pursuit of a theory who were willing to slight objectivity and look past their failures and see only success. For those reasons, Freeman and Cotton are
object lessons for physicians and scientists of all eras. MM

Charles Meyer is editor in chief of Minnesota Medicine.