Well-meaning but controversial, even Kafkaesque, was the surgical technique introduced by the American neurologist Walter Freeman to treat severe mental illness in the 1940s and 1950s. The Portuguese neurologist Egas Moniz began in 1935 to operate on psychotic patients under the theory that interruption of undetectable but abnormal connections to the frontal cerebral cortex would ameliorate the patient’s condition. Freeman enthusiastically followed this lead, convinced that this was a revolution in the care of otherwise untreatable conditions. He initially worked with a neurosurgeon, using the Moniz technique of placing bitemporal burr holes in the skull. Starting with the procedure as a last resort, Freeman then wildly expanded the indications for it. He found the Moniz technique impractical if he were to provide the treatment in mental hospitals to the full spectrum of patients he felt could benefit. Therefore in 1946 Freeman originated the use of an icepick, placing it himself under the upper lid in the superior fornix, striking it sharply with a mallet and driving it into the orbit and through the orbital roof into the anterior fossa and frontal lobes, where blind manipulations severed subcortical white matter. Most of this of course was before the coming of effective antipsychotic drugs, and some patients were undoubtedly helped, but the crudeness and unpredictability of the procedure, let alone the horrendous ethical issues involved, has made it one of the most notorious episodes in the history of medicine.

REFERENCES

Lerner, BH: Last Ditch Medical Therapy – Revisiting Lobotomy. N Engl J Med . 2005. 353:119-121.

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

Submitted by Ron Fishman from the Cogan Ophthalmic History Society.