Why do surgeons have bad bedside manners
Lobotomy: Deep cuts in the brain
Twelve-year-old Howard Dully is strapped to a hospital bed. The neurologist Walter Freeman gave him four electric shocks. But after the first electrical surge, the boy quickly regained consciousness. The doctor then put the child's brain under tension three more times - with success: Howard falls into a coma.
Now Freeman can begin the brain surgery. He reaches for his special instrument: a sturdy steel needle about 20 centimeters long with a sharp blade at the tip. With his free hand he lifts one of the boy's eyelids and pushes the instrument sideways past the eyeball, deeper and deeper into his head. When he hits the bulge that separates the eye socket and the brain, Freeman picks up a hammer: a quick blow is enough to drive the steel needle through the thin layer of bone.
Lobotomy is said to change Howard Dully's personality
Now Freeman can press his tool right into the boy's frontal lobe, two inches deep. He also inserts a steel needle through the other eye socket.
Then he grasps both instruments at the same time and swings them back and forth at certain angles: This is how Freeman wants to cut nerve fibers in the frontal lobes of the brain. Signal strands that lead to the diencephalon, connect perceptions and thoughts with feelings, and which are incorrectly linked in Howard's head. The cuts in the brain are supposed to change his personality.
Freeman has another photo of the twelve-year-old taken, then he pulls out both steel needles. The operation at the Doctors General Hospital in San Jose, California takes less than ten minutes. It is the minutes that destroy Howard Dully's life.
Two months earlier, in October 1960, Howard's stepmother had appeared at Walter Freeman's office. Something is wrong with the boy's head. He was defiant, made malicious faces, behaved badly at the table. The boy has also committed minor thefts, stealing sweets or change from a newspaper box. The stepmother has already visited six psychiatrists. They all sent them away with the diagnosis that Howard was completely normal. But that's not the answer his stepmother wants to hear.
Walter Freeman is talking to the boy. Howard likes him right away. The cultivated, elegant, friendly man with the carefully trimmed goatee has warm eyes and a soft voice. And he can listen - unlike Howard's parents. At home, the boy is beaten up if he is late on the way home from school or if he takes a banana from the kitchen table without permission. Often his body is covered with bruises. Howard has good grades and is an excellent chess player. But his stepmother wants to get rid of him.
Psychosurgery pioneer is a Portuguese
After several conversations, Freeman's diagnosis was made: Howard suffers from schizophrenia. But he can be cured: through a "lobotomy", an operation on the frontal lobe of the brain that will soothe his defiant nature. The parents agree.
Howard has no idea what to do with him when he arrives at the hospital 16 days later. He does not know that Walter Freeman has already "lobotomized" thousands. That the 65-year-old is a revolutionary who once set out to renew psychiatric medicine.
With an operation that some consider a milestone in science and others reminiscent of a medieval torture ritual.
Walter Freeman, born on November 14, 1895 in Philadelphia, came from a wealthy background. He studies languages and history at Yale, rather aimlessly. Then, when he was 20, he turned to medicine. Freeman was suddenly fascinated by nervous diseases and the physiology of the human brain.
These are the years when Sigmunds Freud's psychoanalysis became popular in the United States. But the new theory also has strong adversaries. They believe that diseases of the psyche have purely organic causes: malfunctions of the nervous system that cannot be cured through conversation. Walter Freeman also counts himself among the anti-Freudians.
In fact, Freud's analysis mostly fails in severe psychoses, and many patients are only kept in sanatoriums. That is why neurologists in Europe and the USA are daring ever more brutal cures: They let electricity run through the bodies of depressed people, torture schizophrenics with ice baths and showers, even inject them with malaria pathogens to create a "healing" fever, or toxic cyanides to cause them Stimulate the brain and nervous system.
Walter Freeman, who has worked as a neurologist and psychiatrist in Washington since 1924, also uses the shock therapies. He injects substances like insulin and metrazol - an analeptic that causes severe seizures, similar to electroshock therapy - even if the patient writhes in convulsions so severe that they sometimes break bones.
He accepts the side effects. Freeman believes that the fact that psychiatric hospitals are so overcrowded is a waste of human resources. He wants to turn sick people into useful members of society - by whatever means.
In the spring of 1936, Freeman reads in a medical journal about a method that is more radical than anything previously tried. In Portugal, the neurologist Egas Moniz operates the mentally ill directly on the brain in order to cure them. He drills two holes in the roof of their skull so that a cannula can penetrate the frontal lobes.
So far, little is known about the function of the individual brain areas. We know, however, that innumerable nerve fibers branch out in the frontal lobe. Moniz believes that these connecting paths have become frozen in the mentally ill, that fixed ideas and delusions have become entrenched in them. You have to destroy the nerve tracts and force the brain to make new, healthier connections.
Initially, Moniz injects alcohol into the frontal lobe to kill the nerve fibers. Then he makes circular cuts with a steel loop or a small cutting blade to cut through nerve tissue - a highly imprecise and destructive procedure.
Many patients then suffer from fever, paralysis, appear disoriented and apathetic: all supposedly only temporary symptoms.
After 20 operations, Moniz announced in an essay that seventy percent of his patients were completely cured or in better shape - and that they had lost neither memory nor intelligence. The cuts in the brain worked particularly well against depression.
But the survey was published much too hastily, and the long-term consequences are completely uncertain. Many psychiatrists react indignantly to the new "psychosurgery", as Moniz calls his method. Especially since he fails to provide any proof for his theories.
But Walter Freeman is impressed by the Portuguese's results - he doesn't care whether his theory is correct. The Philadelphia man dreams of becoming the pioneer of “psychosurgery” in the United States. Isn't there half a million patients in state psychiatric hospitals with no hope of a cure? And there are more every year.
Failure doesn't slow Freeman's zeal
Without further ado, he orders some of the special instruments with which Moniz operates. Because he has no surgical training, Freeman asks a neurosurgeon for help. Together they both practice the new surgical method on the brains of corpses.
In September 1936, they feel ready for the procedure: their first case is a 63-year-old housewife from Kansas who suffers from insomnia, anxiety and depression. They trephine two holes in the skull and make cuts in the frontal lobes in twelve places.
Several days later, the patient stutters and is unable to write legibly. But Freeman and his colleague congratulate themselves on a “brilliant” result: Apparently all fears have disappeared - and she will soon be able to run her own household again.
Freeman is happy to accept the side effects, he is euphoric. Especially since the second patient also seems to have been relieved of her depression and hallucinations: the accountant can even go back to work two months after the operation.
But there are also setbacks: the fourth patient suffers again from her old anxiety states after six weeks. In the fifth procedure, the two surgeons injure blood vessels in the brain of the person being operated on. The consequences: epileptic seizures and bladder incontinence.
But the failures do not curb Freeman's zeal. After only six attempts, he invited a newspaper reporter to attend a “lobotomy”, as he now calls the incisions in the frontal lobes (from English: frontal lobes). The article, which appeared in November 1936, hailed the lobotomy as probably one of the “greatest surgical inventions” of the present day.
The first death occurred just a few weeks later: A 60-year-old woman died of a cerebral haemorrhage after the operation. But the malpractice has no consequences for the two doctors.
Other of her patients also suffer brain damage, and sometimes have to be fed or long-term care. Rosemary Kennedy, the sister of the future US president, remains with a childlike mind after her lobotomy in 1941 and spends the remaining 63 years of her life in closed facilities.
Even Walter Freeman still considers the procedure to be the last one, as it is particularly risky. At the same time, however, he propagated the lobotomy at medical congresses across the country. Most colleagues remain skeptical, however. They think the operation is too destructive, and some also think it is criminal.
Only a few other neurologists are trying out the new “psychosurgery”. Less likely than Freeman had hoped. Between 1940 and 1944, US medical records show 684 lobotomies. Walter Freeman alone had operated on over 200 cases up to 1943, and he gives the success rate at 63 percent.
This does not satisfy his missionary zeal. Especially since the country's 180 state psychiatric hospitals are overcrowded after the end of World War II. Freeman estimates that hundreds of thousands are waiting in the institutions for treatment. He wants to help as many as possible with a lobotomy. Soon it should no longer be the very last resort, but the first step towards therapy.
To do this, however, he has to simplify the laborious procedure.
The surgical tool comes from the kitchen drawer
Freeman recalls that there is easier access to the brain than drilling holes in the top of the skull: through the eye socket (orbit), which is only separated from the frontal lobe by a thin wall of bone. But he still lacks a suitable tool; the Portuguese's special instruments break too easily. Freeman finds what he is looking for in the kitchen drawer at home: a long steel pick, with which you can crush cocktail ice, seems just right.
In January 1946, Freeman tried the "transorbital" lobotomy for the first time. He pushes the ice pick past the eyeball to the frontal lobe of a 29-year-old woman who suffers from manic attacks and depression. Then he swings his new instrument back and forth to cut nerve tracts. Again the patient seems to have healed suddenly; Although the woman seems noticeably subdued in her whole being, she can work as a nurse again.
This time, Freeman did not operate in a hospital, but in his office room - that saves time and money. The anesthetic method is also unconventional: From now on, Freeman puts his patients into a brief coma with electric shocks. When she wakes up, he sends her home in a taxi. He operates without sterile gloves, without a face mask and doctor's gown, everything should go quickly.
Invention of the lobotomy is honored with a Nobel Prize
Freeman's vision: In the future, psychiatrists across the country should practice ice pick lobotomy in their examination rooms. The “transorbital” method only takes about seven minutes.
And it is life-threatening: blood vessels in the head can be injured at any time, and brain tissue can become infected. The neurosurgeon with whom Freeman previously operated turns away from him in horror. However, it can be used to make new special tools based on the model of the ice ax, made of hard steel and with a sharp blade.
In the meantime, more and more psychiatric hospitals in the country are opening their doors to him. The staff is often overwhelmed with the patients - and Freeman's promises sound tempting. In fact, many can be discharged after his ice pick lobotomy. Because the cuts apparently cut all emotions, turning psychotics into peaceful and apathetic beings.
The surgeon hopes to go down in medical history as a revolutionary who eradicates ancient human evils such as depression and hysteria. Freeman may even have hopes for the Nobel Prize in Medicine; In 1949, however, Egas Moniz, the inventor of the conventional lobotomy, was awarded it.
The award from Stockholm is like an official seal of approval; it silences many opponents. Doctors now practice the procedure in many European countries, in Japan, New Zealand and in some countries in South America. Up until then about 5,000 lobotomies had been performed worldwide, in the first four years after the award of the prize there were 20,000 in the USA alone. A third of these were performed using Freeman's transorbital method.
He's operating everywhere now. The surgical instruments fit in his jacket pocket; he has a portable electric shock device with him, a hammer and a camera - all he needs is that. Freeman travels the US states on the Atlantic and Pacific coasts, in the Midwest and in the south by car and plane.
In the summer of 1951 alone, he covered 11,000 miles, operating like an assembly line. The following year he treated 228 patients in twelve days in West Virginia; after the mass lobotomy - four people die - 81 patients can leave the institutions; the state saves tens of thousands of dollars in housing costs.
Freeman enjoys the big gigs. He once operated in front of an audience of 50 doctors and reporters. Another time even with a broken arm, as if obsessed with his campaign. And he's negligent. A patient dies because the lobotomy knife slips into the brain when Freeman takes the usual photo during the operation.
Despite such mishaps, articles about Freeman appear in popular magazines such as Life, Time, Newsweek and Reader's Digest. He is a celebrity at the beginning of the 1950s and even has to send out autograph cards; Callers request a lobotomy - for themselves or for relatives.
But then the revolutionary was stopped by a new invention: Thorazine, the first neuroleptic, came onto the market in 1954. A “chemical lobotomy”, as the manufacturing company advertises. The drug suppresses hallucinations and delusions. The hospital staff can use it to calm raging and screaming patients.
The miracle cure is tested on two million people in the first year. The effect is amazing: many patients are so subdued that they can be discharged home. The number of psychiatric inmates is starting to decline steadily after years of overcrowding.
Thorazine is far safer than Freeman's psychosurgery. The great days of the lobotomist are over. Walter Freeman moves from Washington to Los Altos, California in 1954. Only a hospital on the outskirts there still allows him to perform lobotomies.
Los Altos is the city Howard Dully grew up in. The word got around that Freeman's fame is fading and his ice pick method is controversial. Someone must have recommended the fallen star to the boy's stepmother. On December 16, 1960, at 1:30 p.m., Freeman did the swift operation.
The morning after, Howard Dully wakes up disoriented, as if shrouded in a fog. His head hurts and his eyes are rimmed with black bruises (Freeman always advises the surgeon to wear sunglasses). After five days, the twelve-year-old is discharged home from the hospital.
He can't go to school, stares apathetically. Howard seems to have become a different person: jaded, disinterested, numb. But for Walter Freeman, the operation is a complete success: "Howard no longer throws his stepmother scary looks," he writes in the medical file about three weeks after the operation.
A week later he drives up in the car. The surgeon wants to show Howard to an audience of doctors in San Francisco - he is still tirelessly leading his campaign for the lobotomy. But outrage rises in the hall when Freeman mentions the age of the tall boy. He lobotomized a twelve year old child?
Walter Freeman loses his composure. He throws a box onto the podium filled with hundreds of greeting and Christmas cards written by grateful patients. “How many Christmas cards do you get from your patients?” He shouts into the hall. Then Freeman is booed off the stage.
The scandal accelerates its decline. Freeman’s continued advocacy of child lobotomy is ruining his scientific reputation for good.
Howard Dully's time of suffering is only just beginning. Although he does not feel any failures - like so many other Freemans patients, he can speak and think clearly. But the fog in the head remains. And the stepmother is still dissatisfied with Howard's table manners: she wants him out of the house. Freeman helps with an expert opinion to get the child away. Howard comes to a foster family and is then deported to relatives.
Despite going back to school, his stepmother is determined to put him in a mental hospital. In 1963 the fourteen-year-old was transported there in handcuffs. The internment lasts a year - a lost time, the doctors don't know what to do with the boy. Then Howard goes to special school and then to psychiatry again for two years.
Freeman's last patient dies of a brain hemorrhage
In 1969 there is an entry in Freeman's notes about Howard Dully: The boy is going through an "unsatisfactory" development. Two years earlier, Walter Freeman performed the last of his approximately 3,500 lobotomies. After three days the patient dies of a cerebral haemorrhage. No hospital in Los Altos allows him to operate anymore.
Freeman sells his house and from then on drives through the USA in a camperbus. Like a ghost on the trail of his patients whom he visits and questions. The data collection is supposed to save his reputation. Freeman's success statistics were always dubious, based on fleeting observations. When Walter Freeman died of colon cancer on May 31, 1972 at the age of 76, hardly any doctor was practicing the lobotomy.
But in the previous decades, one historian has estimated, 100,000 people worldwide were lobotomized, including prison inmates and possibly dissidents in the Soviet Union. In 1978 the US Department of Health issued strict restrictions on all psychosurgery, but refused to ban psychosurgery altogether; in Japan, Australia and Germany the lobotomy had already been banned beforehand.
Surgery on the brain may be facing a renaissance today, in the age of imaging processes and modern precision instruments. However, such interventions are still very rare and are only considered by doctors if all other treatment methods are unsuccessful: because neurologists and psychiatrists know that the brain is a complicated network in which individual functions cannot be precisely localized. And because the shadow of the lobotomist Walter Freeman hangs over psychosurgery.
Howard Dully is not finally released until the spring of 1969, more than eight years after the lobotomy. He has no education, lives temporarily as a homeless person and on state welfare. He drifts. At the age of 45 he graduated as a computer specialist but couldn't find a job. Howard Dully later works as a bus driver and lives with his wife in San Jose, California.
He'll never find out exactly what the cuts did to his brain.
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