Elliot Valenstein interview
Better Living Through Lobotomy: What can the history of psychosurgery tell us about medicine today?
An Interview with Elliot Valenstein
By Allison Xantha Miller | Issue #21
In the mid-1930s, the eminent Portuguese neurologist Egas Moniz, nearing the end of his career, was anxious to secure his reputation in the annals of science. He attended a medical symposium where a researcher reported marked behavioral changes in two chimpanzees after he had removed the frontal lobes of their brains; Moniz decided to try something similar in humans. His first operations (performed by a colleague, because Moniz suffered from crippling gout) consisted of injecting alcohol into several holes in the patients’ skulls. He soon moved on to cutting brain tissue by inserting an instrument comparable to a long, thin apple corer into the skull and twisting it around. As modified over the next fifteen years by other physicians, this procedure became one of the most widely prescribed treatments for serious mental illness: lobotomy. For this contribution to medicine, Moniz won the Nobel Prize in 1949.
Of course, lobotomy now seems like a medically sanctioned form of torture. The main theory behind it was that anxiety and agitation could be quelled by severing the emotional center of the brain from the part that controls intellect, but the evidence to support this idea was meager. The person performing the surgery usually couldn’t even see what he was cutting, and doctors considered patients "cured" after minimal follow-up. Yet, as Elliot S. Valenstein points out in Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books, 1986), "Even a surgeon who was convinced that he was not obtaining good results seldom gave up lobotomy. It was difficult to admit that the effort had been completely wasted, especially when other surgeons were reporting success. Rather than abandoning psychosurgery, neurosurgeons much more commonly introduced some change in the operation in the hope of increasing the success rate."
Though now out of print, Valenstein’s book provides the best history of the lobotomy’s heyday, in the 1940s and ’50s, a story that is not a medical aberration but rather a cautionary tale. "The factors that fostered [the operations’] development and made them flourish," writes Valenstein, "are still active today." Valenstein, professor emeritus of psychology at the University of Michigan, took time from his Fourth of July holiday to speak at length to Stay Free! –Allison Xantha Miller
STAY FREE!: It seems that in the 1930s, when Egas Moniz was doing the first lobotomies on humans, treating mental illness was urgent for some reason. The new "somatic" treatments--not only lobotomy but insulin comas and electroshock treatments [see sidebar]--weren’t just a way to help individuals, they were seen as something that could help solve a great social crisis.
VALENSTEIN: Well, there was a social crisis, you’re right. Mental institutions, particularly state institutions and large governmental institutions in all countries, were becoming more and more overcrowded because there weren’t any treatments for serious mental illness. They would try anything that held out hope and wasn’t very costly. Mostly it was somatic treatments, which people grasped at as a way of getting patients to a point where they could go home. Governments were concerned about the rising costs of taking care of the mentally ill, making legislators and the superintendents of institutions very receptive to anyone who claimed that insulin treatment, electroconvulsive shock, or fever treatment would cure schizophrenia. These somatic treatments tended to be much less costly and less labor intensive [than psychoanalysis].
STAY FREE!: Why were so many people in mental hospitals?
VALENSTEIN: Lots of people were mentally ill, just as there are many today. But now they tend to be treated with drugs and outpatient care. If all of these people were institutionalized, we would have the same kind of problem. Also, there were some patients who were committed more for the convenience of the husband or the family--wives who became mentally ill and troublesome. But I think mainly it was that there’s always a baseline number of mentally ill, and they kept accumulating in institutions.
STAY FREE!: Were the people who were lobotomized poor?
VALENSTEIN: Probably in most cases they were, but they weren’t all poor by any means. Private sanatoria, where lobotomies were also performed, catered to people who had money. It’s well known that President Kennedy’s sister Rosemary was mentally retarded and became difficult to control when she reached her twenties. Joseph Kennedy, the father, got the best medical advice he could at the time from people at Massachusetts General Hospital, one of the most prestigious places, and his daughter was lobotomized. It wasn’t a very good outcome, and to this day she’s living in an institution.
STAY FREE!: I guess lobotomy would have been hard to avoid if you were in psychiatry in the late ’40s and ’50s and you worked in a state hospital.
VALENSTEIN: That’s certainly true. People talked about psychoanalysis--ego and superego and ids and repressed early experiences. But using that for treatment, particularly in state hospitals, was totally impractical, even if one judged that it could be effective. Most people today would think that for seriously ill people, psychoanalysis probably couldn’t help very much. Freud himself didn’t think psychoanalysis was appropriate for people with schizophrenia.
STAY FREE!: So lobotomy was used to treat schizophrenia and affective disorders [mood problems such as depression, mania, and bipolarity].
VALENSTEIN: At first it was considered for almost any kind of disorder. After a while, it was limited to people with affective disorders, people with obsessive-compulsive disorders. Very deteriorated schizophrenics did receive the operation when it began to be performed on a huge scale [in the 1940s]. In the literature, one can sense a feeling that the best results occurred with patients who had depressive affective disorders, were manic or obsessive in a way that prevented them from going on with their life.
STAY FREE!: Maybe it was the first time any treatment could actually produce a change in their personality and their behavior.
VALENSTEIN: Yeah, probably that’s true. There are records from state hospitals that have come out since I’ve written the book which say that "We’ve tried one lobotomy on a patient and tried electroconvulsive shock, and they’re still unmanageable. We ought to consider doing a second lobotomy." It was very common to do a second procedure if the first one didn’t work or didn’t calm a patient down.
STAY FREE!: How would they adapt the procedure to do it a second time? I mean, presumably they’ve cut the thing already.
VALENSTEIN: Yeah, but, for example, [Walter Freeman and his partner, neurosurgeon James Watts] had kind of a standard procedure and a more radical procedure. The more radical meant that they essentially cut more; they disrupted more of the connections to the frontal lobes. The literature is filled with people who have had two and even three lobotomies.
STAY FREE!: Did you ever meet anyone who had had a lobotomy?
VALENSTEIN: Oh, yes. Quite a few. They vary tremendously. Some, you would not suspect that there was anything especially wrong with them. They may have seemed a little shallow, but you might not even be struck by that. There were people who went back to work and held responsible jobs after lobotomies, and others who essentially became vegetables. Some became very impulsive and childish in their behavior. The operations were so crude. Different parts of the brain were damaged, and the outcomes varied widely.
STAY FREE!: Walter Freeman’s transorbital lobotomy did not even require a surgeon or anesthesia. You wrote that Freeman, after electroshocking the patient into unconsciousness, used a surgical ice pick to enter the brain through the eye socket and moved the ice pick from side to side. He performed these operations in nonmedical settings such as his office, and in one case, a motel room. Was this invention a popular procedure?
VALENSTEIN: Oh, yes. Freeman spent his summers traveling in order to teach it. Walter Freeman had quite a reputation in the medical field. He was on a lot of boards that were setting up the credentialing of psychiatrists and neurologists. And he was a very charismatic teacher. He had a lot of former students who became hospital superintendents and were only too willing to have their former professor come by and demonstrate a new technique. Freeman would train psychiatrists on cadavers and watch them perform a few procedures, all within a day and a half. And in the month or two following his departure, they would perform twenty or thirty such procedures and write them up in the state medical journals. This went on all over the country.
STAY FREE!: Walter Freeman is kind of the villain of Great and Desperate Cures, if there is one.
VALENSTEIN: Well, I try to describe him in a more complicated way. First of all, he was a very smart man. He knew the literature very well, he knew a lot of anatomy, and he had a rationale for lobotomy, which made some kind of sense in terms of what specific nerve tracts he thought should be cut. He was very concerned about his patients and he followed them up in a very conscientious way, out of his own pocket. I tried to describe him in terms of the conditions that existed at the time, and his belief that these patients were going to deteriorate, for which there was some justification because the state hospitals were very unhealthy. He did have cases in which people were able to be discharged after operations and went home to their families. Some held jobs, a few even held responsible jobs. So he was convinced that he was helping to clear out the state hospitals and really believed he was doing a good thing. I talked at length to one of Walter Freeman’s sons, Walter Freeman III, because I knew his father had written an unpublished autobiography. He was a little reluctant to share it at first. After my book came out, he sent me a letter, and I was really concerned about his reaction to the book, but he paid me the nicest compliment. He said he went out after reading the book and bought five copies to give to his children so they would know something about their grandfather. So I felt that I had not described him simply as a villain. I think to do that tends to trivialize the whole story--saying there’s an evil man out there or a group of men and they did evil things, viewing it only in that context of abnormality. It was not an abnormality. It was something that was praised. You know, the Nobel Prize was given to the Portuguese neurologist who introduced prefrontal lobotomy, Egas Moniz.
STAY FREE!: It’s very touching that Freeman sent Christmas cards to all his lobotomy patients.
VALENSTEIN: That’s right. He mailed thousands of them and made great efforts to follow up with his patients.
STAY FREE!: He seemed to be very media savvy, judging by both what he was publishing in the medical journals and in how he dealt with the popular press.
VALENSTEIN: There’s no question that he liked publicity. Practically every time he went to a meeting, he packed the audience with reporters he knew, and it was written up in Time magazine, The New York Times, or Life. Media coverage played a huge role in popularizing the lobotomy. When Freeman went around to the state hospitals in little rural areas, the local newspaper would make his visit the lead article. And the superintendents of these places encouraged that because it made them look good: here they are out in the boondocks and a famous doctor has visited them.
STAY FREE!: Did Freeman ever contact the local newspaper before he got there?
VALENSTEIN: He probably suggested it at times, but the superintendents would be only too happy to do it on their own. It not only gave them publicity, it had practical implications. You could take that to the state legislature and show them how up-to-date your hospital was and how you needed more funding and things of that sort. But these articles in the popular media just generated a demand for the procedure.
STAY FREE!: Was the medical media establishment as big as it is now? We see news stories every night about some breakthrough.
VALENSTEIN: I’d hesitate to make a comparison, but everyone in those days--I can remember having lived through them--got Time magazine or sat in a barber chair and looked through Life magazine. There were three or four large articles on lobotomy in the Saturday Evening Post or Life, all suggesting that people who were hopeless could be cured. There wasn’t television, so we didn’t get bombarded the way we are today, but I think almost everyone browsed through those magazines. These state asylums were also being covered in all kinds of articles and books about how horrible they were. Life actually compared them--unjustifiably--to concentration camps. Right after the end of the war, when all the pictures of all the camps were being revealed, Life ran pictures of mental patients, nude, sitting on concrete steps in big halls and rooms that just reeked of excrement.
STAY FREE!: Why did lobotomy go into decline?
VALENSTEIN: It started in the middle to late ’50s, at the time of the introduction of neuroleptic drugs--Thorazine and some of the antidepressants. There was a whole group of them that came out in the late 1950s. They were often given in massive doses, and they seemed to be producing the same kind of effects as a lobotomy. If you’ve seen anybody on drugs like Thorazine, their face is expressionless and the saliva’s dripping out of the corner of their mouth. People referred to Thorazine as a chemical lobotomy, and it was much more convenient than performing surgery. It was more cost-efficient because it didn’t require a neurosurgeon and it didn’t require intensive postoperative care. So it very quickly replaced the operations.
STAY FREE!: And the popular media didn’t play a role in that?
VALENSTEIN: No, not really. It was just that within the institutions themselves there was a switch. People just sort of forgot about lobotomy when the physicians began to use drugs.
STAY FREE!: Was there also a social or political backlash against the procedure, kind of what you see going on today against the "talking cure"?
VALENSTEIN: No, there wasn’t, for several reasons. The custom of attacking medicine and even suing for malpractice didn’t exist at that time, or was almost nonexistent. Doctors were rarely questioned about anything they tried, and institutionalized patients were completely at the disposal of the staff in terms of treatment. And it was almost considered unethical for physicians to criticize other physicians, which certainly isn’t the case now. So there was a surprisingly little amount of criticism of lobotomy. There were certainly psychiatrists who didn’t like the procedure at all and were critical among themselves. But in terms of public statements and articles in medical journals, criticism was scarce until the end of the heyday of lobotomy. The backlash against lobotomy actually came up in the ’70s, when there was a fear of a revival of the operation and people began to talk about the horrible things that happened during the lobotomy period.
STAY FREE!: What brought on the backlash? How did that come about?
VALENSTEIN: Well, there were some scientists who argued that, since we now know a lot more about the brain, psychosurgery should be revisited. This was at a time when there was a lot of public concern about violence in the streets. Two doctors, Frank Ervin and Vernon Mark, had published a book called Violence and the Brain, which argued that brain abnormalities can cause violence. Word got out that the Department of Justice, which maintains federal prisons and special prisons for violent inmates, had some exchanges with the authors. There was a lot of suspicion that the Department of Justice was going to perform massive psychosurgical procedures on violent prisoners as a means of social control. So it became a big issue in some circles. I was at some neuroscience meetings that discussed the biology of aggression, and people came in and broke up the meeting and demanded time on the program.
STAY FREE!: Was there any truth to the rumors that lobotomy was being performed in prisons?
VALENSTEIN: Well, I did some investigation, and there were suspicious things happening in one prison in California. When I wrote, the warden was very open and sent me material. It turned out that there were a few operations performed on prisoners--people who had seizures and behavior abnormalities associated with the seizures, and the operations were really done in part at least to ameliorate the number of seizures, which is not uncommon. But these people also had violent outbursts sometimes associated with the seizures. In general, that’s sort of a fuzzy borderline between psychosurgery and neurological surgery. Still, I think the reports of what went on there were grossly exaggerated. But there was this fear that there was going to be a revival of interest in lobotomy, and it became a political and a civil rights issue because of the prevalence of minority groups in prison. I became interested in the topic because in Brain Control [published in 1973] I had talked a little bit about how certain neurosurgical procedures were a result of misinterpreting animal experiments.
STAY FREE!: How did the people you were writing about respond to your work?
VALENSTEIN: All the people I talked to were quite open. Occasionally when I would talk at meetings, a surgeon would stand up and say, "You don’t understand what was going on; we really helped all of those people," clearly being very defensive. But I talked to people who not only had performed some of the procedures but had attempted to study what was going on and had a broader perspective than, say, a clinician who had just performed the operations. Many of the people I saw, even though they themselves had participated in it, recognized that the exuberance that took place just went out of control.
STAY FREE!: What are the parallels between the lobotomy period and what’s going on today? There’s a lot of enthusiasm for what used to be called somatic treatment, going after mental disease as a physical set of symptoms. You wrote about this in your latest book, Blaming the Brain.
VALENSTEIN: The influence of the pharmaceutical companies is so great these days because of the resources they have at their disposal. There are tremendous economic factors distorting the practice of medicine, just as there were in the lobotomy period. It is hard to find any clinicians or researchers who don’t have vested interests in the development of procedures or drugs. I mean that. Of course, they will deny that funding from drug companies has an influence, but it is so subtle that they’re unaware of it themselves. Studies have shown that if you look at reports on drugs that are competing to treat the same patient population, and if you look at the connection that the people doing the studies have with the companies involved, the results that they find--not only the opinions they express but the actual data--clearly reflect their own vested interest. I don’t think people really lie, but it happens in very subtle ways, like disqualifying patients because they are ill with something else. Those same patients would not be omitted if their outcome supported the conclusions the researcher wanted. And there are professional interests as well: psychiatrists have to compete with social workers, clinical psychologists, counselors of all sorts. Most people who seek help for a mental problem do not go to a psychiatrist. So there’s a strong economic reason why psychiatrists are very supportive of drugs: protecting their own turf. That’s not the only reason, but it certainly has an influence.
Electroconvulsive (electroshock) therapy (ECT): In electroshock, a series of electric pulses delivered to the brain causes a seizure. Today ECT is used most often to treat major depression after drugs have failed. Scientists think it works by altering electrochemical pro-cesses in the brain. ECT is controversial due to side effects that include memory loss and, some argue, brain damage.
Fever treatment: Introduced in 1917 by injecting malaria into patients whom syphilis had turned insane. Surprisingly effective, the treatment was widely used before the rise of penicillin and antibiotics.
Insulin coma: In 1933 Manfred Sakel mistakenly gave a diabetic mental patient too much insulin, which put her into a coma. After he revived the patient, her psychological symptoms had improved, and the first form of shock treatment was born.
Metrazol shock therapy: Introduced in 1934 as a safer, easier alternative to insulin therapy. An injection of Metrazol induced an epileptic seizure.