Freeman’s Lobotomy to Deep Brain Stimulation: What Changed?

American neurologist Walter J. Freeman II (1895-1972) became one of the most influential and controversial figures in the history of lobotomy in the US. He brought the procedure to national attention and later developed a simplified technique known as transorbital lobotomy.Freeman came from a family of physicians. After studying medicine and completing his training in neurology, he moved to St. Elizabeth’s Hospital in Washington, DC, where he gained attention for his unconventional approaches to treating individuals with severe mental illness. He later headed the Department of Neurology at George Washington University in Washington, DC. In 1936, he and neurosurgeon James Watts (1904-1994) performed the first prefrontal lobotomy in the US.The First InterventionsThe impetus for lobotomy came from Europe, where physicians began surgically severing connections between the prefrontal cortex and deeper brain structures to alleviate severe psychiatric symptoms. Freeman adopted the approach and initially collaborated with Watts. In September 1936, they performed the first such procedure in the US in a female patient with agitated depressive symptoms.The procedure lasted approximately an hour. Two small openings were drilled into the skull, allowing the insertion of an instrument and removal of several small sections of white matter from the frontal lobes. After the procedure, the patient experienced temporary speech difficulties, disorientation, and restlessness but was later discharged. Freeman regarded the outcome as a success. A few months later, he stopped using the term “leukotomy” and began referring to the procedure as a “lobotomy,” highlighting its focus on the frontal lobes and distinguishing his approach from earlier techniques.The psychiatric landscape at the time favored the spread of the procedure. Psychiatric hospitals cared for large numbers of severely ill individuals, effective pharmacologic treatments were largely unavailable, and interventions that reduced agitation and facilitated discharge were viewed as advances. By 1942, Freeman and Watts had performed approximately 200 frontal lobotomies. In their early evaluation, they reported improvement in 63% of those treated, no change in 23%, and severe postoperative complications or death in 14%.Freeman also actively promoted his work through the media. Journalists were allowed to observe operations, and news reports often reflected his interpretations. His image as a charismatic physician, who combined medical innovation with a strong public presence, reinforced the perception that lobotomy was a promising new treatment. This public attention contributed to the rapid spread of lobotomy.Transorbital TechniqueFreeman later developed the transorbital approach to simplify the procedure further. Using an orbitoclast, he penetrated the thin bone above the eye socket to access the frontal lobe and then moved the instrument from side to side to destroy the brain tissue. A portable electroshock device was used to render individuals unconscious, eliminating the need for openings in the skull and general anesthesia.The technique made the operation simpler and less dependent on conventional neurosurgical facilities. Because Freeman was a neurologist, he was able to perform the surgery himself. Watts rejected the technique due to inadequate sterility and the use of an outpatient setting. Their professional partnership eventually ended over these differences.In the years that followed, lobotomy became not only a medical issue but also a social and institutional one. At that time, a patient was often considered cured simply because he or she was calmer, had fewer disturbances, and could be discharged from the hospital. Whether psychotic or obsessive-compulsive symptoms had actually been resolved was often overlooked. Historical analyses also show that lobotomies were used to maintain order in psychiatric institutions.The consequences of the procedure could be severe. Reported complications included intracranial hemorrhage, epilepsy, changes in mood and personality, brain abscesses, dementia, and death. Other accounts of the history of psychosurgery describe apathy, emotional blunting, and disinhibition as typical features of post-leukotomy syndrome. At the time, however, robust scientific methods for systematically assessing the benefits and harms were not available.Freeman’s reputation was affected by cases involving serious complications, most notably the lobotomy performed on Rosemary Kennedy (1918-2005), sister of the US President John F. Kennedy (1917-1963). After the procedure, she was permanently and severely impaired, unable to care for herself, and dependent on institutional care. Criticism also grew within the professional community, with psychiatrists and neurosurgeons increasingly questioning the scientific basis, safety, and professional appropriateness of Freeman’s approach.At the same time, public perceptions of lobotomy began to change. Literature, theater, and films played a major role in portraying lobotomy as an instrument of institutional violence. These portrayals shifted away from presenting the procedure as a treatment and instead depicted it as a means of suppressing resistance and forcing nonconformists to conform to the needs of families or institutions. This shift had a lasting impact on how the public viewed lobotomies.DevelopmentsLobotomy has become less common with the introduction of effective medications. In 1955, chlorpromazine was approved in the US, and the importance of lobotomy diminished significantly. Freeman remained committed to the procedure, continuing to travel, giving lectures, and visiting former patients, whose conditions he documented photographically. In 1967, he performed his last transorbital lobotomy. The patient survived for only 3 days. Approximately 60,000 lobotomies were performed in the US between 1936 and 1956.However, the use of neurosurgery to treat mental illnesses has not disappeared entirely. Modern procedures, such as deep brain stimulation, follow a different technical and ethical approach. They modulate neural activity through implanted electrodes without destroying large areas of brain tissue. Targeted ablative procedures have also been further developed, including stereotactic procedures for severe, treatment-resistant obsessive-compulsive disorder.Modern procedures use precise targeting, strict eligibility criteria, and scientific evaluation, unlike the transorbital approach developed by Freeman. The history of lobotomy, therefore, remains significant because it shows how therapeutic hope, technical feasibility, and institutional needs can become intertwined. It also highlighted the importance of informed consent, careful patient selection, safety measures, and multidisciplinary oversight when considering such procedures.This story was translated from Univadis Germany, part of the Medscape Professional Network.