THREE FRONTAL LOBE GUYS
John F. Rice, MD, FACR January 9, 2007
My topic this evening dates back to the Twentieth Century. I will discuss the professional and personal lives of three amazing individuals, all trained in the fields of Neurology and Psychiatry, and their quests to understand and treat diseases which, in large part, involve the frontal lobes of the brain.
I will not be recounting the contrived lunacy of The Three Stooges; nor will I contribute to the pseudointellectual adoration of Iglesias, Domingo and Pavarotti, The Three Tenors. Much as I admire and emulate The Three Pickers-Earl Scruggs, Doc Watson and Ricky Skaggs, they have little to interest a medical history audience.
Rather, my Three Guys are veritable Giants: Egas Moniz, Walter J. Freeman and Spafford Ackerly. In their professional careers these three physicians faced the misery and despair of patients locked away in the great Asylums of America and Europe in the first half of the Twentieth Century. Psychiatry was at that time emerging as a clinical discipline, but it offered only a limited treatment algorithm, resulting in ever expanding State Institutions that, in the worst cases, more closely resembled a veterinary facility than a hospital.
In the late Nineteenth and early Twentieth Century, European and American scientists had made important observations about the function of the brain in psychiatric disease. The German Friedrich Golz in 1890 showed a calming effect in dogs that had undergone temporal lobe cortical ablation. In 1892 Gottlieb Burckhardt, in Switzerland, performed craniotomies on six patients with schizophrenia, removing areas of brain that he thought related to the patients’ varied symptoms; some behavior alteration was observed, particularly in the two patients who died. Burckhardt was universally criticized for this in vivo experimentation.
Experimental work on chimpanzees by Fulton and Jacobsen at Yale in the 1930s demonstrated that aggressive animals could be made manageable, yet still retain memory and other higher functions, after frontal lobe interruptions.
Based in part on this early experience, Dr. Antonio Egas Moniz of Lisbon developed an interest in a surgical procedure to alter the behavior of patients with intractable, unmanageable psychoneurotic symptoms.
Moniz is a fascinating character, diplomat, bon vivant, and esteemed as a founder of my field of medicine, Neuroradiology. He was born Antonio Caetano de Abreu Freire, in 1874. As a young man he adopted the name “Egas Moniz”, to commemorate a 12th Century Portuguese patriot, sort of a Portuguese “El Cid”. . Apart from his subsequent productive medical career Moniz was also an involved public citizen-member of the National Parliament in Portugal, Minister to Spain, Minister of Foreign Affairs, and signatory of the Treaty of Versailles for Portugal in 1919.
Trained as a neurologist, Moniz studied brain injuries from World War I, and also wrote a text on the Neurology of Human Sexuality. In 1927 he reported his work with Dr. Almeida Lima, a neurosurgeon, on the x-ray technique to visualize the cerebrovascular circulation. For this signal work he received a nomination for the Nobel Prize in 1928.
Moniz was appointed Dean of the Lisbon medical faculty, and he began to focus on psychiatric disease. In 1935 he and Lima began working on “leucotomy”, a procedure to interrupt white matter tracts in the prefrontal region. Moniz referred to these procedures as “psychosurgery”, introducing that word to the neurosurgery vocabulary.
Prior to his first leucotomy efforts Moniz had attended the Second International Neurological Congress in London, in 1935. At that important meeting, also attended by the American Dr. Walter Freeman, a breakout session on frontal lobe disorders was held. There was much discussion of the Fulton/Jacobsen monkey work, as well as speculation about the famous traumatic frontal lobe amputation of poor Phineas Gage, reported in 1847. Additional presentations of the recent resections of massive frontal lobe meningiomas by Wilder Penfield (his sister!) and Walter Dandy (Joe A-patient of Dr. Richard Brickner at the Neurological Institute of New York) were made.
In that same year Dr. Ackerly reported at the American Psychiatric Association meeting in Washington, D.C. of his patient (operated on by Innominate Founder Dr. Glen Spurling) who had lost three-fourths of her prefrontal lobe tissue after removal of a large olfactory groove meningioma.
The clinical resolutions of these subjects were somewhat similar postoperatively: loss of self-restraint and ability for complex thought, impulsiveness, poor judgment, distractibility, and a notable decrease in aggression and temper tantrums in the famous monkeys.
Although Moniz did not cite the Congress as significant in his decision to pursue prefrontal leucotomy, it is a fact that later that same year, November 1935, Moniz and Lima performed their first frontal leucotomy, utilizing an intracerebral injection of ethanol, on an inmate of the Bombarda Asylum suffering from agitated depression. Moniz pronounced her cured; however, she never left the asylum.
Following the ethanol experience Lima and Moniz began direct physical interruption of frontal lobe white matter with a surgical instrument, the “leucotome”, sometimes making several approaches per side through burr-hole craniotomies. The lesions generated were significant. Moniz reported his initial results in Paris in 1936, and the encouraging findings stimulated international interest in the procedure. In 1937, Moniz reported on his further experience in the American Journal of Psychiatry. His summary is a monument to scientific arrogance and naivete:
Following this exposition I do not wish to make any comment since the facts speak for themselves. These were hospital patients who were well studied and well followed. The recoveries have been maintained. I cannot believe that the recoveries can be explained upon simple coincidence. Prefrontal leucotomy is a simple operation, always safe, which may prove to be an effective surgical treatment in certain cases of mental disorder.
In 1939 Moniz was attacked by a former patient, and this injury, in addition to his advanced gout, caused him to curtail his medical practice and lobotomy work. He now had, however, an evangelical advocate in the person of American neurologist Walter J. Freeman, of George Washington University. The two men corresponded for many years, until Moniz’ death in 1955. Moniz was awarded the Nobel Prize in 1949 for his work on “Prefrontal Leucotomy”. His more notable and earlier work in cerebral angiography was passed on by the Nobel committee.
Walter Jackson Freeman,Jr., born in 1895, was the son and grandson of physicians.
Maternal grandfather William Williams Keen was an eminent Philadelphia surgeon. He was involved in the clandestine surgical procedures performed on then sitting President Grover Cleveland, who suffered from an oral malignancy. Keen, who was also interested in what later became known as neurosurgery, had reported on his technique for tapping the cerebral ventricles to reduce elevated intracranial pressure at the same Berlin meeting in which Gottlieb Burckhardt had described his brief, and reviled, experience with cranial surgery for schizophrenia.
Keen’s son in law, Walter Jackson Freeman Sr., was an otolaryngologist with his office in the home. A humorless, distant father, he discouraged his children from a career in medicine. As a young boy Walter Jr. developed generalized lymphadenopathy, and grandfather Dr. Keen operated to remove the larger cervical nodes, producing damage to the left spinal accessory nerve, and giving the youngster a head tilt and shoulder depression seen in this photograph. Nevertheless, Walter Jr. was very fond of his distinguished grandfather, and imprinted strongly on him.
Young Walter attended Yale as an undergraduate, and did his medical schooling at Penn, where he developed an interest in neuropathology under the influence of Charles Frazier. Following his neurology residency he traveled in Europe as a sort of visiting fellow in Paris and Rome, quite an experience for a young man in the years between world wars.
Upon Walter’s return, his influential grandfather had found an opening for the young neuroscientist at St. Elizabeth’s Hospital, in Washington, D.C. A federal institution for the insane, St. Elizabeth’s is now the home of failed presidential assassin John Hinckley. Freeman was to be senior medical officer in charge of laboratories, and he assumed that post in July 1924.
At St. Elizabeth’s Freeman was primarily a neuropathologist, and he performed a large number of autopsies in futile search for brain abnormalities in the insane patient population. He also functioned as a psychiatrist clinically, although the 4,300 bed facility was largely a domiciliary. Like others at the hospital, Freeman began a private practice. In addition he became affiliated with local hospitals and medical schools, such as the U. S. Naval Medical School, and Georgetown University, primarily as an autopsy demonstrator. At nearby George Washington University his eccentric and theatrical teaching abilities were much appreciated by the students, and in 1926 he was appointed Professor and Chairman of the Department of Neurology at GWU.
The dynamic GWU professor maintained his association with Georgetown as a graduate student, earning a Ph.D. in 1931 for studies of biometrics in psychiatry. At this same time he was working on his first book: Neuropathology:The Anatomic Foundation of Nervous Diseases, which was published in 1933.
Freeman eventually left St. Elizabeth’s and devoted himself to GWU, where he remained until 1954. The energetic academic neurologist was becoming an influential figure locally and nationally. In 1934 he was part of the group which established certification by the American Board of Psychiatry and Neurology. He also worked to enhance the teaching environment at GWU. One of his priorities was to obtain a neurosurgeon, preferably a Harvey Cushing trainee who would devote himself to neurological surgery. The persistent, flamboyant and eccentric W. J. Freeman found his mark in James Winston Watts, and Watts joined the GWU faculty in 1935.
1935 was the year of the Second International Neurological Congress in London, central to the rise of lobotomy, and there Freeman and Moniz met and formed a strong professional relationship that was to last many years. Upon his return to GWU Freeman and Watts began preparations for their venture into psychosurgery. Watts had trained at Yale and was familiar with Fulton and his monkeys. That connection and Freeman’s zeal infected Watts with a desire to pursue frontal lobotomy.
The socioeconomics of mental illness were daunting in 1936. An estimated 432,000 patients packed overcrowded state hospitals, and admissions were up 80 percent per year. Treatment was minimal; most patients just sat around and deteriorated. Clearly a treatment or procedure that could alleviate this problem would have enormous public benefit.
In September 1936 Freeman and Watts performed the first frontal lobotomy in the United States on Alice Hammatt, age 63, in the GWU Hospital. Hammatt had suffered a long history of emotional problems, which Freeman labeled “agitated depression”. She was unable to sleep, prone to fits of tearfulness and great apprehension, and entertained thoughts of suicide. Post lobotomy she was placid, almost too placid, and developed “odd rubbing and rolling movements” with her hands. However, she could talk and read, and she was now able to sleep and could function without constant nursing care. She lived five years before succumbing to pneumonia.
By the end of 1936 Freeman and Watts had operated on twenty patients, the last of whom died. Only twelve patients were operated in 1937, as the doctors sought to refine their techniques. Freeman prepared an elaborate exhibit for the American Medical Association meeting later that year, which received considerable publicity. He continued to show his wares at the AMA through 1946.
Numerous changes were made to the operative technique during the years leading up to 1945. New instruments, different approaches, and local anesthesia were all tried. Freeman, not technically a surgeon, had on occasion proceeded without Watts on some cases, and this had provoked controversy. After ten years of lobotomies Freeman surmised that one third of his patients had benefited from the procedure; two thirds were unchanged or worse. His most famous failure was Rosemary Kennedy, daughter of alcohol baron Joseph Kennedy. Her lobotomy in 1941, arranged between Freeman and old Joe in the absence of Mrs. Kennedy, left the young girl bedridden and unable to speak; she spent the remainder of her long life in an institution in Wisconsin.
At the end of World War II there was a significant influx of returning soldiers suffering from psychiatric illness. Freeman felt there was a real need to provide lobotomy on an expanded basis. He and Watts were not the only psychosurgeons in the country, but all procedures were limited by the time involved in performing a surgical procedure.
Without informing Watts, Freeman began experimenting on cadavers in an attempt to develop an alternate approach to the frontal lobes. He was aware that Amarro Fiamberti in Italy in 1937 had utilized an approach to the anterior cranial fossa through the roof of the orbit in a limited lobotomy series. Freeman appropriated an ice pick from his kitchen at home and, with a light tap from a hammer, was able to puncture the thin orbital roof and enter the brain. To further simplify the procedure, Freeman would forego anesthesia. Administration of Electroconvulsive Therapy would render the patient senseless instantaneously, and allow the procedure to be performed within a few minutes.
Although he would later perform transorbital lobotomies in the operating room, Watts did not approve of the cavalier approach of Freeman to brain surgery. It was said that Freeman would perform a lobotomy in his office after ECT, and send the patient home in a cab an hour later with two black eyes. Freeman envisioned wide usage of the transorbital procedure in state hospitals around the country. Watts protested that few state hospital psychiatrists had the vast knowledge of brain anatomy and function as Freeman. Freeman dismissed this objection as a turf battle waged by neurosurgery.
Freeman loved to drive his family on long automobile trips, and he now took his solo procedure on the road. He loaded his portable ECT machine and lobotomy tools and visited state hospitals, performing lobotomies and making training films to demonstrate the efficacy and simplicity of his procedure. Beginning in February 1949 Freeman hit Galveston, Little Rock, Lincoln Nebraska, Minnesota, and Ohio. His patients walked in and, usually, walked out. There were no gowns and masks; there was a lot of banter and showmanship. Subsequent years brought similar trips in the “lobotomobile”, as well as visits to Puerto Rico and Curacao. His ever expanding list of state hospitals included Virginia, Ohio, West Virginia, California, the Dakotas, Pennsylvania, and on and on.
The cross-country trips of the itinerant psychosurgeon peaked in 1954. That year the drug Chlorpromazine, or Thorazine, was introduced as an antipsychotic, or “chemical lobotomy”. As its usefulness became widely accepted, there were fewer and fewer invitations to the big state hospitals. In New Jersey the Columbia- Greystone Project demonstrated the efficacy of “topectomy”, partial removal of cortical areas 9 and 10, as an alternative to lobotomy, laying the groundwork for more precise surgical ablative techniques. Clearly, the icepick lobotomy was under serious challenge.
Leaving GWU and St. Elizabeth’s behind, Freeman moved to California, in the Bay Area, in 1954. Lobotomies were less and less frequent. One by one, his hospital privileges for lobotomy were revoked. Freeman’s automobile odysseys were becoming more and more simply follow up visits, as he tracked down patients he had operated on over the last three decades. He published “Frontal Lobotomy 1936-1956: A Follow Up Study of 3,000 Patients from One to Twenty Years.”
His last hospital was Herrick Memorial, in Berkeley. A female patient, whom Freeman had operated on twice before, returned for a third procedure after eight years. She suffered a cerebral hemorrhage and died. Freeman’s operating privileges were revoked in 1967. His health progressively declined, although he kept up his almost manic pursuit of patient follow up. He died in 1972.
The opening sentence of Jack El-Hai’s book The Lobotomist reads: “Aside from the Nazi doctor Josef Mengele, Walter Freeman ranks as the most scorned physician of the twentieth century.” Certainly criticism of Freeman’s career is justified, but I believe that a number of physicians, certainly during my time in medical practice, have egregiously pursued alternative, radically new therapies, often without thorough substantiating research, and have been celebrated for their work. We must leave the final decision to ethicists and historians.
Spafford Ackerly arrived in Louisville in 1932 following psychiatry residency and post-graduate work in New York, London and Vienna. Born in 1895, he had already lived an eventful life-wounded in the trenches of World War I, he suffered from chronic osteomyelitis for the rest of his life.
As he lay abed in London recuperating from the persistent infection, he was examined by Sir William Osler. Ackerly knew that he was a candidate for amputation, and that Osler would make the final decision. To his immense relief, young Ackerly received the good news that he was to keep his troublesome leg. Except for a brief period in the 1960s, following an intense round of antibiotics, Ackerly suffered from pain and drainage of the old battle wound until his death in 1982.
Frontal lobe disease was a major interest of Ackerly. In 1935 he described the case of a woman from eastern Kentucky, “K”, who had undergone extensive surgery for a large olfactory groove meningioma which had produced marked compression and atrophy of her frontal lobes. Her post-operative neuropsychiatric findings were highly interesting to that segment of the medical profession which was trying to analyze the concepts of frontal lobe resection or disconnection, as described by the monkey work of Fulton and the “leucotomy” project of Moniz.
The relatively benign outcome of the Ackerly/Spurling case (and also the Dandy/Brickner case in New York) was encouraging to Moniz and others, like Freeman, who were proposing radical interruption of frontal lobe connections. Ackerly’s name and work became familiar to those working in the burgeoning lobotomy field.
In 1933 Ackerly first met a patient with a different sort of frontal lobe pathology. James Pickrell, or “J.P.” was nineteen years old at that time, and his had been a troubled existence for most of those years. Jimmy had been seen first in the Louisville Psychological Clinic in 1926, at age 12. His early problems, which only became amplified as he aged, concerned inappropriate behavior at home and in school-exposing himself and masturbating, indifferent school work, and a tendency to wander, or run away from home. The latter problem manifest as auto theft when Jimmy became old enough to drive. He did not seem to learn from his spate of bad experiences and punishments, frequently repeating the same offenses.
Strangely, young JP made quite a favorable initial impression. Well spoken, alert and talkative, he was excessively polite, and anxious to please. Ackerly referred to his mannerisms as “Chesterfieldian”. Today, we might consider him an “Eddie Haskell” type, after the cloying character on the old TV show “Leave it to Beaver”. His math skills were poor, but verbally he was at least adequate, and his IQ test scores ranged from the 90s to 100. More focused testing showed defects in planning and foresight, and inability to direct toward a remote goal.
Ackerly would follow JP for the next forty-four years, attending at his autopsy in 1977.
Jimmy had two early life events which may have been significant, in light of his final neuropathology evaluation. He weighed 11.5 pounds at birth, and his mother had a prolonged labor. He became severely jaundiced in the neonatal period, but showed normal preschool development and milestones. At age four he had fallen from a bed, striking his head. One hour later he began to talk peculiarly, then lost consciousness and suffered a convulsion. Taken to the hospital, he was considered for surgery, but began to regain consciousness. He was released the next day.
JP was evaluated carefully by Ackerly, and, for the next thirty plus years, Jimmy served as a “trap” case for unwitting medical students fumbling through their first days on the psychiatry rotation. Medical student education, of course, was a first priority for Ackerly, and extended far beyond showing his famous patient. JP was taken to various psychiatric centers for evaluation-Yale, U Chicago and Johns Hopkins-Phipps. His case was known world wide.
Because of the disturbing pattern of JP’s behavior, he underwent pneumoencephalography in 1933. There were no simple screening tests for brain pathology at that time, and an air study provided the only means for evaluating the intracranial contents. The PEG showed air filling enlarged and deformed frontal horns, and a communicating cavity filled with air anteriorly, suggesting a brain abscess.
Dr. Glen Spurling operated in October 1933 through a left frontal craniotomy and found thickened arachnoid with adhesions with compression and atrophy of the left frontal pole. As the adhesions were released a bulging right anterior fossa mass presented itself, absent cortex, and filled with yellowish fluid. The impression was: “Cystic degeneration of the left frontal lobe, absence of the prefrontal lobe on the right, chronic arachnoiditis, adhesions in the anterior cranial fossa.” Three years later, the PEG was repeated (a further indication of JP’s limited judgment!) and it showed little change.
Ackerly first introduced JP to the medical world at large through publication in 1948. And in 1964 Spaff published a follow up article detailing thirty years of JP’s behavior. “He is the same boastful little boy he always was, refreshingly forthright, excessively docile when not threatened, completely involved with the immediate world around him.” His memory is “capricious”, and he may interchange facts. He finds it difficult to finish even the simplest tasks. Several short term jobs included salesman, night watchman, bus driver, gas station attendant and errand boy. There is mention of occasional seizure activity, and he took daily Dilantin. Spaff asserts that, in 1964, there were only two other verified cases of circumscribed bifrontal lesions occurring early in childhood, both severely retarded.
Reflecting on his thirty years’ longitudinal study of JP, Ackerly concludes his subject is “a relatively simple, uncomplicated, inflexible, stereotyped human being, deficient in self-preservation and in self-realization where continuity with the past, insight, planfulness, fruitfulness and the sense of enjoyment are so essential.” And, Ackerly conjectures, “the frontal cortex is an important ‘nursery’ if indeed not the main nursery for the growth and potentiation of those faculties that distinguish man as man.”
JP died in May 1977, and a limited autopsy was performed. Attending the neuropathology, or “brain cutting”, session were Dr. Spafford Ackerly and his teenaged grandson William Spafford Smock, now a Faculty member at the University of Louisville Medical School. I also attended the session, which was presided over by the late Dr. Ryland Byrd.
The enclosed material demonstrates evidence of prior craniotomy, including a recent shunt for “Normal Pressure Hydrocephalus”. Thickened membranes are evident, with old and somewhat more recent hemorrhage. There is bifrontal atrophy, right more than left with bifrontal porencephaly, also R>L. Adhesions within the cavities are striking on the right. The overall picture is that of old encephaloclastic porencephaly, likely from old hemorrhage, with old subdural fluid collections, membrane thickening and hemosiderin staining, probably the sequelae of the fall at age four. Likely there is superimposed damage from craniotomy and an incompletely controlled seizure disorder.
Ackerly’s career was not just as J.P.’s watchdog and sentinel. He was awarded numerous grants, including a Guggenheim Fellowship. He was Chairman of the Department of Psychiatry at U of L, and Director of the Child Guidance Clinic, later the Bingham Child Guidance Clinic. He helped organize the Norton Psychiatric Clinic and the Ackerly Child Psychiatric Inpatient Service. He served on the Editorial Board of the American Journal of Psychiatry.
He was concerned with the plight of the mentally ill, abandoned to the horrors of enormous state institutions. In 1937 he helped Barry Bingham, Sr. with a series of newspaper articles calling attention to the needs at Central State: “Need theirs be a living death?”
The cutting edge of Neuroimaging in 2007 involves Functional MRI to display activation of specific cortical structures and Diffusion Tensor Imaging to produce maps of the white matter tracts that Moniz and Freeman, without accurate localization, sought to interrupt.
The Three Frontal Lobe Guys all saw their medical careers marked by the quest to understand and treat diseases of the frontal lobes. One, Moniz, received international acclaim, albeit for the lesser of his two medical innovations, and he died before the critics began to howl. Freeman, the P.T. Barnum of itinerant psychosurgery, plunged from the heights of academia to the depths of scorn because of his evangelical pursuit of a surgical cure for mental disorders. Our local Guy, Ackerly, survived the horrors of the trenches in World War I and left his native New York to establish a tradition of psychiatric care in Louisville which continues to serve over twenty years after his death.
My thanks to the Ackerly family: his son Dr. William Ackerly (of Cambridge MA), his daughter Carita Ackerly Warner, and grandson Dr. William Spafford Smock. Also to Dr. Dan Tucker, Dr. Sam Smith and Dr, Joseph Parker. And also to Jack El- Hai, fellow mandolinist and author of the excellent biography of Walter Freeman, The Lobotomist.