Dr Phil Hammond, broadcaster and sessional GP in Bristol

Judgement and evidence base must go hand in hand

'If a study of the history of medicine reveals anything, it reveals that clinical judgment without the check of scientific controls is a highly fallible compass.1

So said Dr Arthur Schafer, a Canadian ethicist, and his quote sprang to mind as I was reading Blood and guts: a history of surgery by Richard Hollingham.2 The book is based on a BBC4 series about pioneering surgery, and the point is well made that the first patients in the queue are usually unlucky altruists. The first dozen or so heart bypasses, valve replacements, and organ transplants didn’t prolong life at all, but helped get it right for those further down the list. So how can you ethically develop a new surgical technique without any evidence to guide you?

All you can do is be open and upfront with your patients: ‘This is the first time I’ve done this and I really can’t say how it’s going to end up.’ There are chapters on hand and face transplants that make compelling reading, but it was the final chapter on surgery of the soul that really shocked me. Those with severe mental illness are often unable to give informed consent, and we should if anything be more rigorous about whether we allow them to be experimented on. So how was one neurologist—neither a surgeon nor an anaesthetist—able to travel around America in a camper van and perform thousands of lobotomies with an ice pick?

The story of Dr Walter Freeman is truly shocking, not least because his last lobotomy was performed as recently as 1967. He knocked patients out with electroconvulsive therapy (ECT), pulled back an eyelid, pushed in and up with the ice pick, whacked it with a rubber mallet through the orbital bone and into the brain, sliced through the frontal lobe and yanked it out again. His ‘patients’ were apparently conscious again—if a little unsteady and confused—in under 10 minutes. It was a mobile, production-line lobotomy service, largely unsupported by evidence, using a household tool emblazoned on the side with Uline Ice Company.

To be fair, the treatment of the severely mentally ill in Freeman’s time was pretty barbaric. Psychiatric hospitals were known as snake pits and jammed full of patients locked away for a lifetime. Some were tied up and force fed, with mouths clamped open. There were faeces smeared all over the walls, terrible overcrowding and a never-ending rise in demand. In the 1940s, treatment largely revolved around shocking patients back to health either with ECT without anaesthesia, or forced chemical convulsions (e.g. with insulin). Freeman decided to go one step further and rewire the brain permanently by removing part of the frontal lobe.

It was just a theory, but a Portuguese surgeon called Egas Moniz was getting interesting results by leucotomy (removing chunks of brain with a device like an apple corer) and even got a 1949 Nobel Prize for his efforts. Freeman developed his eye socket approach and used it on, among many others, the sister of John F Kennedy. He crisscrossed America and Europe plying his trade, often moving on before his patients relapsed or died. In the mid-fifties, he moved to California, offering lobotomies to neurotic housewives and disruptive children. By then, there was ample evidence that his treatment was harmful, and he was largely discredited by the establishment. But he believed in what he was doing, patients trusted his clinical judgement, and nobody stopped him until he was 72 years old, and had clocked up nearly 3500 ‘un-evidence-based’ lobotomies. So next time someone asks you why we have clinical guidelines, tell them the story of Walter Freeman MD.

  1. Schafer A. The ethics of the randomized clinical trial. N Eng J Med 1982; 307 (12): 719–724.
  2. Richard Hollingham. Blood and guts: a history of surgery. St Ives: BBC Books, 2008.G