I wasn't going to review this book, but the issues that it brought to mind by its conclusion were more than enough to inspire me to write about it.

I could have called this review My Lobotomy, which is the title of the book and which I know is eye catching. But for me, the question that is asked of the author after a groundbreaking NPR story was done on him gets to the heart of why the book is so important and why I am writing this review. "How could this happen?" This is, sadly, a question that can be asked of many aspects of our society and which is too rarely asked.

I was browsing at my local library and saw the title My Lobotomy. When you see a title like that it's like when you hear the screech of brakes and the sound of metal hitting metal. You know there is a car wreck and you know there's something you probably shouldn't want to gawk at but you just can't help yourself. The title of the book is like that. I had no idea what the book was, but I felt compelled to check it out.

It sat around awhile until I had finished a few other books I was working on, but then I picked it up. It is largely the memoirs of Howard Dully who was, at age 12, given a "transorbital lobotomy" by none other than Dr. Walter Freeman, the man who made transoribital lobotomies chic. This is the third memoir I have recently read where it is clear that the author has such a literal mind that you know what you are reading is the solid truth as the author sees it. The first such memoir I read was Grief of my Heart (which I reviewed here), the memoirs of a Chechen physician who lived through the two Chechen wars. The Chechen/Russia conflict has so many twists and turns and distortions that when you read anything about it you have to look for the bias of the author. Yet this book rang true. My wife's comment on this book was that she felt the author was not very imaginative and that he was telling the brutal truth about what he lived through. I felt the same. The power of the story was enhanced by the fact the author seemed so literal. The second memoir I recently read that had that same literal, unvarnished truth feel to it was A Long Way Gone, the memoirs of a child soldier from Sierra Leone who now lives in New York. This is a book I have been meaning to review for months now but haven't gotten up the emotional energy to do so.

Grief of my Heart and A Long Way Gone are both powerful, amazing stories that were riveting to read and bring up difficult issues that are too often ignored. My Lobotomy is not quite the same. It is starkly and simply written and sometimes comes off trivial and too self-focused to be of broad interest...at times it almost seems the author is whining about his life. But I also found it compelling in a way that I couldn't put my finger on at first but by the last chapters became clear. The issues that bothered me throughout the book, subconsciously at first, then overtly by the end, are so critical to any healthcare debate in America and can be summed up in the question, "How could this happen."

Howard Dully's life was tough by any standards. His father was distant and unemotional due to his own upbringing. Howard adored his mother, but she died when he was young. His father, probably with all the best intentions, did not tell Howard his mother had died, he merely told him that she had left and was never returning. This devastated Howard, making him feel, as children will, that he was at fault for his mother abandoning him.

His father married a woman named Lou who probably was unstable herself. She developed an almost immediate, irrational hatred of Howard, her step son, and set up an adversarial relationship with him that led her to seek a way to "fix" his behavior. He was apparently a pretty typical boy, but, as he puts it, maybe a little more so. Perhaps not the best hygiene (all of us with kids know that's typical), often surly and defiant (well, pre-teens often are like that), and prone to get into trouble. Nothing about his behavior stood out as abnormal, but perhaps was a clear sign of a child who was being emotionally abused. Which, it seems, is precisely what his step mother was doing.

I personally know many people who underwent similar abuse. Many of them had troubles, often including defiance and addiction. I also know that it is hard as a parent to find the right way of disciplining difficult children. Howard Dully was a difficult child and the way his father and stepmother handled it would clearly be considered abuse, both emotional and probably physical, today.

The stepmother spent a great deal of time trying to find a doctor who would "fix" Howard's behavior. Most of the doctors said there was nothing to fix...Howard was normal. A few suggested that it was Lou who needed help. Obviously Lou didn't want to hear that. Finally she met Dr. Walter Freeman.

Freeman is one of those famous/infamous figures in medicine who once was considered a savior but now is vilified. He did not invent the lobotomy, or even the transorbital lobotomy, but he single handedly made it a popular "cure" for decades and performed thousands such "cures" during his lifetime. He trivialized lobotomies, making them "fast, easy and cheap" and convinced many overburdened mental institutions that this was the way to cure patients.

Howard Dully is amazingly sympathetic to Freeman in this book. He portrays Freeman as the product of a period of medical history when a flood of information on mental illness was being published and our understanding of how the brain works and how the brain affects our mental health was growing by leaps and bounds. Doctors began to look at mental patients no longer as people to simply be shut away for life in a mental institution (often under horrific conditions) but as people with legitimate health problems who could be cured.

But how to cure them was still a complete mystery. It was a period where "miracle cures" for mental illnesses were proposed all over, though almost all of them look brutal and stupid to us today. Electroshock therapy, insulin therapy (the actual induction of a diabetic coma as a treatment for mental illness!), hydrotherapty of many sorts...and surgery.

Dr. Freeman genuinely wanted to help people. His observation of mental institutions left him desperate for an actual cure. Somehow the lobotomy struck him as THE answer to mental illness. The severing of our frontal lobes from the rest of the brain seemed to him to be a legitimate "miracle cure."

The pre-frontal cortex is where many aspects of who we are are carried out. Our ability to differentiate right from wrong, the suppression of socially "wrong" actions, the ability to work towards a goal...all of these are part of the function of the pre-frontal cortex. To give you an idea of what happens when we lose those functions, keep in mind that the pre-frontal cortex is what is first affected by alcohol when we get drunk. The loss of inhibitions and the tendency to think things seemed to be "a good idea at the time" no matter how stupid they really are is what happens when our pre-frontal cortex is impaired.

A lobotomy is a surgical technique wherein the connections between the pre-frontal cortex and the rest of the brain are severed. How the destruction of the pre-frontal cortex is supposed to help mental illness is unclear to me. Clearly it would seem to help with anxiety because a lobotomy will deaden one's sense of caring about things. The sense of right and wrong, of having to achieve a goal, etc. would be reduced, thus reducing, at least in theory, anxiety. But at what cost?

A transorbital lobotomy is a technique whereby a doctor inserts "ice picks" (sometimes literally!) behind the eyeball and into the brain and moves them around blindly, thus severing somewhat randomly the connections between the pre-frontal cortex and the rest of the brain.

Howard Dully's stepmother brought him to Dr. Freeman for evaluation. To his credit, Freeman initially seems to have thought Howard normal and eyed Lou with suspicion. But in the end, Lou told Freeman stories, some of which were fabrications, that convinced him that Howard was schizophrenic and would "benefit" from a lobotomy. Howard was never told what was to happen. His father objected but then let himself be convinced that it would be okay. His father insisted later that he always thought Howard normal but went along with the operation to make Lou happy... Yeah...pretty fucked up, if you ask me. The decision to operate occurred, coincidentally, on Howard's 12th birthday. Soon after, the operation was performed.

In 10 minutes, a doctor mangled Howard's brain. It is unclear how much of Howard's later troubles were due to this 10 minutes. I suspect that the family problems would have led to his having troubles anyway, but it is also clear that the nature of some of those troubles and his inability to make clear decisions of right and wrong probably were partly due to having part of his brain sliced up. There is no way to tease out what early problems caused what later problems, but there is also no question that having your parents agree to mangling your brain to "fix" you was both physically and emotionally a disastrous decision.

"How could this happen?"

The next part of the book outlines in perhaps excessive detail the difficult and often horrible cycles of self-destructive behavior that Howard's life became. I think this part is mostly cathartic for Howard himself and is the least interesting part of the book. But near the end of the book, Howard is contacted by an NPR radio team doing a story on Dr. Freeman. This turns out to be the best part of the book. After meeting with a reluctant Howard and interviewing him, the NPR team made a decision. The show would no longer be about Dr. Freeman...but about Howard. They had a hard time convincing Howard, but convince him they did. And the result was not only one of NPR's most successful radio programs, but also was the path to a sense of peace and self-worth for Howard, and a chance for others whose lives had been affected by lobotomies (either their own or those of loved ones) a chance to reach some sense of understanding. The last few chapters are much more fast paced and much more inspiring than the rest of the book...and raise the ultimate question:

"How could this happen?"

Among those Howard ultimately interviews for the NPR program is a woman whose mother had been given a lobotomy...to "cure" postpartum depression. Yeah...SERIOUSLY fucked up! Mangling a woman's brain because she has perfectly normal postpartum depression???? The operation made the woman useless as a mother, though she was a good playmate for her kids. But kids don't need their mother to be a playmate! They need a mother. The family was seriously affected by this and it really wasn't until the interview with Howard that some sense of peace was achieved. This led to perhaps the most moving dialogue in the book.

"It's been so painful that I've tried to stay very far away from it for a long time," she said...

"What has changed your mind about hiding it?" [Howard asks]

"You," she said, and started to cry..."Do you know how many people you are championing?...You are like all those people who were locked away who could not go on this quest, who could not ask all those questions. You're doing it for all of them."

That is a defining moment for Howard...and the most moving moment of the book. This is when Howard almost seems to find a meaning in his life, the moment he starts to feel good about himself.

But the most significant question is:

"How could this happen?"

There are dark corners of medical practice that we like to think are the exception. And mostly modern medicine saves lives...period. But sometimes accepted practice turns out to be horrific, and we HAVE to ask us how something horrific can become accepted practice.

Sometime back I wrote about forced sterilization of women in the US, a practice that did not really end until 1981...and, I am told, may be continuing even today in North Carolina. Then there is the FDA's refusal to allow over the counter sales of "Plan B" birth control despite nearly unanimous scientific and medical support for such sales. Then there is the suppression of a campaign to promote breast feeding, which scientific evidence clearly shows is beneficial for children, because the formula industry objected. Then there is the gross overuse of cesarean sections in the United States, far far above any other industrial nation. There are so many ill-conceived aspects to healthcare in America today. Yet we have more scientific and medical information than ever before. How can it happen?

I think there are several reasons.

First, there is the genuine desire patients AND doctors have for "miracle cures." The fact that most "miracle cures" are not miraculous and sometimes aren't even cures does not stop people from hoping. Where there is no hope, crazy ideas start sounding good. It is clear that Dr. Freeman and some of his patients were desperate for SOMETHING to "fix" a problem. They ignored actual evidence and relied on faith in a technique that in the vast majority of cases failed them. When there is no hope, people will rely on faith and faith in itself does not cure. Without science to back it up, a technique will fail and will probably fail spectacularly. There never was good evidence that lobotomies were appropriate in the vast majority of cases. Yet the faith of people like Freeman and some of his patients sustained the technique even against the opinion of the majority of doctors for decades.

Second, there is the submission of actual medicine to financial interests. Why do hospitals in America rely excessively on C-sections even though there is no evidence that they improve outcome in the majority of cases and may be harmful in many cases? It is because for insurance purposes it is better to do a C-section than not. It covers the collective ass of the hospital. There are cases where C-section is absolutely necessary. It is very likely my son's birth would have resulted either in his death or my wife's had a C-section not been performed once our baby's heartbeat started showing "decelerations." But in the majority of cases when hospitals recommend a C-section, it is just not the right thing to do. But hospitals do them anyway for insurance reasons. This is not isolated.

Why were lobotomies embraced so willingly in America? Why was so much faith placed in them? This has to be understood in the context of the time, which Howard Dully outlines excellently. At the time about all someone could do with a mentally ill relative was institutionalize them. This was a great cost either to the family or, more often, on society. Most institutions were grossly underfunded, like many hospitals and prisons and schools today. Overcrowding and high costs created a situation where almost ANYTHING would be welcomed if it got some patients out. The apparent success rate generally was about equal to the death rate...each about 20%. So about 20% of lobotomy patients died. Sad though that may be, it relieved crowding in institutions when a patient died. The "successes" could be released, even though often these people wound up dependent on society in other ways, in prisons or on welfare. But from the point of view of institutions, this still relieved their chronic problems of crowding and costs.

Institutions welcomed Freeman's lobotomy technique because it was fast, easy and cheap...and was about the only thing at the time that helped relieve THEIR financial problems. From the point of view of the institution, this was beneficial.

When the needs of the individual in a society are placed below the interests of money and those who have the most money, some really bad decisions are going to be made. This can even apply to things like the maintenance of bridges and levees in America or dealing with global warming. In the interests of cutting taxes for the very wealthy, the Republican Party under Bush neglected the infrastructure of America, contributing to several disasters including the aftermath of Hurricane Katrina. The interests of PEOPLE were placed below the interests of MONEY. It is in this context that things like lobotomies become understandable.

Finally, there is one more reason why these things happen. There is in our society an almost willful ignorance, an anti-science attitude that makes it harder for real science to be heard. Bush epitomizes this with his administration's censorship of science coming from NASA, NOAH, etc. But it is a wider issue where people don't trust science, usually for all the wrong reasons. Creationists spread false information about science, and the media and politicians give them equal time with the actual science. The fact that creationism and intelligent design are factually wrong and evolution has over a century of solid support, with new supporting evidence coming out every year, doesn't seem to matter. This problem of anti-science bias in our society is extremely harmful because it ALLOWS denial of global warming, acceptance of dubious techniques like lobotomies, and the suppression of facts for financial gain. This anti-science bias is something organizations like the Union of Concerned Scientists and Scientists and Engineers for America are trying to address. But it is a difficult thing when we have someone who openly admits he doesn't believe in the scientific fact of evolution is running for President and has a reasonable shot of winning! If I said I believed the world was flat, should people vote for me? It is ignorance and suspicion of science that also leads to some very poor decisions in our society.

My Lobotomy is well worth reading both because Howard's life is so much like the lives of people we all know who made bad decisions and/or suffered from difficult family situations, and because the fundamental question it raises about decisions our society makes and how it makes them are critical for us all to consider...particularly at a time when our healthcare system seems to be getting deeper and deeper into crisis. It is just at such times of crisis and financial difficulty that societies make poor decisions.