In the past, this treatment was used for handlingpsychiatric disorders as a mainstream procedure in some countries. A preoccupation with the ability to work and personal responsibility over patient well-being were contributing factors to the success of lobotomies in the US.[2]
The originator of the procedure, Portuguese neurologistAntónio Egas Moniz, shared theNobel Prize for Physiology or Medicine of 1949 for the "discovery of the therapeutic value of leucotomy in certain psychoses",[n 1] although the awarding of the prize has been subject to controversy.[4]
The procedure was modified and championed byWalter Freeman, who performed the first lobotomy at a mental hospital in the United States in 1936. Its use increased dramatically from the early 1940s and into the 1950s; by 1951, almost 20,000 lobotomies had been performed in the US and proportionally more in the United Kingdom.[5] More lobotomies were performed on women than on men: a 1951 study found that nearly 60% of American lobotomy patients were women, and limited data shows that 74% of lobotomies inOntario from 1948 to 1952 were performed on female patients.[6][7][8] From the 1950s onward, lobotomy began to be abandoned,[9] first in theSoviet Union,[10] where the procedure immediately garnered extensive criticism and was not widely employed, before being banned in December 1950,[11] and then Europe.[12] However, derivatives of it such as stereotactic tractotomy andbilateral cingulotomy are still used.[13]
Historically, patients of frontal lobotomy were, immediately following surgery, oftenstuporous andincontinent. Some developed an enormous appetite and gained considerable weight.Seizures were another common complication of surgery. Emphasis was put on the training of patients in the weeks and months following surgery.[14]
The purpose of the operation was to reduce the symptoms ofmental disorders, and it was recognized that this was accomplished at the expense of a person's personality and intellect. British psychiatrist Maurice Partridge, who conducted a follow-up study of 300 patients, said the treatment achieved its effects by "reducing the complexity of psychic life". Following the operation, spontaneity, responsiveness, self-awareness, and self-control were reduced. Activity was replaced by inertia, and people were mostly leftemotionally blunted and restricted in their intellectual range.[15]
The consequences of the operation have been described as "mixed".[16] However, many lobotomy patients suffered devastating postoperative complications, including intracranial hemorrhage, epilepsy, alterations in affect and personality, brain abscess, dementia, and death. Ominous portrayals of lobotomized patients in novels, plays, and films further diminished public opinion, and the development of antipsychotic medications led to a rapid decline in lobotomy's popularity andWalter Freeman's reputation. Others could leave the hospital or become more manageable within the hospital.[16] A precarious number of people managed to return to responsible work, while at the other extreme, people were left with severe and disabling impairments.[17] Most people fell into an intermediate group, left with some improvement of their symptoms but also with emotional and intellectual deficits to which they made a better or worse adjustment.[17] On average, there was a mortality rate of approximately 5% during the 1940s.[17] A survey of British lobotomy patients lobotomised between 1942 and 1954 found that 13% of patients were deemed to have made a full recovery and a further 28% were deemed to have made a significant recovery; for 25% lobotomy was deemed to have made no change and 4% died as a result of the surgery.[18]
The frontal lobotomy procedure could have severe negative effects on a patient's personality and ability to function independently.[19] Lobotomy patients often show a marked reduction in initiative and inhibition.[20] They may also exhibit difficulty imagining themselves in the position of others because of decreased cognition and detachment from society.[21]
Walter Freeman coined the term "surgically induced childhood" and used it constantly to refer to the results of lobotomy. The operation left people with an "infantile personality"; a period of maturation would then, according to Freeman, lead to recovery. In an unpublished memoir, he described how the "personality of the patient was changed in some way in the hope of rendering him more amenable to the social pressures under which he is supposed to exist." He described one 29-year-old woman as being, following lobotomy, a "smiling, lazy and satisfactory patient with the personality of an oyster" who could not remember Freeman's name and endlessly poured coffee from an empty pot. When her parents had difficulty dealing with her behavior, Freeman advised a system of rewards (ice cream) and punishment (smacks).[22]
In the early 20th century, the number of patients residing in mental hospitals increased significantly[n 2] while little in the way of effective medical treatment was available.[n 3][28] Lobotomy was one of a series of radical and invasive physical therapies developed in Europe at this time that signaled a break with the psychiatric culture oftherapeutic nihilism which had prevailed since the mid-nineteenth-century.[29] The new "heroic" physical therapies devised during this experimental era,[30] includingmalarial therapy forgeneral paresis of the insane (1917),[31]deep sleep therapy (1920),insulin shock therapy (1933),cardiazol shock therapy (1934), andelectroconvulsive therapy (1938),[32] served to galvanize a profession which had been both therapeutically moribund and systemically demoralized. Unlike other medical disciplines (e.g., cardiology, dermatology, orthopedics, etc.) which applied surgical and pharmacological treatments that were both apparent and measurable regarding their efficacy, psychiatry had often struggled with quantification. These novel remedial methodologies, however, meant that (at the time) modern psychiatric treatments were no longer relegated to the metaphysical or abstract, and this increased the popularity of the field among clinicians and prospective patients alike. Suddenly, conditions like insanity, psychosis, and others felt less like incurable afflictions and more like surmountable diagnoses, emboldening psychiatrists to attempt new procedures.[33] Additionally, the relative (and quantitative) success of the shock therapies, despite the considerable risks they posed to patients, also helped to inspire doctors in the field to pioneer ever more drastic forms of medical interventions, including lobotomies.[30]
The clinician-historian Joel Braslow argues that from malarial therapy onward to lobotomy, physical psychiatric therapies "spiral closer and closer to the interior of the brain", with this organ increasingly taking "center stage as a source of disease and site of cure".[34] For medical historianRoy Porter,[35] the often violent and invasive psychiatric interventions developed during the 1930s and 1940s are indicative of both the well-intentioned desire of psychiatrists to find some medical means of alleviating the suffering of the vast number of patients then in psychiatric hospitals and also the relative lack of social power of those same patients to resist the increasingly radical and even reckless interventions of asylum doctors.[36] Many doctors, patients, and family members of the period believed that despite potentially catastrophic consequences, the results of lobotomy were seemingly positive in many instances or were at least deemed as such when measured next to the apparent alternative of long-term institutionalisation. Lobotomy has always been controversial, but for a period of the medical mainstream, it was regarded as a legitimate last-resort remedy for categories of patients who were otherwise regarded as hopeless.[37] Today, lobotomy has become a disparaged procedure, a byword for medical barbarism and an exemplary instance of the medical trampling ofpatients' rights.[2]
Before the 1930s, individual doctors had infrequently experimented with novel surgical operations on those deemed insane. Most notably in 1888, Swiss psychiatristGottlieb Burckhardt initiated what is commonly considered the first systematic attempt at modern humanpsychosurgery.[38] He operated on six chronic patients under his care at the Swiss Préfargier Asylum, removing sections of theircerebral cortex. Burckhardt's decision to operate was informed by three pervasive views on the nature of mental illness and its relationship to the brain. First, the belief that mental illness was organic in nature, and reflected an underlying brain pathology; next, that the nervous system was organized according to anassociationist model comprising an input orafferent system (a sensory center), a connecting system where information processing took place (anassociation center), and an output orefferent system (a motor center); and, finally, a modular conception of the brain whereby discrete mental faculties were connected to specific regions of the brain.[39] Burckhardt's hypothesis was that by deliberately creatinglesions in regions of the brain identified as association centers, a transformation in behaviour might ensue.[39] According to his model, those mentally ill might experience "excitations abnormal in quality, quantity and intensity" in the sensory regions of the brain and this abnormal stimulation would then be transmitted to the motor regions giving rise tomental pathology.[40] He reasoned, however, that removing material from either of the sensory or motor zones could give rise to "grave functional disturbance". Instead, by targeting the association centers and creating a "ditch" around the motor region of thetemporal lobe, he hoped to break their lines of communication and thus alleviate both mental symptoms and the experience ofmental distress.[41]
Intending to ameliorate symptoms in those with violent and intractable conditions rather than effect a cure,[42] Burckhardt began operating on patients in December 1888,[43] but both his surgical methods and instruments were crude and the results of the procedure were mixed at best.[40] He operated on six patients in total and, according to his own assessment, two experienced no change, two patients became quieter, one patient experiencedepileptic convulsions and died a few days after the operation, and one patient improved.[n 4] Complications included motor weakness,epilepsy,sensory aphasia and "word deafness".[45] Claiming a success rate of 50 percent,[46] he presented the results at the Berlin Medical Congress and published a report, but the response from his medical peers was hostile and he did no further operations.[47]
In 1912, two physicians based inSaint Petersburg, the leading Russian neurologistVladimir Bekhterev and his younger Estonian colleague, the neurosurgeonLudvig Puusepp, published a paper reviewing a range of surgical interventions that had been performed on the mentally ill.[48] While generally treating these endeavours favorably, in their consideration of psychosurgery they reserved unremitting scorn for Burckhardt's surgical experiments of 1888 and opined that it was extraordinary that a trained medical doctor could undertake such an unsound procedure.[49]
We have quoted this data to show not only how groundless but also how dangerous these operations were. We are unable to explain how their author, holder of a degree in medicine, could bring himself to carry them out ...[50]
The authors neglected to mention, however, that in 1910 Puusepp himself had performed surgery on the brains of three mentally ill patients,[n 5][52] sectioning thecortex between thefrontal andparietal lobes.[53] He had abandoned these attempts because of unsatisfactory results and this experience probably inspired the invective that was directed at Burckhardt in the 1912 article.[49] By 1937, Puusepp, despite his earlier criticism of Burckhardt, was increasingly persuaded that psychosurgery could be a valid medical intervention for the mentally disturbed.[n 6][55] In the late 1930s, he worked closely with the neurosurgical team of the Racconigi Hospital nearTurin to establish it as an early and influential centre for the adoption of leucotomy in Italy.[56]
The pioneer of lobotomies, the Portuguese neurologist and Nobel LaureateAntónio Egas Moniz
Leucotomy was first undertaken in 1935 under the direction of thePortugueseneurologist (and inventor of the termpsychosurgery)António Egas Moniz.[n 7][60] First developing an interest in psychiatric conditions and their somatic treatment in the early 1930s,[61] Moniz conceived a new opportunity for recognition in the development of a surgical intervention on the brain as a treatment for mental illness.[42]
The source of inspiration for Moniz's decision to hazard psychosurgery has been clouded by contradictory statements made on the subject by Moniz and others both contemporaneously and retrospectively.[62] The traditional narrative addresses the question of why Moniz targeted the frontal lobes by way of reference to the work of the Yale neuroscientistJohn Fulton and, most dramatically, to a presentation Fulton made with his junior colleague Carlyle Jacobsen at the Second International Congress of Neurology held in London in 1935.[63] Fulton's primary area of research was on the cortical function of primates and he had established America's first primateneurophysiology laboratory at Yale in the early 1930s.[64] At the 1935 Congress, with Moniz in attendance,[n 8] Fulton and Jacobsen presented twochimpanzees named Becky and Lucy who had had frontal lobectomies and subsequent changes in behaviour and intellectual function.[65] According to Fulton's account of the congress, they explained that before surgery, both animals, and especially Becky, the more emotional of the two, exhibited "frustrational behaviour" – that is, tantrums that could include rolling on the floor and defecating – if, because of their poor performance in a set of experimental tasks, they were not rewarded.[66] Following the surgical removal of their frontal lobes, the behaviour of both primates changed markedly and Becky was pacified to such a degree that Jacobsen apparently stated it was as if she had joined a "happiness cult".[65] During the question and answer section of the paper, Moniz, it is alleged, "startled" Fulton by inquiring if this procedure might be extended to human subjects suffering from mental illness. Fulton stated that he replied that while possible in theory it was surely "too formidable" an intervention for use on humans.[67]
Brain animation: leftfrontal lobe highlighted in red. Moniz targeted the frontal lobes in the leucotomy procedure he first conceived in 1933.
Moniz began his experiments with leucotomy just three months after the congress had reinforced the apparent cause-and-effect relationship between the Fulton and Jacobsen presentation and the Portuguese neurologist's resolve to operate on the frontal lobes.[68] As the author of this account Fulton, who has sometimes been claimed as the father of lobotomy, was later able to record that the technique had its true origination in his laboratory.[69] Endorsing this version of events, in 1949, the Harvard neurologistStanley Cobb remarked during his presidential address to theAmerican Neurological Association that "seldom in the history of medicine has a laboratory observation been so quickly and dramatically translated into a therapeutic procedure". Fulton's report, penned ten years after the events described, is, however, without corroboration in the historical record and bears little resemblance to an earlier unpublished account he wrote of the congress. In this previous narrative, he mentioned an incidental, private exchange with Moniz, but it is likely that the official version of their public conversation he promulgated is without foundation.[70] In fact, Moniz stated that he had conceived of the operation sometime before his journey to London in 1935, having told in confidence his junior colleague, the youngneurosurgeon Pedro Almeida Lima, as early as 1933 of his psychosurgical idea.[71] The traditional account exaggerates the importance of Fulton and Jacobsen to Moniz's decision to initiate frontal lobe surgery, and omits the fact that a detailed body of neurological research that emerged at this time suggested to Moniz and other neurologists and neurosurgeons that surgery on this part of the brain might yield significant personality changes in the mentally ill.[72]
The frontal lobes have been the object of scientific inquiry and speculation since the late 19th century. Fulton's contribution, while it may have functioned as a source of intellectual support, is in itself unnecessary and inadequate as an explanation of Moniz's resolution to operate on this section of the brain.[73] Under an evolutionary and hierarchical model of brain development it had been hypothesized that those regions associated with the more recent development, such as themammalian brain and, most especially, the frontal lobes, were responsible for more complex cognitive functions.[74] However, this theoretical formulation found little laboratory support, as 19th-century experimentation found no significant change in animal behaviour following surgical removal or electrical stimulation of the frontal lobes.[74] This picture of the so-called "silent lobe" changed in the period after World War I with the production of clinical reports of ex-servicemen withbrain trauma. The refinement of neurosurgical techniques also facilitated increasing attempts to remove brain tumours, and treatfocal epilepsy in humans and led to more precise experimental neurosurgery in animal studies.[74] Cases were reported where mental symptoms were alleviated following the surgical removal of diseased or damaged brain tissue.[53] The accumulation of medical case studies on behavioural changes following damage to the frontal lobes led to the formulation of the concept ofWitzelsucht, which designated a neurological condition characterised by a certain hilarity and childishness in those with the condition.[74] The picture of frontal lobe function that emerged from these studies was complicated by the observation that neurological deficits attendant on damage to a single lobe might be compensated for if the opposite lobe remained intact.[74] In 1922, the Italian neurologistLeonardo Bianchi published a detailed report on the results of bilateral lobectomies in animals that supported the contention that the frontal lobes were both integral to intellectual function and that their removal led to the disintegration of the subject's personality.[75] This work, while influential, was not without its critics due to deficiencies in experimental design.[74]
The first bilateral lobectomy of a human subject was performed by the American neurosurgeonWalter Dandy in 1930.[n 9][76] The neurologist Richard Brickner reported on this case in 1932,[77] relating that the recipient, known as "Patient A", while experiencing ablunting of affect, had no apparent decrease in intellectual function and seemed, at least to the casual observer, perfectly normal.[78] Brickner concluded from this evidence that "the frontal lobes are not 'centers' for the intellect".[79] These clinical results were replicated in a similar operation undertaken in 1934 by the neurosurgeonRoy Glenwood Spurling and reported on by the neuropsychiatristSpafford Ackerly.[80] By the mid-1930s, interest in the function of the frontal lobes reached a high-water mark. This was reflected in the 1935 neurological congress in London, which hosted[80] as part of its deliberations,[80] "a remarkable symposium ... on the functions of the frontal lobes".[81] The panel was chaired byHenri Claude, a French neuropsychiatrist, who commenced the session by reviewing the state of research on the frontal lobes, and concluded that "altering the frontal lobes profoundly modifies the personality of subjects".[79] This parallel symposium contained numerous papers by neurologists, neurosurgeons and psychologists; amongst these was one by Brickner, which impressed Moniz greatly,[78] that again detailed the case of "Patient A".[80] Fulton and Jacobsen's paper, presented in another session of the conference on experimental physiology, was notable in linking animal and human studies on the function of the frontal lobes.[80] Thus, at the time of the 1935 Congress, Moniz had available to him an increasing body of research on the role of the frontal lobes that extended well beyond the observations of Fulton and Jacobsen.[82]
Nor was Moniz the only medical practitioner in the 1930s to have contemplated procedures directly targeting the frontal lobes.[83] Although ultimately discounting brain surgery as carrying too much risk, physicians and neurologists such asWilliam Mayo, Thierry de Martel, Richard Brickner, andLeo Davidoff had, before 1935, entertained the proposition.[n 10][85] Inspired byJulius Wagner-Jauregg's development of malarial therapy for the treatment ofgeneral paresis of the insane, the French physician Maurice Ducosté reported in 1932 that he had injected 5 ml of malarial blood directly into the frontal lobes of over 100 paretic patients through holes drilled into the skull.[83] He claimed that the injected paretics showed signs of "uncontestable mental and physical amelioration" and that the results for psychotic patients undergoing the procedure were also "encouraging".[86] The experimental injection of fever-inducing malarial blood into the frontal lobes was also replicated during the 1930s in the work of Ettore Mariotti and M. Sciutti in Italy and Ferdière Coulloudon in France.[87] In Switzerland, almost simultaneously with the commencement of Moniz's leucotomy programme, the neurosurgeon François Ody had removed the entire right frontal lobe of acatatonic schizophrenic patient.[88] In Romania, Ody's procedure was adopted by Dimitri Bagdasar and Constantinesco working out of the Central Hospital in Bucharest.[84] Ody, who delayed publishing his own results for several years, later rebuked Moniz for claiming to have cured patients through leucotomy without waiting to determine if there had been a "lasting remission".[89]
The theoretical underpinnings of Moniz's psychosurgery were largely commensurate with the nineteenth-century ones that had informed Burckhardt's decision to excise matter from the brains of his patients. Although in his later writings, Moniz referenced both theneuron theory ofRamón y Cajal and theconditioned reflex ofIvan Pavlov,[90] in essence he simply interpreted this new neurological research in terms of the old psychological theory ofassociationism.[62] He differed significantly from Burckhardt, however in that he did not think there was any organic pathology in the brains of the mentally ill, but rather that their neural pathways were caught in fixed and destructive circuits leading to "predominant, obsessive ideas".[n 11][92] As Moniz wrote in 1936:
[The] mental troubles must have ... a relation with the formation of cellulo-connective groupings, which become more or less fixed. The cellular bodies may remain altogether normal, their cylinders will not have any anatomical alterations; but their multiple liaisons, very variable in normal people, may have arrangements more or less fixed, which will have a relation with persistent ideas and deliria in certain morbid psychic states.[93]
For Moniz, "to cure these patients", it was necessary to "destroy the more or less fixed arrangements of cellular connections that exist in the brain, and particularly those which are related to the frontal lobes",[94] thus removing their fixed pathological brain circuits. Moniz believed the brain would functionally adapt to such injury.[95] Unlike the position adopted by Burckhardt, it wasunfalsifiable according to the knowledge and technology of the time as the absence of a known correlation between physical brain pathology and mental illness could not disprove his thesis.[96]
The hypotheses underlying the procedure might be called into question; the surgical intervention might be considered very audacious; but such arguments occupy a secondary position because it can be affirmed now that these operations are not prejudicial to either physical or psychic life of the patient, and also that recovery or improvement may be obtained frequently in this way.
On 12 November 1935 at theHospital de Santa Marta inLisbon, Moniz initiated the first of a series of operations on the brains of people with mental illnesses.[98] The initial patients selected for the operation were provided by the medical director of Lisbon's Miguel Bombarda Mental Hospital, José de Matos Sobral Cid.[99] As Moniz lacked training in neurosurgery and his hands were impaired by gout, the procedure was performed under general anaesthetic by Pedro Almeida Lima, who had previously assisted Moniz with his research oncerebral angiography.[n 12][101] The intention was to remove some of the long fibres that connected the frontal lobes to other major brain centres.[102] To this end, it was decided that Lima wouldtrephine into the side of the skull and then injectethanol into the "subcorticalwhite matter of the prefrontal area"[97] so as to destroy the connecting fibres, orassociation tracts,[103] and create what Moniz termed a "frontal barrier".[n 13][104] After the first operation was complete, Moniz considered it a success and, observing that the patient's depression had been relieved, he declared her "cured" although she was never, in fact, discharged from the mental hospital.[105] Moniz and Lima persisted with this method of injecting alcohol into the frontal lobes for the next seven patients but, after having to inject some patients on numerous occasions to elicit what they considered a favourable result, they modified the means by which they would section the frontal lobes.[105] For the ninth patient they introduced a surgical instrument called aleucotome; this was acannula that was 11 centimetres (4.3 in) in length and 2 centimetres (0.79 in) in diameter. It had a retractable wire loop at one end that, when rotated, produced a 1 centimetre (0.39 in) diameter circular lesion in the white matter of the frontal lobe.[106] Typically, six lesions were cut into each lobe, but, if they were dissatisfied by the results, Lima might perform several procedures, each producing multiple lesions in the left and right frontal lobes.[105]
By the conclusion of this first run of leucotomies in February 1936, Moniz and Lima had operated on twenty patients with an average period of one week between each procedure; Moniz published his findings with great haste in March of the same year.[107] The patients were aged between 27 and 62 years of age; twelve were female and eight were male. Nine of the patients were diagnosed withdepression, six withschizophrenia, two withpanic disorder, and one each withmania,catatonia andmanic-depression. Their most prominent symptoms were anxiety and agitation. The duration of their illness before the procedure varied from as little as four weeks to as much as 22 years, although all but four had been ill for at least one year.[108] Patients were normally operated on the day they arrived at Moniz's clinic and returned within ten days to the Miguel Bombarda Mental Hospital.[109] A perfunctory post-operative follow-up assessment took place anywhere from one to ten weeks following surgery.[110] Complications were observed in each of the leucotomy patients and included: "increased temperature, vomiting,bladder andbowel incontinence, diarrhea, and ocular affections such asptosis andnystagmus, as well as psychological effects such as apathy,akinesia, lethargy, timing, and local disorientation,kleptomania, and abnormal sensations of hunger".[111] Moniz asserted that these effects were transitory and,[111] according to his published assessment, the outcome for these first twenty patients was that 35%, or seven cases, improved significantly, another 35% were somewhat improved and the remaining 30% (six cases) were unchanged. There were no deaths and he did not consider that any patients had deteriorated following leucotomy.[112]
Moniz rapidly disseminated his results through articles in the medical press and a monograph in 1936.[104] Initially, however, the medical community appeared hostile to the new procedure.[113] On 26 July 1936, one of his assistants, Diogo Furtado, gave a presentation at the Parisian meeting of the Société Médico-Psychologique on the results of the second cohort of patients leucotomised by Lima.[104] Sobral Cid, who had supplied Moniz with the first set of patients for leucotomy from his own hospital in Lisbon, attended the meeting and denounced the technique,[113] declaring that the patients who had been returned to his care post-operatively were "diminished" and had experienced a "degradation of personality".[114] He also claimed that the changes Moniz observed in patients were more properly attributed to shock and brain trauma, and he derided the theoretical architecture that Moniz had constructed to support the new procedure as "cerebral mythology."[114] At the same meeting the Parisian psychiatrist, Paul Courbon, stated he could not endorse a surgical technique that was solely supported by theoretical considerations rather than clinical observations.[115] He also opined that the mutilation of an organ could not improve its function and that such cerebral wounds as were occasioned by leucotomy risked the later development ofmeningitis, epilepsy andbrain abscesses.[116] Nonetheless, Moniz's reported successful surgical treatment of 14 out of 20 patients led to the rapid adoption of the procedure on an experimental basis by individual clinicians in countries such as Brazil, Cuba, Italy, Romania and the United States during the 1930s.[117]
In the present state of affairs if some are critical about lack of caution in therapy, it is, on the other hand, deplorable and inexcusable to remain apathetic, with folded hands, content with learned lucubrations upon symptomatologic minutiae or upon psychopathic curiosities, or even worse, not even doing that.
Throughout the remainder of the 1930s, the number of leucotomies performed in most countries where the technique was adopted remained quite low. In Britain, which was later a major centre for leucotomy,[n 14] only six operations had been undertaken before 1942.[120] Generally, medical practitioners who attempted the procedure adopted a cautious approach and few patients were leucotomised before the 1940s. Italian neuropsychiatrists, who were typically early and enthusiastic adopters of leucotomy, were exceptional in eschewing such a gradualist course.[56]
Leucotomy was first reported in the Italian medical press in 1936 and Moniz published an article in Italian on the technique in the following year.[56] In 1937, he was invited to Italy to demonstrate the procedure and for two weeks in June of that year, he visited medical centres inTrieste,Ferrara, and one close toTurin – the Racconigi Hospital – where he instructed his Italian neuropsychiatric colleagues on leucotomy and also oversaw several operations.[56] Leucotomy was featured at two Italian psychiatric conferences in 1937 and over the next two years a score of medical articles on Moniz's psychosurgery was published by Italian clinicians based in medical institutions located inRacconigi,Trieste,Naples,Genoa,Milan,Pisa,Catania andRovigo.[56] The major centre for leucotomy in Italy was the Racconigi Hospital, where the experienced neurosurgeonLudvig Puusepp provided a guiding hand.[n 15][56] Under the medical directorship of Emilio Rizzatti, the medical personnel at this hospital had completed at least 200 leucotomies by 1939.[122] Reports from clinicians based at other Italian institutions detailed significantly fewer leucotomy operations.[56]
Experimental modifications of Moniz's operation were introduced with little delay by Italian medical practitioners.[123] Most notably, in 1937Amarro Fiamberti, the medical director of a psychiatric institution inVarese,[124] first devised the transorbital procedure whereby the frontal lobes were accessed through the eye sockets.[123] Fiamberti's method was to puncture the thin layer oforbital bone at the top of the socket and then inject alcohol or formalin into the white matter of the frontal lobes through this aperture.[125] Using this method, while sometimes substituting aleucotome for ahypodermic needle, it is estimated that he leucotomised about 100 patients in the period up to the outbreak of World War II.[124] Fiamberti's innovation of Moniz's method would later prove inspirational forWalter Freeman's development of transorbital lobotomy.[125]
Site of borehole for the standard pre-frontal lobotomy/leucotomy operation as developed by Freeman and Watts
The first prefrontal leucotomy in the United States was performed at theGeorge Washington University Hospital, on 14 September 1936, by theneurologistWalter Freeman, and his friend and colleague, the neurosurgeonJames W. Watts.[126] Freeman had first encountered Moniz at the London-hosted Second International Congress of Neurology in 1935, where he had presented a poster exhibit of the Portuguese neurologist's work on cerebral angiography.[127] Fortuitously occupying a booth next to Moniz, Freeman, delighted by their chance meeting, formed a highly favourable impression of Moniz, later remarking upon his "sheer genius".[127] According to Freeman, if they had not met in person, it is highly unlikely that he would have ventured into the domain of frontal lobe psychosurgery.[128] Freeman's interest in psychiatry was the natural outgrowth of his appointment in 1924 as the medical director of the Research Laboratories of the Government Hospital for the Insane in Washington, known colloquially as St Elizabeth's.[129] Freeman, who favoured an organic model of mental illness causation, spent the next several years exhaustively, yet ultimately fruitlessly, investigating aneuropathological basis for insanity.[130] Chancing upon a preliminary communication by Moniz on leucotomy in the spring of 1936, Freeman initiated a correspondence in May of that year. Writing that he had been considering psychiatric brain surgery previously, he informed Moniz that, "having your authority I expect to go ahead".[131] Moniz, in return, promised to send him a copy of his forthcoming monograph on leucotomy and urged him to purchase a leucotome from a French supplier.[132]
Upon receipt of Moniz's monograph, Freeman reviewed it anonymously for theArchives of Neurology and Psychiatry.[132] Praising the text as one whose "importance can scarcely be overestimated",[132] he summarised Moniz's rationale for the procedure as based on the fact that while no physical abnormality of cerebral cell bodies was observable in the mentally ill, their cellular interconnections may harbour a "fixation of certain patterns of relationship among various groups of cells" and that this resulted in obsessions, delusions and mental morbidity.[133] While recognising that Moniz's thesis was inadequate, for Freeman it had the advantage of circumventing the search for diseased brain tissue in the mentally ill by instead suggesting that the problem was a functional one of the brain's internal wiring where relief might be obtained by severing problematic mental circuits.[133]
In 1937 Freeman and Watts adapted Lima and Moniz's surgical procedure, and created theFreeman-Watts technique, also known as theFreeman-Watts standard prefrontal lobotomy, which they styled the "precision method".[134]
The Freeman–Watts prefrontal lobotomy still required drilling holes in the skull, so surgery had to be performed in an operating room by trained neurosurgeons. Walter Freeman believed this surgery would be unavailable to those he saw as needing it most: patients in state mental hospitals that had no operating rooms, surgeons, oranesthesia and limited budgets. Freeman wanted to simplify the procedure so that it could be carried out by psychiatrists inpsychiatric hospitals.[135]
Inspired by the work of Italian psychiatristAmarro Fiamberti, Freeman at some point conceived of approaching the frontal lobes through the eye sockets instead of through drilled holes in the skull. In 1945 he took anice pick[n 16] from his own kitchen and began testing the idea on grapefruit[n 17] andcadavers.
The use of lobotomy in the United States was resisted and criticized heavily by American neurosurgeons. However, because Freeman managed to promote the success of the surgery through the media, lobotomy became touted as a miracle procedure, capturing the attention of the public and leading to an overwhelming demand for the operation. In 1945 Freeman streamlined the procedure, replacing it with transorbital lobotomy, in which a picklike instrument was forced through the back of the eye sockets to pierce the thin bone that separates the eye sockets from the frontal lobes. The pick's point was then inserted into the frontal lobe and used to sever connections in the brain (presumably between the prefrontal cortex and thalamus). In 1946 Freeman performed this procedure for the first time on a patient, who was subdued prior to the operation with electroshock treatment.
The transorbital lobotomy procedure, which Freeman performed very quickly, sometimes in less than 10 minutes, was used on many patients with relatively minor mental disorders that Freeman believed did not warrant traditional lobotomy surgery, in which the skull itself was opened. A large proportion of such lobotomized patients exhibited reduced tension or agitation, but many also showed other effects, such as apathy, passivity, lack of initiative, poor ability to concentrate, and a generally decreased depth and intensity of their emotional response to life. Some died as a result of the procedure. However, those effects were not widely reported in the 1940s, and at that time the long-term effects were largely unknown. Because the procedure met with seemingly widespread success, Moniz was awarded the 1949 Nobel Prize for Physiology or Medicine (along with Swiss physiologistWalter Rudolf Hess).
Lobotomies were performed on a wide scale during the 1940s; Freeman himself performed or supervised more than 3,500 lobotomies by the late 1960s. Freeman performed his first transorbital lobotomy on Ellen Ionesco, a woman who suffered from bouts of manic depression and suicidal ideation. Freeman utilized media coverage and penned editorials for numerous interviews promoting the procedure and achieving accolades for his work in psychiatric care.[137]
Watts did not favor the transorbital method, and this difference of opinion contributed to the end of their partnership. Watts resisted the technique itself, Freeman's lack of sterile technique when performing it, and the idea of performing the procedure in an outpatient setting. Watts recalled that the hospital reprimanded Freeman, stating that he was "not a surgeon and if he wants to operate he'll have to apply for surgical privileges."[138]
Freeman performed the first transorbital lobotomy on a live patient in 1946. Its simplicity suggested the possibility of carrying it out in mental hospitals lacking the surgical facilities required for the earlier, more complex procedure. (Freeman suggested that, where conventional anesthesia was unavailable,electroconvulsive therapy be used to render the patient unconscious.)[139] In 1947, the Freeman and Watts partnership ended, as the latter was disgusted by Freeman's barbarism and neglectful modifications of the lobotomy from a surgical operation into a simple "office" procedure.[140] Between 1940 and 1944, 684 lobotomies were performed in the United States. However, because of the fervent promotion of the technique by Freeman and Watts, those numbers increased sharply toward the end of the decade. In 1949, the peak year for lobotomies in the US, 5,074 procedures were undertaken, and by 1951 over 18,608 individuals had been lobotomized in the US.[141]
In the United States, approximately 40,000 people were lobotomized, and in England, 17,000 lobotomies were performed. According to one estimate, in the three Nordic countries of Denmark, Norway, and Sweden, a combined figure of approximately 9,300 lobotomies were performed.[142] Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the US.[143] According to another estimate, Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women. This figure includes young children.[144] And in Norway, there were 2,005 known lobotomies.[145] In Denmark, there were 4,500 known lobotomies.[146] In Japan, the majority of lobotomies were performed on children with behaviour problems. The Soviet Union banned the practice in 1950 on moral grounds.[147][148][149] In Germany, it was performed only a few times.[150] By the late 1970s, the practice of lobotomy had generally ceased, although it continued as late as the 1980s in France.[151] As of 2019, legality of the procedure in the United States varies according to state law, with some states restricting it heavily, while others effectively leave its regulation to laws of general applicability.[152]
Early skepticism toward lobotomy emerged inSoviet psychiatry. As reports on leucotomy and lobotomy surfaced in Soviet medical journals between 1936 and 1937, followed by more extensive reviews of Freeman and Watts's initial studies in 1939, Soviet reviewers expressed alarm at the procedure's severe complications and a reported 5 percent mortality rate, while also questioning its efficacy, observing that symptoms like fear, depression, and agitation often resolved spontaneously without necessitating such a dramatic procedure. These reviews suggested lobotomy should not be performed in the USSR.[153]
Later, by 1944, an author in theJournal of Nervous and Mental Disease remarked: "The history of prefrontal lobotomy has been brief and stormy. Its course has been dotted with both violent opposition and with slavish, unquestioning acceptance." Beginning in 1947 Swedish psychiatrist Snorre Wohlfahrt evaluated early trials, reporting that it is "distinctly hazardous to leucotomize schizophrenics" and that lobotomy was "still too imperfect to enable us, with its aid, to venture on a general offensive against chronic cases of mental disorder", stating further that "Psychosurgery has as yet failed to discover its precise indications and contraindications and the methods must unfortunately still be regarded as rather crude and hazardous in many respects."[154] In 1948Norbert Wiener, the author ofCybernetics: Or the Control and Communication in the Animal and the Machine, said: "Prefrontal lobotomy... has recently been having a certain vogue, probably not unconnected with the fact that it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier."[155]
Concerns about lobotomy steadily grew. Soviet psychiatristVasily Gilyarovsky [ru] criticized lobotomy and the mechanistic brain localization assumption used to carry out lobotomy:
It is assumed that the transection of white substance of the frontal lobes impairs their connection with the thalamus and eliminates the possibility to receive from it stimuli which lead to irritation and on the whole derange mental functions. This explanation is mechanistic and goes back to the narrow localizationism characteristic of psychiatrists of America, from where leucotomy was imported to us.[156]
The Soviet Union officially banned the procedure in 1950[157] on the initiative of Gilyarovsky.[158] Doctors in the Soviet Union concluded that the procedure was "contrary to the principles of humanity" and"'through lobotomy' an insane person is changed into an idiot".[149] By the 1970s, numerous countries had banned the procedure, as had several US states.[159]
In 1977, the US Congress, during the presidency ofJimmy Carter, created the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery – including lobotomy techniques – was used to control minorities and restrain individual rights. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects.[160]
Torsten Wiesel has called the award of the Nobel Prize to Moniz an "astounding [error] of judgment... a terrible mistake",[161] and there have been calls for theNobel Foundation to rescind the award.[162][4]
Rosemary Kennedy, sister of US presidentJohn F. Kennedy, underwent a lobotomy in 1941 that left her incapacitated and institutionalized for the rest of her life.[163]
Howard Dully wrote a memoir of his late-life discovery that he had been lobotomized in 1960 at age 12.[164]
Josef Hassid, a Polish violinist and composer, was diagnosed with schizophrenia and died at the age of 26 following a lobotomy performed on him in England.[165]
Swedish modernist painterSigrid Hjertén died following a lobotomy in 1948.[166]
American playwrightTennessee Williams's older sister Rose received a lobotomy that left her incapacitated for life; the episode is said to have inspired characters and motifs in some of his works.[167]
It is often said that when an iron rod was accidentally driven through the head ofPhineas Gage in 1848, this constituted an "accidental lobotomy", or that this event somehow inspired the development of surgical lobotomy a century later. According to the only book-length study of Gage, careful inquiry turns up no such link.[168]
In 2011, Daniel Nijensohn, an Argentine-born neurosurgeon at Yale, examined X-rays ofEva Perón and concluded that she underwent a lobotomy for the treatment of pain and anxiety in the last months of her life.[169]
Lobotomies have been featured in several literary and cinematic presentations that both reflected society's attitude toward the procedure and, at times, changed it. Writers and filmmakers have played a pivotal role in turning public sentiment against the procedure.[4]
Robert Penn Warren's 1946 novelAll the King's Men describes a lobotomy as making "a Comanche brave look like a tyro with a scalping knife", and portrays the surgeon as a repressed man who cannot change others with love, so he instead resorts to "high-grade carpentry work".[170]
Tennessee Williams criticized lobotomy in his playSuddenly, Last Summer (1958) because it was sometimes inflicted onhomosexuals – to render them "morally sane".[4] In the play, a wealthy matriarch offers the local mental hospital a substantial donation if the hospital will give her niece a lobotomy, which she hopes will stop the niece's shocking revelations about her son.[171] Warned that a lobotomy might not stop her niece's "babbling", she responds, "That may be, maybe not, but after the operation, who wouldbelieve her, Doctor?".[172]
InKen Kesey's 1962 novelOne Flew Over the Cuckoo's Nest and its1975 film adaptation, lobotomy is described as "frontal-lobe castration", a form of punishment and control after which "There's nothin' in the face. Just like one of those store dummies." In one patient, "You can see by his eyes how they burned him out over there; his eyes are all smoked up and gray and deserted inside."[170]
InSylvia Plath's 1963 novelThe Bell Jar, the protagonist reacts with horror to the "perpetual marble calm" of a lobotomized young woman.[170]
Elliott Baker's 1964 novel and 1966 film version,A Fine Madness, portrays the dehumanizing lobotomy of a womanizing, quarrelsome poet who, afterward, is just as aggressive as ever. The surgeon is depicted as an inhumane crackpot.[173]
The 1982biopic filmFrances depicts actressFrances Farmer (the subject of the film) undergoing transorbital lobotomy (though the idea[174] that a lobotomy was performed on Farmer, and that Freeman performed it, has been criticized as having little or no factual foundation).[175]
^Walter Rudolf Hess, who was the joint winner with Moniz of the Nobel Prize in 1949 for his work on the function of the midbrain, had no involvement with leucotomy.[3]
^A 1937 report detailed that in the United States there were then 477 psychiatric institutions with a total population of approximately 451,672 patients, almost half of whom had been resident for five years or more.[23] The report also observed that psychiatric patients occupied 55 percent of all hospital beds in America.[23] Conditions within US mental hospitals became the subject of public debate as a series of exposes were published in the 1940s.[24] A 1946Life magazine article remarked that the nation's system of mental hospitals resembled "little more than concentration camps on the Belsen pattern";[25] a point the piece emphasized with documentary photography that depicted patient neglect and dilapidated material conditions within psychiatric institutions.[26]
^Ugo Cerletti, the Italian psychiatrist and joint inventor withLucio Bini ofelectroconvulsive therapy, described psychiatry during the interwar period as a "funereal science".[27] Likewise Egas Moniz, the inventor of leucotomy, referred to the "impotência terapeutica" (therapeutic impotence) of existing therapeutic remedies during the 1930s.[28]
^The patient he thought improved subsequently committed suicide.[44]
^According to Puusepp, the three patients had manic depression or considered "epileptic equivalents".[51]
^Puusepp admitted to his 1910 experimentation with psychosurgery in a 1937 publication.[54] At that point he had completed a series of 14 leucotomies to relieve aggressive symptoms in patients. Convinced that the results had been positive in these cases, he felt that further research into psychosurgery was warranted.[53]
^Professor of neurology at the University of Lisbon from 1911 to 1944, Moniz was also for several decades a prominent parliamentarian and diplomat. He was Portugal's ambassador to Spain during World War I and represented Portugal at the postwarVersailles Treaty negotiations,[57] but after the Portuguesecoup d'état of 1926, which ushered in theDitadura Nacional (National Dictatorship), theRepublican Moniz, then 51 years old, devoted his considerable talents and energies to neurological research entirely. Throughout his career he published on topics as diverse as neurology, sexology, historical biography, and the history of card games.[58] For his 1927 development ofcerebral angiography, which allowed routine visualisation of the brain's peripheral blood vessels for the first time, he was twice nominated, unsuccessfully, for a Nobel Prize. Some have attributed his development of leucotomy to a determination on his part to win the Nobel after these disappointments.[59]
^The American neuropsychiatrist Walter Freeman also attended the Congress where he presented his research findings oncerebral ventriculography. Freeman, who would later play a central role in the popularisation and practice of leucotomy in America, also had an interest in personality changes following frontal lobe surgery.[53]
^Brickner and Davidoff had planned, before Moniz's first leucotomies, to operate on the frontal lobes to relieve depression.[84]
^Moniz wrote in 1948: 'sufferers from melancholia, for instance, are distressed by fixed and obsessive ideas ... and live in a permanent state of anxiety caused by a fixed idea which predominates over all their lives ... in contrast to automatic actions, these morbid ideas are deeply rooted in the synaptic complex which regulates the functioning of consciousness, stimulating it and keeping it in constant activity ... all these considerations led me to the following conclusion: it is necessary to alter these synaptic adjustments and change the paths chosen by the impulses in their constant passage so as to modify the corresponding ideas and force thoughts along different paths ...'[91]
^Lima described his role as that of an "instrument handled by the Master".[100]
^Before operating on live subjects, they practised the procedure on a cadaver head.[85]
^The 14 leucotomies reported by Puusepp in his 1937 paper were performed at the Racconigi Hospital.[121]
^Frank Freeman, Walter Freeman's son, stated in an interview with Howard Dully that: "He had several ice-picks that just cluttered the back of the kitchen drawer. The first ice pick came right out of our drawer. A humble ice-pick to go right into the frontal lobes. It was, from a cosmetic standpoint, diabolical. Just observing this thing was horrible, gruesome." When Dully asked Frank Freeman, then a 79-year-old security guard, whether he was proud of his father, he replied: "Oh yes, yes, yeah. He was terrific. He was really quite a remarkable pioneer lobotomist. I wish he could have gotten further."[136]
^Rodney Dully, whose son Howard Dully had had a transorbital lobotomy performed on him by Walter Freeman when he was twelve years old, stated in an interview with his son that: "I only met him [Freeman] I think the one time. He described how accurate it [transorbital lobotomy] was and that he had practised the cutting on, literally, a carload of grapefruit, getting the right move and the right turn. That's what he told me."[136]
^Zajicek, Benjamin (2017). "Banning the Soviet Lobotomy: Psychiatry, Ethics, and Professional Politics during Late Stalinism".Bulletin of the History of Medicine.91 (1):38–51.doi:10.1353/bhm.2017.0002.ISSN1086-3176.PMID28366896.
^Zajicek, Benjamin (2017). "Banning the Soviet Lobotomy: Psychiatry, Ethics, and Professional Politics during Late Stalinism".Bulletin of the History of Medicine.91 (1): 38.doi:10.1353/bhm.2017.0002.ISSN1086-3176.PMID28366896.Reports about leucotomy and lobotomy began to appear in Soviet journals in 1936 and 1937,26 followed in 1939 by longer reviews of Freeman and Watts's early publications. Soviet reviewers were disturbed by the serious complications and high rate of mortality (5 percent) that Freeman and Watts reported, and they questioned lobotomy's effectiveness, noting that the symptoms it eliminated, such as fear, depression, and agitation, often went away on their own. They concluded that these were "insurmountable obstacles" to recommending lobotomy for use in the Soviet Union.
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