Frontal Lobotomy
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A lobotomy, or leucotomy, is a form of neurosurgical treatment for
psychiatric disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitt ...
or
neurological disorder A neurological disorder is any disorder of the nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord or other nerves can result in a range of symptoms. Examples of symptoms include paralysis, muscle weakn ...
(e.g.
epilepsy Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical ...
) that involves severing connections in the brain's
prefrontal cortex In mammalian brain anatomy, the prefrontal cortex (PFC) covers the front part of the frontal lobe of the cerebral cortex. The PFC contains the Brodmann areas BA8, BA9, BA10, BA11, BA12, BA13, BA14, BA24, BA25, BA32, BA44, BA45, BA46, ...
. The surgery causes most of the connections to and from the prefrontal cortex, the
anterior Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position prov ...
part of the
frontal lobe The frontal lobe is the largest of the four major lobes of the brain in mammals, and is located at the front of each cerebral hemisphere (in front of the parietal lobe and the temporal lobe). It is parted from the parietal lobe by a groove betwe ...
s of the
brain A brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as vision. It is the most complex organ in a v ...
, to be severed. In the past, this treatment was used for treating
psychiatric disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitt ...
s as a mainstream procedure in some countries. The procedure was controversial from its initial use, in part due to a lack of recognition of the severity and chronicity of severe and enduring psychiatric illnesses, so it was claimed to be an inappropriate treatment. Frontal lobe surgery, including lobotomy, is the second most common surgery for epilepsy to this day, and usually done on one side of the brain, unlike lobotomies for psychiatric disorder which were done on both sides of the brain. The originator of the procedure, Portuguese neurologist
António Egas Moniz António Caetano de Abreu Freire Egas Moniz (29 November 1874 – 13 December 1955), known as Egas Moniz (), was a Portuguese neurologist and the developer of cerebral angiography. He is regarded as one of the founders of modern psychosurgery, ...
, shared the
Nobel Prize for Physiology or Medicine The Nobel Prize in Physiology or Medicine is awarded yearly by the Nobel Assembly at the Karolinska Institute for outstanding discoveries in physiology or medicine. The Nobel Prize is not a single prize, but five separate prizes that, according ...
of 1949 for the "discovery of the therapeutic value of leucotomy in certain psychoses", although the awarding of the prize has been subject to controversy. The use of the procedure increased dramatically from the early 1940s and into the 1950s; by 1951, almost 20,000 lobotomies had been performed in the United States and proportionally more in the United Kingdom. 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 in
Ontario Ontario ( ; ) is one of the thirteen provinces and territories of Canada.Ontario is located in the geographic eastern half of Canada, but it has historically and politically been considered to be part of Central Canada. Located in Central Ca ...
from 1948 to 1952 were performed on female patients. From the 1950s onward, lobotomy began to be abandoned, first in the Soviet Union and Europe. The term is derived from el, λοβός lobos "lobe" and "cut, slice".


Effects

Historically, patients of lobotomy were, immediately following surgery, often stuporous,
confused In medicine, confusion is the quality or state of being bewildered or unclear. The term "acute mental confusion"
, and incontinent. Some developed an enormous appetite and gained considerable weight.
Seizures An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or neural oscillation, synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much o ...
were another common complication of surgery. Emphasis was put on the training of patients in the weeks and months following surgery. The purpose of the operation was to reduce the symptoms of
mental disorders A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
, 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 that the treatment achieved its effects by "reducing the complexity of psychic life". Following the operation, spontaneity, responsiveness, self-awareness, and self-control were reduced. The activity was replaced by inertia, and people were mostly left emotionally blunted and restricted in their intellectual range. The consequences of the operation have been described as "mixed". Some patients died as a result of the operation and others later committed suicide. Some were left severely brain damaged. Others were able to leave the hospital, or became more manageable within the hospital. A few people managed to return to responsible work, while at the other extreme, people were left with severe and disabling impairments. 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. On average, there was a mortality rate of approximately 5% during the 1940s. The lobotomy procedure could have severe negative effects on a patient's personality and ability to function independently. Lobotomy patients often show a marked reduction in initiative and inhibition. They may also exhibit difficulty imagining themselves in the position of others because of decreased cognition and detachment from society. 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 behaviour, Freeman advised a system of rewards (ice-cream) and punishment (smacks).


History

In the early 20th century, the number of patients residing in mental hospitals increased significantly while little in the way of effective medical treatment was available. Lobotomy was one of a series of radical and invasive physical therapies developed in Europe at this time that signaled a break with a psychiatric culture of
therapeutic nihilism Therapeutic nihilism is a contention that it is impossible to cure people or societies of their ills through treatment. In medicine, it was connected to the idea that many "cures" do more harm than good, and that one should instead encourage the ...
that had prevailed since the late nineteenth-century. The new "
heroic Heroic may mean: *characteristic of a hero *typical of heroic poetry or of heroic verse *belonging to the Greek Heroic Age *Heroic (esports), a Danish esports organization *Heroic (horse) Heroic (1921–1939) was an Australian Thoroughbred ra ...
" physical therapies devised during this experimental era, including
malarial therapy The malaria therapy (or malaria inoculation, and sometimes malariotherapy) is a medical procedure of treating diseases using artificial injection of malaria parasites. It is a type of pyrotherapy (or pyretotherapy) by which high fever is induced to ...
for
general paresis of the insane General paresis, also known as general paralysis of the insane (GPI), paralytic dementia, or syphilitic paresis is a severe neuropsychiatric disorder, classified as an organic mental disorder and is caused by late-stage syphilis and the chro ...
(1917),
deep sleep therapy Deep sleep therapy (DST), also called prolonged sleep treatment or continuous narcosis, is a discredited form of ostensibly psychiatric treatment in which drugs are used to keep patients unconscious for a period of days or weeks. The controversia ...
(1920),
insulin shock therapy Insulin shock therapy or insulin coma therapy was a form of psychiatric treatment in which patients were repeatedly injected with large doses of insulin in order to produce daily comas over several weeks.Neustatter WL (1948) ''Modern psychiatry ...
(1933),
cardiazol Pentylenetetrazol, also known as pentylenetetrazole, leptazol, metrazol, pentetrazol (INN), pentamethylenetetrazol, Corazol, Cardiazol, Deumacard, or PTZ, is a drug formerly used as a circulatory and respiratory stimulant. High doses cause convuls ...
shock therapy (1934), and
electroconvulsive therapy Electroconvulsive therapy (ECT) is a psychiatry, psychiatric treatment where a generalized seizure (without muscular convulsions) is electrically induced to manage refractory mental disorders.Rudorfer, MV, Henry, ME, Sackeim, HA (2003)"Electroco ...
(1938), helped to imbue the then therapeutically moribund and demoralised psychiatric profession with a renewed sense of optimism in the curability of insanity and the potency of their craft. The success of the shock therapies, despite the considerable risk they posed to patients, also helped to accommodate psychiatrists to ever more drastic forms of medical intervention, including lobotomy. 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". For
Roy Porter Roy Sydney Porter, FBA (31 December 1946 – 3 March 2002) was a British historian known for his work on the history of medicine. He retired in 2001 from the director of the Wellcome Institute for the History of Medicine at University College L ...
, once the doyen of medical history, 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. 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 even feted and regarded as a legitimate last resort remedy for categories of patients who were otherwise regarded as hopeless. Today, lobotomy has become a disparaged procedure, a byword for medical barbarism and an exemplary instance of the medical trampling of
patients' rights A patient's bill of rights is a list of guarantees for those receiving medical care. It may take the form of a law or a non-binding declaration. Typically a patient's bill of rights guarantees patients information, fair treatment, and autonomy ov ...
.


Early psychosurgery

Before the 1930s, individual doctors had infrequently experimented with novel surgical operations on the brains of those deemed insane. Most notably in 1888, the Swiss psychiatrist
Gottlieb Burckhardt Johann Gottlieb Burckhardt (24 December 1836 – 6 February 1907) was a Swiss psychiatrist and the medical director of a small mental hospital in the Swiss canton of Neuchâtel. He is commonly regarded as having performed the first modern psychos ...
initiated what is commonly considered the first systematic attempt at modern human psychosurgery. He operated on six chronic patients under his care at the Swiss Préfargier Asylum, removing sections of their
cerebral cortex The cerebral cortex, also known as the cerebral mantle, is the outer layer of neural tissue of the cerebrum of the brain in humans and other mammals. The cerebral cortex mostly consists of the six-layered neocortex, with just 10% consisting of ...
. 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 an
associationist Associationism is the idea that mental processes operate by the association of one mental state with its successor states. It holds that all mental processes are made up of discrete psychological elements and their combinations, which are believed ...
model comprising an input or afferent system (a sensory center), a connecting system where information processing took place (an
association center The cerebral cortex, also known as the cerebral mantle, is the outer layer of neural tissue of the cerebrum of the brain in humans and other mammals. The cerebral cortex mostly consists of the six-layered neocortex, with just 10% consisting of ...
), and an output or efferent system (a motor center); and, finally, a modular conception of the brain whereby discrete mental faculties were connected to specific regions of the brain. Burckhardt's hypothesis was that by deliberately creating
lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classifi ...
s in regions of the brain identified as association centers a transformation in behaviour might ensue. 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 to mental pathology. 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 the
temporal lobe The temporal lobe is one of the four Lobes of the brain, major lobes of the cerebral cortex in the brain of mammals. The temporal lobe is located beneath the lateral fissure on both cerebral hemispheres of the mammalian brain. The temporal lobe ...
, he hoped to break their lines of communication and thus alleviate both mental symptoms and the experience of
mental distress Mental distress or psychological distress encompasses the symptoms and experiences of a person's internal life that are commonly held to be troubling, confusing or out of the ordinary. Mental distress can potentially lead to a change of behavior, a ...
. Intending to ameliorate symptoms in those with violent and intractable conditions rather than effect a cure, Burckhardt began operating on patients in December 1888, but both his surgical methods and instruments were crude and the results of the procedure were mixed at best. He operated on six patients in total and, according to his own assessment, two experienced no change, two patients became quieter, one patient experienced epileptic convulsions and died a few days after the operation, and one patient improved. Complications included motor weakness,
epilepsy Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical ...
,
sensory aphasia Wernicke's aphasia, also known as receptive aphasia, sensory aphasia or posterior aphasia, is a type of aphasia in which individuals have difficulty understanding written and spoken language. Patients with Wernicke's aphasia demonstrate fluent ...
and "
word deafness Auditory verbal agnosia (AVA), also known as pure word deafness, is the inability to comprehend speech. Individuals with this disorder lose the ability to understand language, repeat words, and write from dictation. Some patients with AVA describe ...
". Claiming a success rate of 50 percent, 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. In 1912, two physicians based in
Saint Petersburg Saint Petersburg ( rus, links=no, Санкт-Петербург, a=Ru-Sankt Peterburg Leningrad Petrograd Piter.ogg, r=Sankt-Peterburg, p=ˈsankt pʲɪtʲɪrˈburk), formerly known as Petrograd (1914–1924) and later Leningrad (1924–1991), i ...
, the leading Russian neurologist
Vladimir Bekhterev Vladimir Mikhailovich Bekhterev ( rus, Влади́мир Миха́йлович Бе́хтерев, p=ˈbʲextʲɪrʲɪf; January 20, 1857 – December 24, 1927) was a Russian neurologist and the father of objective psychology. He is best know ...
and his younger Estonian colleague, the neurosurgeon Ludvig Puusepp, published a paper reviewing a range of surgical interventions that had been performed on the mentally ill. 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.; The authors neglected to mention, however, that in 1910 Puusepp himself had performed surgery on the brains of three mentally ill patients, sectioning the
cortex Cortex or cortical may refer to: Biology * Cortex (anatomy), the outermost layer of an organ ** Cerebral cortex, the outer layer of the vertebrate cerebrum, part of which is the ''forebrain'' *** Motor cortex, the regions of the cerebral cortex i ...
between the
frontal Front may refer to: Arts, entertainment, and media Films * ''The Front'' (1943 film), a 1943 Soviet drama film * ''The Front'', 1976 film Music * The Front (band), an American rock band signed to Columbia Records and active in the 1980s and e ...
and
parietal lobe The parietal lobe is one of the four major lobes of the cerebral cortex in the brain of mammals. The parietal lobe is positioned above the temporal lobe and behind the frontal lobe and central sulcus. The parietal lobe integrates sensory informa ...
s. 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. By 1937, Puusepp, despite his earlier criticism of Burckhardt, was increasingly persuaded that psychosurgery could be a valid medical intervention for the mentally disturbed. In the late 1930s, he worked closely with the neurosurgical team of the Racconigi Hospital near
Turin Turin ( , Piedmontese language, Piedmontese: ; it, Torino ) is a city and an important business and cultural centre in Northern Italy. It is the capital city of Piedmont and of the Metropolitan City of Turin, and was the first Italian capital ...
to establish it as an early and influential centre for the adoption of leucotomy in Italy.


Development

Leucotomy was first undertaken in 1935 under the direction of the
Portuguese Portuguese may refer to: * anything of, from, or related to the country and nation of Portugal ** Portuguese cuisine, traditional foods ** Portuguese language, a Romance language *** Portuguese dialects, variants of the Portuguese language ** Portu ...
neurologist Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal c ...
(and inventor of the term ''psychosurgery'')
António Egas Moniz António Caetano de Abreu Freire Egas Moniz (29 November 1874 – 13 December 1955), known as Egas Moniz (), was a Portuguese neurologist and the developer of cerebral angiography. He is regarded as one of the founders of modern psychosurgery, ...
. First developing an interest in psychiatric conditions and their somatic treatment in the early 1930s, Moniz apparently conceived a new opportunity for recognition in the development of a surgical intervention on the brain as a treatment for mental illness.


Frontal lobes

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. The traditional narrative addresses the question of why Moniz targeted the frontal lobes by way of reference to the work of the Yale neuroscientist John 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. Fulton's primary area of research was on the cortical function of primates and he had established America's first primate neurophysiology laboratory at Yale in the early 1930s. At the 1935 Congress, with Moniz in attendance, Fulton and Jacobsen presented two
chimpanzees The chimpanzee (''Pan troglodytes''), also known as simply the chimp, is a species of great ape native to the forest and savannah of tropical Africa. It has four confirmed subspecies and a fifth proposed subspecies. When its close relative the ...
, named Becky and Lucy who had had frontal lobectomies and subsequent changes in behaviour and intellectual function. 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, have tantrums that could include rolling on the floor and defecatingif, because of their poor performance in a set of experimental tasks, they were not rewarded. 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". 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. 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. 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. Endorsing this version of events, in 1949, the Harvard neurologist
Stanley Cobb Stanley Cobb (December 10, 1887 – February 25, 1968) was a neurologist and could be considered "the founder of biological psychiatry in the United States". Early life Cobb was born on December 10, 1887, in Brookline, Massachusetts, to John Can ...
remarked during his presidential address to the
American Neurological Association The American Neurological Association (ANA) is a professional society of academic neurologists and neuroscientists devoted to advancing the goals of academic neurology; to training and educating neurologists and other physicians in the neurologic ...
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. In fact, Moniz stated that he had conceived of the operation some time before his journey to London in 1935, having told in confidence his junior colleague, the young
neurosurgeon Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the medical specialty concerned with the surgical treatment of disorders which affect any portion of the nervous system including the brain, spinal cord and peri ...
Pedro Almeida Lima, as early as 1933 of his psychosurgical idea. 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. The frontal lobes had been the object of scientific inquiry and speculation since the late 19th century. Fulton's contribution, while it may have functioned as source of intellectual support, is of itself unnecessary and inadequate as an explanation of Moniz's resolution to operate on this section of the brain. Under an evolutionary and hierarchical model of brain development it had been hypothesized that those regions associated with more recent development, such as the
mammalian brain A brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as vision. It is the most complex organ in a v ...
and, most especially, the frontal lobes, were responsible for more complex cognitive functions. 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. 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 with brain trauma. The refinement of neurosurgical techniques also facilitated increasing attempts to remove brain tumours, treat
focal epilepsy Focal seizures (also called partial seizures and localized seizures) are seizures which affect initially only one hemisphere of the brain. The brain is divided into two hemispheres, each consisting of four lobes – the frontal, temporal, parie ...
in humans and led to more precise experimental neurosurgery in animal studies. Cases were reported where mental symptoms were alleviated following the surgical removal of diseased or damaged brain tissue. The accumulation of medical case studies on behavioural changes following damage to the frontal lobes led to the formulation of the concept of ''
Witzelsucht Witzelsucht ( " joking addiction") is a set of pure and rare neurological symptoms characterized by a tendency to make puns, or tell inappropriate jokes or pointless stories in socially inappropriate situations. It makes one unable to read sarcasm ...
'', which designated a neurological condition characterised by a certain hilarity and childishness in those with the condition. 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. In 1922, the Italian neurologist
Leonardo Bianchi Leonardo Bianchi (5 April 1848 – 13 February 1927), an Italian neuropathologist, politician, and writer from San Bartolomeo in Galdo in the Province of Benevento, earned fame from his work on cerebral functions and diseases of the nervous sys ...
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. This work, while influential, was not without its critics due to deficiencies in experimental design. The first bilateral lobectomy of a human subject was performed by the American neurosurgeon
Walter Dandy Walter Edward Dandy (April 6, 1886 – April 19, 1946) was an American neurosurgeon and scientist. He is considered one of the founding fathers of neurosurgery, along with Victor Horsley (1857–1916) and Harvey Cushing (1869–1939). Dandy is ...
in 1930. The neurologist Richard Brickner reported on this case in 1932, relating that the recipient, known as "Patient A", while experiencing a blunting of affect, had no apparent decrease in intellectual function and seemed, at least to the casual observer, perfectly normal. Brickner concluded from this evidence that "the frontal lobes are not 'centers' for the intellect".Quoted in These clinical results were replicated in a similar operation undertaken in 1934 by the neurosurgeon
Roy Glenwood Spurling Roy Glenwood "Glen" Spurling (September 6, 1894 in Centralia, Missouri – February 7, 1968 in La Jolla, California) was an American neurosurgeon remembered for describing Spurling's test. Biography R. Glen Spurling studied at the Univers ...
and reported on by the neuropsychiatrist Spafford Ackerly. 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 as part of its deliberations, "a remarkable symposium ... on the functions of the frontal lobes". The panel was chaired by Henri 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". This parallel symposium contained numerous papers by neurologists, neurosurgeons and psychologists; amongst these was one by Brickner, which impressed Moniz greatly, that again detailed the case of "Patient A". 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. 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. Nor was Moniz the only medical practitioner in the 1930s to have contemplated procedures directly targeting the frontal lobes. Although ultimately discounting brain surgery as carrying too much risk, physicians and neurologists such as William Mayo, Thierry de Martel, Richard Brickner, and Leo Davidoff had, before 1935, entertained the proposition. Inspired by
Julius Wagner-Jauregg Julius Wagner-Jauregg (; 7 March 1857 – 27 September 1940) was an Austrian physician, who won the Nobel Prize in Physiology or Medicine in 1927, and is the first psychiatrist to have done so. His Nobel award was "for his discovery of the therapeu ...
's development of malarial therapy for the treatment of
general paresis of the insane General paresis, also known as general paralysis of the insane (GPI), paralytic dementia, or syphilitic paresis is a severe neuropsychiatric disorder, classified as an organic mental disorder and is caused by late-stage syphilis and the chro ...
, 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. He claimed that the injected paretics showed signs of "uncontestable mental and physical amelioration" and that the results for psychotic patients undergoing the procedure was also "encouraging". 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. In Switzerland, almost simultaneously with the commencement of Moniz's leucotomy programme, the neurosurgeon François Ody had removed the entire right frontal lobe of a catatonic schizophrenic patient. In Romania, Ody's procedure was adopted by Dimitri Bagdasar and Constantinesco working out of the Central Hospital in Bucharest. 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".


Neurological model

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 the
neuron theory The neuron doctrine is the concept that the nervous system is made up of discrete individual cells, a discovery due to decisive neuro-anatomical work of Santiago Ramón y Cajal and later presented by, among others, Heinrich Wilhelm Gottfried von W ...
of
Ramón y Cajal Ramón or Ramon may refer to: People Given name * Ramon (footballer, born 1998), Brazilian footballer * Ramón (footballer, born 1990), Brazilian footballer * Ramón (singer), Spanish singer who represented Spain in the 2004 Eurovision Song Contes ...
and the
conditioned reflex Classical conditioning (also known as Pavlovian or respondent conditioning) is a behavioral procedure in which a biologically potent stimulus A stimulus is something that causes a physiological response. It may refer to: *Stimulation **Stimulus ...
of
Ivan Pavlov Ivan Petrovich Pavlov ( rus, Ива́н Петро́вич Па́влов, , p=ɪˈvan pʲɪˈtrovʲɪtɕ ˈpavləf, a=Ru-Ivan_Petrovich_Pavlov.ogg; 27 February 1936), was a Russian and Soviet experimental neurologist, psychologist and physiol ...
, in essence he simply interpreted this new neurological research in terms of the old psychological theory of
associationism Associationism is the idea that mental processes operate by the association of one mental state with its successor states. It holds that all mental processes are made up of discrete psychological elements and their combinations, which are believed ...
. 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". As Moniz wrote in 1936:
hemental 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.
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", thus removing their fixed pathological brain circuits. Moniz believed the brain would functionally adapt to such injury. Unlike the position adopted by Burckhardt, it was
unfalsifiable Falsifiability is a standard of evaluation of scientific theories and hypotheses that was introduced by the Philosophy of science, philosopher of science Karl Popper in his book ''The Logic of Scientific Discovery'' (1934). He proposed it as t ...
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.


First leucotomies

On 12 November 1935 at the Hospital Santa Marta in
Lisbon Lisbon (; pt, Lisboa ) is the capital and largest city of Portugal, with an estimated population of 544,851 within its administrative limits in an area of 100.05 km2. Grande Lisboa, Lisbon's urban area extends beyond the city's administr ...
, Moniz initiated the first of a series of operations on the brains of people with mental illnesses. 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. 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 on
cerebral angiography Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms. It was pioneered in 1927 by the Portugues ...
. The intention was to remove some of the long fibres that connected the frontal lobes to other major brain centres. To this end, it was decided that Lima would
trephine A trephine (; from Greek ''trypanon'', meaning an instrument for boring). is a surgical instrument with a cylindrical blade. It can be of one of several dimensions and designs depending on what it is meant to be used for. They may be specially d ...
into the side of the skull and then inject
ethanol Ethanol (abbr. EtOH; also called ethyl alcohol, grain alcohol, drinking alcohol, or simply alcohol) is an organic compound. It is an Alcohol (chemistry), alcohol with the chemical formula . Its formula can be also written as or (an ethyl ...
into the " subcortical
white matter White matter refers to areas of the central nervous system (CNS) that are mainly made up of myelinated axons, also called tracts. Long thought to be passive tissue, white matter affects learning and brain functions, modulating the distribution ...
of the prefrontal area" so as to destroy the connecting fibres, or
association tract Association fibers are axons that connect cerebral cortex, cortical areas within the same cerebral hemisphere. In human neuroanatomy, axons (nerve fibers) within the brain, can be categorized on the basis of their course and connections as ass ...
s, and create what Moniz termed a "frontal barrier". 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. 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. For the ninth patient they introduced a surgical instrument called a
leucotome A leucotome or McKenzie Leucotome is a surgical instrument used for performing leucotomies (also known as lobotomy) and other forms of psychosurgery. Invented by Canadian neurosurgeon Dr. Kenneth G. McKenzie in the 1940s, the leucotome has a n ...
; this was a
cannula A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
that was in length and in diameter. It had a retractable wire loop at one end that, when rotated, produced a diameter circular lesion in the white matter of the frontal lobe. 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. 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. The patients were aged between 27 and 62 years of age; twelve were female and eight were male. Nine of the patients were diagnosed with depression, six with
schizophrenia Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social withdra ...
, two with
panic disorder Panic disorder is a mental disorder, mental and Abnormal behavior, behavioral disease#Disorder, disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear th ...
, and one each with
mania Mania, also known as manic syndrome, is a mental and behavioral disorder defined as a state of abnormally elevated arousal, affect, and energy level, or "a state of heightened overall activation with enhanced affective expression together wit ...
,
catatonia Catatonia is a complex neuropsychiatric behavioral syndrome that is characterized by abnormal movements, immobility, abnormal behaviors, and withdrawal. The onset of catatonia can be acute or subtle and symptoms can wax, wane, or change during ...
and manic-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. Patients were normally operated on the day they arrived at Moniz's clinic and returned within ten days to the Miguel Bombarda Mental Hospital. A perfunctory post-operative follow-up assessment took place anywhere from one to ten weeks following surgery. Complications were observed in each of the leucotomy patients and included: "increased temperature, vomiting,
bladder The urinary bladder, or simply bladder, is a hollow organ in humans and other vertebrates that stores urine from the kidneys before disposal by urination. In humans the bladder is a distensible organ that sits on the pelvic floor. Urine enters ...
and bowel incontinence, diarrhea, and ocular affections such as ptosis and
nystagmus Nystagmus is a condition of involuntary (or voluntary, in some cases) eye movement. Infants can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in reduced or limited vision. Due to the invol ...
, as well as psychological effects such as apathy,
akinesia Hypokinesia is one of the classifications of movement disorders, and refers to decreased bodily movement. Hypokinesia is characterized by a partial or complete loss of muscle movement due to a disruption in the basal ganglia. Hypokinesia is a sym ...
, lethargy, timing and local disorientation,
kleptomania Kleptomania is the inability to resist the urge to steal items, usually for reasons other than personal use or financial gain. First described in 1816, kleptomania is classified in psychiatry as an impulse control disorder. Some of the main cha ...
, and abnormal sensations of hunger". Moniz asserted that these effects were transitory and, 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.


Reception

Moniz rapidly disseminated his results through articles in the medical press and a monograph in 1936. Initially, however, the medical community appeared hostile to the new procedure. 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. 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, declaring that the patients who had been returned to his care post-operatively were "diminished" and had experienced a "degradation of personality".Quoted in 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." 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. 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 of
meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, headache, and neck stiffness. Other symptoms include confusion or ...
, epilepsy and
brain abscess Brain abscess (or cerebral abscess) is an abscess caused by inflammation and collection of infected material, coming from local (ear infection, dental abscess, infection of paranasal sinuses, infection of the mastoid air cells of the temporal bone ...
es. 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.


Italian leucotomy

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, only six operations had been undertaken before 1942. 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. 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. In 1937, he was invited to Italy to demonstrate the procedure and for a two-week period in June of that year he visited medical centres in
Trieste Trieste ( , ; sl, Trst ; german: Triest ) is a city and seaport in northeastern Italy. It is the capital city, and largest city, of the autonomous region of Friuli Venezia Giulia, one of two autonomous regions which are not subdivided into provi ...
,
Ferrara Ferrara (, ; egl, Fràra ) is a city and ''comune'' in Emilia-Romagna, northern Italy, capital of the Province of Ferrara. it had 132,009 inhabitants. It is situated northeast of Bologna, on the Po di Volano, a branch channel of the main stream ...
, and one close to
Turin Turin ( , Piedmontese language, Piedmontese: ; it, Torino ) is a city and an important business and cultural centre in Northern Italy. It is the capital city of Piedmont and of the Metropolitan City of Turin, and was the first Italian capital ...
the Racconigi Hospitalwhere he instructed his Italian neuropsychiatric colleagues on leucotomy and also oversaw several operations. 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 in
Racconigi Racconigi ( pms, Racunis) is a town and ''comune'' in Piedmont, Italy. It is located in the province of Cuneo, south of Turin, and north of Cuneo by rail. History The town was founded in medieval times. It was a possession of the marquisses of ...
,
Trieste Trieste ( , ; sl, Trst ; german: Triest ) is a city and seaport in northeastern Italy. It is the capital city, and largest city, of the autonomous region of Friuli Venezia Giulia, one of two autonomous regions which are not subdivided into provi ...
,
Naples Naples (; it, Napoli ; nap, Napule ), from grc, Νεάπολις, Neápolis, lit=new city. is the regional capital of Campania and the third-largest city of Italy, after Rome and Milan, with a population of 909,048 within the city's adminis ...
,
Genoa Genoa ( ; it, Genova ; lij, Zêna ). is the capital of the Italian region of Liguria and the List of cities in Italy, sixth-largest city in Italy. In 2015, 594,733 people lived within the city's administrative limits. As of the 2011 Italian ce ...
,
Milan Milan ( , , Lombard: ; it, Milano ) is a city in northern Italy, capital of Lombardy, and the second-most populous city proper in Italy after Rome. The city proper has a population of about 1.4 million, while its metropolitan city h ...
,
Pisa Pisa ( , or ) is a city and ''comune'' in Tuscany, central Italy, straddling the Arno just before it empties into the Ligurian Sea. It is the capital city of the Province of Pisa. Although Pisa is known worldwide for its leaning tower, the cit ...
,
Catania Catania (, , Sicilian and ) is the second largest municipality in Sicily, after Palermo. Despite its reputation as the second city of the island, Catania is the largest Sicilian conurbation, among the largest in Italy, as evidenced also by ...
and
Rovigo Rovigo (, ; egl, Ruig) is a city and ''comune'' in the Veneto region of Northeast Italy, the capital of the eponymous province. Geography Rovigo stands on the low ground known as Polesine, by rail southwest of Venice and south-southwest of P ...
. The major centre for leucotomy in Italy was the Racconigi Hospital, where the experienced neurosurgeon Ludvig Puusepp provided a guiding hand. Under the medical directorship of Emilio Rizzatti, the medical personnel at this hospital had completed at least 200 leucotomies by 1939. Reports from clinicians based at other Italian institutions detailed significantly smaller numbers of leucotomy operations. Experimental modifications of Moniz's operation were introduced with little delay by Italian medical practitioners. Most notably, in 1937
Amarro Fiamberti Adamo Mario (Amarro) Fiamberti was the first to perform a transorbital lobotomy (by accessing the frontal lobe of the brain through the orbits) in 1937. Fiamberti was later named Director of the Psychiatric Hospital of Varese, when it was open ...
, the medical director of a psychiatric institution in
Varese Varese ( , , or ; lmo, label= Varesino, Varés ; la, Baretium; archaic german: Väris) is a city and ''comune'' in north-western Lombardy, northern Italy, north-west of Milan. The population of Varese in 2018 has reached 80,559. It is the c ...
, first devised the transorbital procedure whereby the frontal lobes were accessed through the eye sockets. Fiamberti's method was to puncture the thin layer of orbital bone at the top of the socket and then inject alcohol or formalin into the white matter of the frontal lobes through this aperture.; ; Using this method, while sometimes substituting a
leucotome A leucotome or McKenzie Leucotome is a surgical instrument used for performing leucotomies (also known as lobotomy) and other forms of psychosurgery. Invented by Canadian neurosurgeon Dr. Kenneth G. McKenzie in the 1940s, the leucotome has a n ...
for a hypodermic needle, it is estimated that he leucotomised about 100 patients in the period up to the outbreak of World War II. Fiamberti's innovation of Moniz's method would later prove inspirational for Walter Freeman's development of transorbital lobotomy.


American leucotomy

The first prefrontal leucotomy in the United States was performed at the George Washington University Hospital on 14 September 1936 by the
neurologist Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal c ...
Walter Freeman and his friend and colleague, the neurosurgeon,
James W. Watts James Winston Watts (January 19, 1904 – November 15, 1994) was an American neurosurgeon, born in Lynchburg, Virginia. He was a graduate of the Virginia Military Institute as well as the University of Virginia School of Medicine. Watts is note ...
. 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.; 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". 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. 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. Ambitious and a prodigious researcher, Freeman, who favoured an organic model of mental illness causation, spent the next several years exhaustively, yet ultimately fruitlessly, investigating a neuropathological basis for insanity. 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". 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. Upon receipt of Moniz's monograph, Freeman reviewed it anonymously for the ''Archives of Neurology and Psychiatry''. Praising the text as one whose "importance can scarcely be overestimated", 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. 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. In 1937 Freeman and Watts adapted Lima and Moniz's surgical procedure, and created the ''Freeman-Watts technique'', also known as the ''Freeman-Watts standard prefrontal lobotomy,'' which they styled the "precision method".


Transorbital lobotomy

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, or
anesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...
and limited budgets. Freeman wanted to simplify the procedure so that it could be carried out by psychiatrists in
psychiatric hospital Psychiatric hospitals, also known as mental health hospitals, behavioral health hospitals, are hospitals or wards specializing in the treatment of severe mental disorders, such as schizophrenia, bipolar disorder, eating disorders, dissociative ...
s. Inspired by the work of Italian psychiatrist
Amarro Fiamberti Adamo Mario (Amarro) Fiamberti was the first to perform a transorbital lobotomy (by accessing the frontal lobe of the brain through the orbits) in 1937. Fiamberti was later named Director of the Psychiatric Hospital of Varese, when it was open ...
, 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 an icepick from his own kitchen and began testing the idea on grapefruit and
cadavers A cadaver or corpse is a dead human body that is used by medical students, physicians and other scientists to study anatomy, identify disease sites, determine causes of death, and provide tissue to repair a defect in a living human being. Stud ...
. This new "transorbital" lobotomy involved lifting the upper eyelid and placing the point of a thin surgical instrument (often called an
orbitoclast An orbitoclast was a surgical instrument used for performing transorbital lobotomies. Because actual ice picks were used in initial experimentation and because of continued close resemblance to ice pick shafts, the procedure was dubbed "ice pick ...
or leucotome, although quite different from the wire loop leucotome described above) under the eyelid and against the top of the eyesocket. A mallet was used to drive the orbitoclast through the thin layer of bone and into the brain along the plane of the bridge of the nose, around 15 degrees toward the interhemispherical fissure. The orbitoclast was malleted 5 centimeters (2 in) into the frontal lobe, and then pivoted 40 degrees at the orbit perforation so the tip cut toward the opposite side of the head (toward the nose). The instrument was returned to the neutral position and sent a further 2 centimeters ( in) into the brain, before being pivoted around 28 degrees each side, to cut outwards and again inwards. (In a more radical variation at the end of the last cut described, the butt of the orbitoclast was forced upwards so the tool cut vertically down the side of the cortex of the
interhemispheric fissure The longitudinal fissure (or cerebral fissure, great longitudinal fissure, median longitudinal fissure, interhemispheric fissure) is the deep groove that separates the two cerebral hemispheres of the vertebrate brain. Lying within it is a continu ...
; the "Deep Frontal Cut".) All cuts were designed to transect the white fibrous matter connecting the cortical tissue of the prefrontal cortex to the
thalamus The thalamus (from Greek θάλαμος, "chamber") is a large mass of gray matter located in the dorsal part of the diencephalon (a division of the forebrain). Nerve fibers project out of the thalamus to the cerebral cortex in all directions, ...
. The leucotome was then withdrawn and the procedure repeated on the other side. 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 Electroconvulsive therapy (ECT) is a psychiatry, psychiatric treatment where a generalized seizure (without muscular convulsions) is electrically induced to manage refractory mental disorders.Rudorfer, MV, Henry, ME, Sackeim, HA (2003)"Electroco ...
be used to render the patient unconscious.) In 1947, the Freeman and Watts partnership ended, as the latter was disgusted by Freeman's modification of the lobotomy from a surgical operation into a simple "office" procedure. 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 towards 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.


Prevalence

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. Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the US. According to another estimate, Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women. This figure includes young children. And in Norway, there were 2,005 known lobotomies. In Denmark, there were 4,500 known lobotomies. In Japan, the majority of lobotomies were performed on children with behaviour problems. The Soviet Union banned the practice in 1950 on moral grounds. In Germany, it was performed only a few times. By the late 1970s, the practice of lobotomy had generally ceased, although it continued as late as the 1980s in France.


Criticism

As early as 1944, an author in the ''
Journal of Nervous and Mental Disease ''The Journal of Nervous and Mental Disease'' is a peer-reviewed medical journal on psychopathology. It was established in 1874 as the ''Chicago Journal of Nervous and Mental Disease''. "Chicago" was dropped from the title beginning in 1876. Articl ...
'' 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." In 1948
Norbert Wiener Norbert Wiener (November 26, 1894 – March 18, 1964) was an American mathematician and philosopher. He was a professor of mathematics at the Massachusetts Institute of Technology (MIT). A child prodigy, Wiener later became an early researcher i ...
, the author of '' Cybernetics: Or the Control and Communication in the Animal and the Machine'', said: " efrontal 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." Concerns about lobotomy steadily grew. Soviet psychiatrist Vasily Gilyarovsky criticized lobotomy and the mechanistic brain localization assumption used to carry out lobotomy: The Soviet Union officially banned the procedure in 1950 on the initiative of Gilyarovsky. 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". By the 1970s, numerous countries had banned the procedure, as had several US states. In 1977, the US Congress, during the presidency of
Jimmy Carter James Earl Carter Jr. (born October 1, 1924) is an American politician who served as the 39th president of the United States from 1977 to 1981. A member of the Democratic Party (United States), Democratic Party, he previously served as th ...
, created the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgeryincluding lobotomy techniqueswas used to control minorities and restrain individual rights. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects.
Torsten Wiesel Torsten Nils Wiesel (born 3 June 1924) is a Swedish neurophysiologist. With David H. Hubel, he received the 1981 Nobel Prize in Physiology or Medicine, for their discoveries concerning information processing in the visual system; the prize was ...
has called the award of the Nobel Prize to Moniz an "astounding rrorof judgment}.. a terrible mistake", and there have been calls for the
Nobel Foundation The Nobel Foundation ( sv, Nobelstiftelsen) is a private institution founded on 29 June 1900 to manage the finances and administration of the Nobel Prizes. The foundation is based on the last will of Alfred Nobel, the inventor of dynamite. It ...
to rescind the award. Foundation has not done so, and its website hosts an article defending lobotomy.


Notable cases

*
Rosemary Kennedy Rose Marie "Rosemary" Kennedy (September 13, 1918 – January 7, 2005) was the eldest daughter born to Joseph P. Kennedy Sr. and Rose Fitzgerald Kennedy. She was a sister of President John F. Kennedy and Senators Robert F. and Ted Kennedy. ...
, sister of US President
John F. Kennedy John Fitzgerald Kennedy (May 29, 1917 – November 22, 1963), often referred to by his initials JFK and the nickname Jack, was an American politician who served as the 35th president of the United States from 1961 until his assassination ...
, underwent a lobotomy in 1941 that left her incapacitated and institutionalized for the rest of her life. *
Howard Dully Howard Dully (born November 30, 1948) is one of the youngest recipients and survivors of the transorbital lobotomy, a procedure performed on him when he was 12 years old. Dully received international attention in 2005, following the broadcasting ...
wrote a memoir of his late-life discovery that he had been lobotomized in 1960 at age 12. * New Zealand author and poet
Janet Frame Janet Paterson Frame (28 August 1924 – 29 January 2004) was a New Zealand author. She was internationally renowned for her work, which included novels, short stories, poetry, juvenile fiction, and an autobiography, and received numerous awar ...
received a literary award in 1951 the day before a scheduled lobotomy was to take place, and it was never performed. * 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. * Swedish modernist painter
Sigrid Hjertén Sigrid Hjertén (27 October 1885 – 24 March 1948) was a Swedish modernist painter. Hjertén is considered a major figure in Swedish modernism. Periodically she was highly productive and participated in 106 exhibitions. She worked as an artist ...
died following a lobotomy in 1948. * American playwright
Tennessee Williams Thomas Lanier Williams III (March 26, 1911 – February 25, 1983), known by his pen name Tennessee Williams, was an American playwright and screenwriter. Along with contemporaries Eugene O'Neill and Arthur Miller, he is considered among the thre ...
' older sister Rose received a lobotomy that left her incapacitated for life; the episode is said to have inspired characters and motifs in certain works of his. * It is often said that when an iron rod was accidentally driven through the head of Phineas 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. * In 2011, Daniel Nijensohn, an Argentine-born neurosurgeon at Yale, examined X-rays of
Eva Perón María Eva Duarte de Perón (; ; 7 May 1919 – 26 July 1952), better known as just Eva Perón or by the nickname Evita (), was an Argentine politician, activist, actress, and philanthropist who served as First Lady of Argentina from June 194 ...
and concluded that she underwent a lobotomy for the treatment of pain and anxiety in the last months of her life.


Literary and cinematic portrayals

Lobotomies have been featured in several literary and cinematic presentations that both reflected society's attitude towards the procedure and, at times, changed it. Writers and film-makers have played a pivotal role in turning public sentiment against the procedure. * Robert Penn Warren's 1946 novel ''
All the King's Men ''All the King's Men'' is a 1946 novel by Robert Penn Warren. The novel tells the story of charismatic populist governor Willie Stark and his political machinations in the Depression-era Deep South. It was inspired by the real-life story of U.S ...
'' 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". * Tennessee Williams criticized lobotomy in his play '' Suddenly, Last Summer'' (1958) because it was sometimes inflicted on
homosexuals Homosexuality is romantic attraction, sexual attraction, or sexual behavior between members of the same sex or gender. As a sexual orientation, homosexuality is "an enduring pattern of emotional, romantic, and/or sexual attractions" to pe ...
to render them "morally sane". 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 the matriarch's son. Warned that a lobotomy might not stop her niece's "babbling", she responds, "That may be, maybe not, but after the operation, who would ''believe'' her, Doctor?". * In
Ken Kesey Ken Elton Kesey (September 17, 1935 – November 10, 2001) was an American novelist, essayist and countercultural figure. He considered himself a link between the Beat Generation of the 1950s and the hippies of the 1960s. Kesey was born in ...
's 1962 novel '' One Flew Over the Cuckoo's Nest'' and its 1975 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." * In
Sylvia Plath Sylvia Plath (; October 27, 1932 – February 11, 1963) was an American poet, novelist, and short story writer. She is credited with advancing the genre of confessional poetry and is best known for two of her published collections, ''The ...
's 1963 novel ''
The Bell Jar ''The Bell Jar'' is the only novel written by the American writer and poet Sylvia Plath. Originally published under the pseudonym "Victoria Lucas" in 1963, the novel is semi-autobiographical with the names of places and people changed. The book ...
'', the protagonist reacts with horror to the "perpetual marble calm" of a lobotomized young woman. *
Elliott Baker Elliott Baker (December 15, 1922 – February 9, 2007), born Elliot Joseph Cohen, was a screenwriter and novelist. He died from cancer. Baker was born in Buffalo, New York, and graduated from Indiana University. He was the author of the com ...
's 1964 novel and 1966 film version, ''
A Fine Madness ''A Fine Madness'' is a 1966 American Technicolor comedy film based on the 1964 novel by Elliott Baker that tells the story of Samson Shillitoe, a frustrated poet unable to finish a grand tome. It stars Sean Connery (in the midst of his James Bo ...
'', portrays the dehumanizing lobotomy of a womanizing, quarrelsome poet who, afterwards, is just as aggressive as ever. The surgeon is depicted as an inhumane crackpot. * The 1982
biopic A biographical film or biopic () is a film that dramatizes the life of a non-fictional or historically-based person or people. Such films show the life of a historical person and the central character's real name is used. They differ from docudra ...
film ''
Frances Frances is a French and English given name of Latin origin. In Latin the meaning of the name Frances is 'from France' or 'free one.' The male version of the name in English is Francis. The original Franciscus, meaning "Frenchman", comes from the F ...
'' depicts actress Frances Farmer (the subject of the film) undergoing transorbital lobotomy (though the idea that a lobotomy was performed on Farmer, and that Freeman performed it, has been criticized as having little or no factual foundation). * The 2018 film ''
The Mountain The Mountain (french: La Montagne) was a political group during the French Revolution. Its members, called the Montagnards (), sat on the highest benches in the National Convention. They were the most radical group and opposed the Girondins. Th ...
'' centers around lobotomization, its cultural significance in the context of 1950s America, and mid-century attitudes surrounding mental health in general. The film interrogates the ethical and social implications of the practice through the experiences of its protagonist, a young man whose late mother had been lobotomized. The protagonist takes a job as a medical photographer for the fictional Dr. Wallace Fiennes, portrayed by
Jeff Goldblum Jeffrey Lynn Goldblum (; born October 22, 1952) is an American actor and musician. He has starred in some of the highest-grossing films of his era, such as ''Jurassic Park'' (1993) and '' Independence Day'' (1996), as well as their sequels. ...
. Fiennes is loosely based on Freeman.


See also

*
Bilateral cingulotomy Bilateral cingulotomy is a form of psychosurgery, introduced in 1948 as an alternative to lobotomy. Today, it is mainly used in the treatment of depression and obsessive-compulsive disorder. In the early years of the twenty-first century, it was ...
destruction of a part of the brain *
Bioethics Bioethics is both a field of study and professional practice, interested in ethical issues related to health (primarily focused on the human, but also increasingly includes animal ethics), including those emerging from advances in biology, med ...
and
Medical ethics Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. T ...
*
Frontal lobe disorder Frontal lobe disorder, also frontal lobe syndrome, is an impairment of the frontal lobe that occurs due to disease or frontal lobe injury. The frontal lobe of the brain plays a key role in executive functions such as motivation, planning, social ...
*
Frontal lobe injury The frontal lobe of the human brain is both relatively large in mass and less restricted in movement than the posterior portion of the brain. It is a component of the cerebral system, which supports goal directed behavior. This lobe is often ci ...
* Psychosurgery *
History of psychosurgery in the United Kingdom Psychosurgery is a surgical operation that destroys brain tissue in order to alleviate the symptoms of mental disorder. The lesions are usually, but not always, made in the frontal lobes. Tissue may be destroyed by cutting, burning, freezing, el ...


Notes


Citations


Sources

Print Sources * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Online sources * * * * *


External links


My Lobotomy Radio story: Interview with Sallie Ellen Ionesco, lobotomised in 1946

Mental Cruelty: ''Sunday Times'' article on lobotomy and contemporary psychosurgery

Lobotomy's back: ''Discover'' article on cingulotomy

'My Lobotomy': Howard Dully's Journey. NPR Radio Documentary

A Qualified Defence of 'Then': QJM

Ten Notable Lobotomies

Nobel Panel Urged to Rescind Prize for Lobotomies

The Lobotomists: BBC Radio 4 documentary on the history of lobotomy
{{Authority control Medical controversies Neurosurgical procedures Ethically disputed medical practices Portuguese inventions