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A lobotomy (Greek: lobos: Lobe of brain, tomos: "cut/slice") is a form of psychosurgery, also known as a leukotomy or leucotomy (from Greek leukos: clear or white and tomos meaning "cut/slice"). It consists of cutting the connections to and from the prefrontal cortex. These procedures often result in major personality changes and possible mental disabilities. Lobotomies were used in the past to treat a wide range of severe mental illnesses, including schizophrenia, clinical depression, and various anxiety disorders, as well as people who were considered a nuisance by demonstrating behaviour characterised as, for example, "moodiness" or "youthful defiance". After the introduction of the antipsychotic Thorazine, lobotomies fell out of common use[1] and the procedure has since been characterized "as one of the most barbaric mistakes ever perpetrated by mainstream medicine".[2]
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In 1890, Dr. Gottlieb Burckhardt removed pieces of the frontal lobes of six patients in a psychiatric hospital in Switzerland. One died after the operation, and another was found dead in a river 10 days after release (whether by accident, suicide, or crime is unknown). The others exhibited altered behavior. These experiments marked one of the first forays into the field of psychosurgery.
The Portuguese physician and neurologist António Egas Moniz pioneered a surgery called prefrontal leucotomy in 1935. The procedure involved drilling holes in the patient's head and destroying tissue in the frontal lobes by injecting alcohol. He later improved the technique using a surgical instrument called a leucotome that cut brain tissue with a retractable wire loop.[3] Moniz won the Nobel Prize for medicine in 1949 for this work.[4]
The American neurologist and psychiatrist Walter Freeman was intrigued by Moniz's work, and with the help of his close friend, a neurosurgeon named James W. Watts, he performed the first prefrontal leucotomy in the U.S. in 1936. Freeman and Watts gradually refined the surgical technique, and created the Freeman-Watts procedure (the "precision method," the standard prefrontal lobotomy). The Freeman-Watts prefrontal lobotomy still required drilling holes in the scalp, so it had to be performed in an operating room by trained neurosurgeons. Walter Freeman believed that this surgery would be unavailable to the patients who needed it most: those that lived in state mental hospitals with no operating rooms, no surgeons, no anesthesia, and very little money. Freeman wanted to simplify the procedure so that it could be carried out by psychiatrists in mental asylums, which housed roughly 600,000 American inpatients at the time.
Freeman decided to access the frontal lobes through the eye sockets, instead of through drilled holes in the scalp. In 1945, he took an icepick from his own kitchen and began to test the new surgical technique on cadavers. The technique was called "transorbital lobotomy," and it involved lifting the upper eyelid and placing the point of a thin surgical instrument (often called a leucotome or orbitoclast) under the eyelid and against the top of the eyesocket. A hammer or mallet was then used to drive the leucotome through the thin layer of bone and into the brain. The leucotome was then moved from side to side, to sever the nerve fibers connecting the frontal lobes to the thalamus. In selected patients, the butt of the leucotome was pulled upward, sending the tip farther back into the brain and producing a "deep frontal cut," a more radical form of lobotomy. The leucotome was then withdrawn, and the procedure was repeated on the other side. Walter Freeman first performed a transorbital lobotomy on a live patient in 1946. This new form of psychosurgery was intended for use in State mental hospitals that often did not have the facilities for anesthesia, so Freeman suggested using electroconvulsive therapy to render the patient unconscious.[5]
Concerns about lobotomy steadily grew. The USSR banned the procedure in 1950.[6] Doctors in the Soviet Union concluded that the procedure was "contrary to the principles of humanity", and, that it turned "an insane person into an idiot".[7] Numerous countries subsequently banned the procedure, including Yugoslavia, Germany and Japan, as did several U.S. states. Lobotomy was legally practiced in controlled and regulated U.S. centers and in Finland, Sweden, Norway (2,005 known cases[8]), the United Kingdom, Spain, India, Belgium and the Netherlands.
In 1977, the U.S. Congress created a 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. It also investigated after-effects of the surgery. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects.
By the early 1970s the practice had generally ceased, but some countries continued small-scale operations through the late 1980s. In France, 32 lobotomies were performed between 1980 and 1986 according to an IGAS report; about 15 each year in the UK, 70 in Belgium, and about 15 for the Massachusetts General Hospital of Boston.[9]
Quantitatively, most lobotomy procedures were done in the United States, where approximately 40,000 persons were so treated. Great Britain performed procedures on 17,000 people, and the three Scandinavian countries had a combined figure of approximately 9,300 people treated.[10] Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the United States.[11]
Lobotomies have been featured in several literary and cinematic presentations that both reflected society's attitude towards the procedure and, at times, changed it. The 1946 novel All the King's Men by Robert Penn Warren described a lobotomy in such nauseating detail "that [it] would have made a Comanche brave look like a tyro [novice] with a scalping knife". The surgeon is portrayed as a repressed person who couldn't change others with love but instead resorted to "high-grade carpentry work".[16] In Tennessee Williams's 1958 play, Suddenly, Last Summer, the protagonist is threatened with a lobotomy to stop her from telling the truth about her cousin Sebastian.[17] The surgeon said, "I can't guarantee that a lobotomy would stop her—babbling!!!" To which her aunt responded, "That may be, maybe not, but after the operation who would believe her, Doctor?"[18]
A most damning portrayal of the procedure is found in Ken Kesey's 1962 novel One Flew Over the Cuckoo's Nest and the subsequent 1975 movie adaptation. Randle McMurphy was lobotomized after he angrily attacked Nurse Ratched. The operation is described as brutal and abusive, a "frontal-lobe castration". Chief Bromden is shocked: "There's nothin' in the face. Just like one of those store dummies." Another patient's surgery changed him from an acute to a chronic condition. "You can see by his eyes how they burned him out over there; his eyes are all smoked up and gray and deserted inside."[16]
Other sources include Sylvia Plath's depiction of a young woman, Valerie, who was lobotomized in her 1963 novel The Bell Jar. The character Esther reacts with horror to her "perpetual marble calm".[16] Elliott Baker's 1964 novel and 1966 film version A Fine Madness portrayed the dehumanizing lobotomy of a womanizing, quarrelsome poet who, in the end, is just as aggressive as ever. The surgeon is portrayed as inhumane and a crackpot.[19] The 1982 biopic Frances included a fictional, disturbing scene of the eponymous actress Frances Farmer undergoing transorbital lobotomy. Whether a lobotomy ever occurred or whether it was performed by Dr. Freeman himself is a matter of much debate.[20]
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