Lobotomy

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Instruments used in transorbital lobotomy

Lobotomy (Greek: λοβός — lobos: "lobe (of brain)", τομή — tome: "cut/slice") is a neurosurgical procedure, a form of psychosurgery, also known as a leukotomy or leucotomy (from Greek λευκός — leukos "clear/white" and tome). It consists of cutting the connections to and from the prefrontal cortex, the anterior part of the frontal lobes of the brain. Lobotomies have now fallen out of use, as doctors use various drugs and psychological therapies to treat mental illnesses. Lobotomies were used mainly from the 1930s to 1950s to treat a wide range of severe disorders, including schizophrenia, clinical depression, and various anxiety disorders. There is significant evidence that the procedure was used as a means of controlling persons whose behavior (such as "moodiness" or "youthful defiance") was considered annoying or embarassing, often without the patient's informed consent in the modern sense. During the 1960s increasing awareness of the equivocal and unpredictable effects of the procedure, together with the introduction of antipsychotic drugs, caused lobotomies to rapidly fall from all but the most limited use.^[1]

Historical Context

Properly considered in its historical context, the lobotomy was one of a series of radical physical therapies developed in Europe in the late 1910s, the 1920s and, most particularly, the 1930s. Among these we may note the Austrian psychiatrist Julius Wagner-Jauregg's groundbreaking malarial therapy for general paralysis of the insane (or neurosyphilis) first used in 1917, and for which he won a Noble Prize in 1927.^[2] This treatment heralded the beginning of a radical and experimental era in psychiatric medicine that increasingly broke with an asylum based culture of therapeutic nihilism in the treatment of chronic psychiatric disorders,^[3] most particularly dementia praecox (increasingly known as schizophrenia from the 1910s, although the two terms were used more or less interchangeably until at least the end of the 1930s), which were typically regarded as hereditary degenerative disorders and therefore unamenable to any therapeutic intervention.^[4] Malarial therapy was followed in 1920 by barbituate induced deep sleep therapy to treat dementia praecox, which was popularized by the Nazi sympathiser and Swiss psychiatrist Jacob Klaesi. In 1933 the Jewish Viennese based psychiatrist Manfred Sakel introduced insulin shock therapy and in August 1934 Ladislas J. Meduna, a Jewish Hungarian neuropathologist and psychiatrist working in Budapest, introduced cardiazol shock therapy (cardiazol is the tradename of the chemical compound pentylenetetrazol, known by the tradename metrazol in the United States), which was the first convulsive or seizure therapy for a psychiatric disorder. Again, both of these therapies were initially targetted at curing dementia praecox. Cardiazol shock therapy, founded on the theoretical notion that there existed a biological antagonism between schizophrenia and epilepsy and that therefore inducing epiletiform fits in schizophrenic patients might effect a cure, was superceded by electroconvulsive therapy, invented by the Italian neurologist Ugo Cerletti in 1938.^[5]

In relation to the development of the leucotomy procedure by Moniz in 1936, it is important to remember that all of the above therapeutic interventions were extreme and experimental forms of therapy and posed serious risks to the health of the patients who underwent them. In many ways, leucotomy was seen by many psychiatrists as no more severe than therapies such as insulin or cardiazol shock^[6] and, indeed, these apparently successful procedures conceived for the treatment of patients suffering severe mental illnesses helped to create the intellectual climate and medical and social warrants that allowed a surgical procedure as radical and irreversible as leucotomy to appear as a viable and even necessary proposition. Moreover, 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 "centre stage as a source of disease and site of cure."^[7] For Roy Porter, these often violent and invasive psychiatric interventions are indicative of both the well-intentioned desire of psychiatrists to find some medical means of alleviating the suffering of the thousands of patients in psychiatric hospitals in the twentieth century and also the relative lack of social power of those self-same patients to resist the increasingly radical and even reckless interventions of asylum doctors.^[8]

History of the Lobotomy Procedure

Gottlieb Burkhardt

In December 1888 Gottlieb Burckhardt, a psychiatrist with little experience of surgery, made one of the first forays into the field of psychosurgery when he operated on six patients, two women and four men aged between 26 and 51, in a private psychiatric hospital in Switzerland. Their diagnoses were, variously, one of chronic mania, one of primary dementia and four of original paranoia (primäre Verrücktheit, an obsolete diagnostic category sometimes anachronistically equated with schizophrenia) and, according to Burckhardt's case notes, they exhibited serious psychiatric symptoms such as auditory hallucinations, paranoid delusions, aggression, excitement and violence.. He operated on the frontal, temporal, and tempoparietal lobes of these patients. The results were not overly encouraging as one patient died five days after the operation after experiencing epileptic convulsions, one improved but later committed suicide, another two showed no change, and the last two patients became "quieter". This equated to a success rate of 50%. Complications consequent to the procedure included epilepsy (in two patients), motor weakness, "word deafness" and sensory aphasia. Only two patients are recorded as having no complications.^[9]

The theoretical basis of Burckhardt's action rested on three propositions. The first was that mental illness had a physical basis and that disordered minds were merely a reflection of disordered brains. Next, the associationist viewpoint of nerve functioning which conceived the nervous system as operating according to the following three fold division of labour: an input (or sensory or afferent) system, a connecting system which processed information and an output (or efferent or motor) system. The final assumption of Buckhardt's was that the brain was modular which meant that each mental module or mental faculty could be linked to a specific location in the brain. In accordance with such a viewpoint Buckhardt postulated that lesions in specific areas of the brain might impact on behaviour in a specific manner.In other words, he thought that by cutting the connecting system, or second association state of brain's system of communication troubling symptoms might be alleviated without compromising either the nervous system's input or output systems. The procedure was aimed at relieving symptoms not at curing a given mental disease. ^[10] Thus, he wrote in 1891:

[I]f excitation and impulsive behaviour are due to the fact that from the sensory surfaces excitations abnormal in quality, quantity and intensity do arise, and do act on the motor surfaces, then an improvement could be obtained by creating an obstacle between the two surfaces. The extirpation of the motor or the sensory zone would expose us to the risk of grave functional disturbances and to technical difficulties. It would be more advantageous to practice the excision of a strip of cortex behind and on both sides of the motor zone creating thus a kind of ditch in the temporal lobe.^[11]

Burkhardt attended the Berlin Medical Conference of 1889, which was also attended by such heavyweight alienists as Victor Horsely, Valentine Magnan and Emil Kraepelin, and presented a paper on his brain operations. Whilst his findings were subsequently widely reported in the psychiatric literature, the reviews were unremittingly negative and there was much ill ease generated by the surgical procedures he had performed.^[12] Kraepelin, writing in 1893, was scathing of Burckhardt's attempts, and stated that "he [Burkhardt] suggested that restless patients could be pacified by scratching away the cerebral cortex."^[13] Whilst Giuseppe Seppilli, the Italian professor of neuropsychiatry, remarked in 1891 that Burkhardt's view of the brain as modular did not "fit in well with the view held by most [experts] that the psychoses reflect a diffuse pathology of the cerebral cortex and [ran counter to] the conception of the psyche as a unitary entity".^[14]

Burckhardt wrote in 1891 that "Doctors are different by nature. One kind adheres to the old principle: first, do no harm (primum non nocere); the other one says: it is better to do something than do nothing (melius anceps remedium quam nullum). I certainly belong to the second category".^[15] The response to this statement was provided by the French alienist Armand Semelaigne when he wrote that "an absence of treatment was better than a bad treatment".^[16] After the publication of his impressive 81 page monograph on the subject in 1891, Burkhardt ended his research and practice of psychosurgery no doubt in part due the ridicule he received from his colleagues over the dangerous methods he had employed.^[17]

Commenting on his monograph in 1891 the British psychiatrist William Ireland provided a succinct summation of his position:

Dr. Burckhardt has a firm faith in the view that the mind is made up of a number of faculties, holding their seats in distinct portions of the brain. Where excess or irregularity of function occurs he seeks to check it by ablation of a portion of the irritated centres. He defends himself from the criticisms which are sure to be directed against his bold treatment by showing the desperate character of the prognosis of the patients upon whom the operations were performed ...^[18]

Ireland, however, doubted that any English psychiatrist would have the "hardihood" to follow the path taken by Burkhardt.^[19]

Egas Moniz

The next stage in the development of the procedure was provided by the Portuguese physician and neurologist António Egas Moniz, who was highly acclaimed for his work on cerebral angiography (radiographical visual of the blood vessels in the brain) in 1927.^[20] Indeed, prior to his exploration of psychosurgery, he had twice been nominated for, and twice failed to win, a Nobel Prize for this work. Edward Shorter, perhaps unfairly, attributes his development of the leucotomy procedure to his desire to finally capture that noble accolade.^[21] He pioneered a surgery he called prefrontal leucotomy. The procedure involved drilling holes in the patient's head and destroying tissue in the frontal lobes by injecting alcohol. He later changed technique, using a surgical instrument called a leucotome that cut brain tissue by rotating a retractable wire loop (a quite different cutting instrument also used for lobotomies shares the same name).^[22] Moniz was given the Nobel Prize for medicine in 1949 for this work.^[23]

Walter Freeman

The American neurologist and psychiatrist Walter Freeman was intrigued by Moniz's work, and with the help of his close friend, neurosurgeon 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 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 having no operating rooms, surgeons, or anesthesia, and limited budgets. 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.

Inspired by the work of Italian psychiatrist Amarro 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 an icepick^{[citation needed]} from his own kitchen and began testing the idea on grapefruit^{[citation needed]} and cadavers. This new "transorbital" lobotomy involved lifting the upper eyelid and placing the point of a thin surgical instrument (often called an orbitoclast 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 leucotome through the thin layer of bone and into the brain. The leucotome was then swept from side to side, thus severing the nerve fibers connecting the frontal lobes to the thalamus. (In a more radical variation, the butt of the leucotome was pulled upward, sending the tip farther back into the brain, producing a "deep frontal cut.") 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 suggesting that, where conventional anesthesia was unavailable, electroconvulsive therapy be used to render the patient unconscious).^[24]

Reaction

As early as 1944 an author in the Journal of Nervous and Mental Disease remarked that "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 lobotomy to be "distinctly hazardous to leucotomize schizophrenics," "still too imperfect to enable us, with its aid, to venture on a general offensive against chronic cases of mental disorder," and 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."^[25] In 1948 Norbert Wiener, the author of Cybernetics, 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."^[26]

Concerns about lobotomy steadily grew. The USSR banned the procedure in 1950.^[27] 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."^[28] Numerous countries subsequently banned the procedure, including Yugoslavia, Germany and Japan, as did several U.S. states. Lobotomy continued to be legally practiced in controlled and regulated U.S. centers and in Finland, Sweden, Norway (2,005 known cases^[29]), 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 the after-effects of 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. According to a report by the International Graphoanalysis Society (IGAS), between 1980 and 1986 there were 70 lobotomies performed in Belgium, 32 in France, 15 per year in the United Kingdom and several cases performed for the Massachusetts General Hospital in Boston.^[30]

Prevalence

Quantitatively, most lobotomy procedures were done in the United States, where approximately 40,000 persons were lobotomized. In Great Britain lobotomies were performed on 17,000 people, and the three Scandinavian countries had a combined figure of approximately 9,300 lobotomies.^[31] Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the United States.^[32] Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women and including young children.^[25]

Notable cases (and an oft-cited non-case)

• Rosemary Kennedy, the sister of President John F. Kennedy, was given a lobotomy when her father complained to doctors about the 23-year-old's moodiness. Dr. Walter Freeman personally performed the procedure. Rather than any improvement, the lobotomy reduced Rosemary to an infantile mentality including incontinence. Her verbal skills were reduced to unintelligible babble. Her father hid the nature of Rosemary's affliction for years and described it as the result of mental retardation. Rosemary's sister, Eunice Kennedy Shriver, founded the Special Olympics in her honor in 1968.^[33]
• Howard Dully had a lobotomy at 12 after his stepmother grew tired of his "youthful defiance." At the age of 56 he said "I've always felt different -- wondered if something's missing from my soul. I have no memory of the operation." Late in his life Dully uncovered the story of his lobotomy. Crown Publishers published Dully's memoir (co-written by Charles Fleming), My Lobotomy,^[34] in September 2007.^[35][36]
• New Zealand author and poet Janet Frame was due to have a lobotomy because of a diagnosis of mental illness. She was saved from this procedure by receiving a literary award the day before her operation was to take place.
• French Canadian singer Alys Robi was renowned worldwide during the 1940s. In the 1950s, following many cases of violence and disturbance, she was admitted to a Quebec mental hospital where she underwent a lobotomy. She was later released and resumed singing professionally.
• Swedish modernist painter Sigrid Hjertén died following a botched lobotomy in 1948.
• The older sister of playwright Tennessee Williams, Rose, received a lobotomy which left her incapacitated for life and provided inspiration for his plays Suddenly, Last Summer, The Glass Menagerie and the character Blanche in his play A Streetcar Named Desire.
• 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 Gage's biographer, careful inquiry turns up no such link.^[37][38]

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. The 1946 novel All the King's Men by Robert Penn Warren described a lobotomy, saying it "would have made a Comanche brave look like a tyro [novice] with a scalping knife." The surgeon is portrayed as a repressed man who couldn't change others with love but instead resorted to "high-grade carpentry work."^[39] 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.^[40] The surgeon says, "I can't guarantee that a lobotomy would stop her babbling." Her aunt responds, "That may be, maybe not, but after the operation who would believe her, Doctor?"^[41]

A damning portrayal of the procedure is found in Ken Kesey's 1962 novel One Flew Over the Cuckoo's Nest and its 1975 movie adaptation. Several patients in the mental ward receive lobotomies in order to discipline or calm them. The operation is described as brutal and abusive, a "frontal-lobe castration." The book's narrator, Chief Bromden, is shocked: "There's nothin' in the face. Just like one of those store dummies." One patient's surgery changes him from an acute to a chronic mental 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."^[39]

Other sources include Sylvia Plath's 1963 novel The Bell Jar, in which the protagonist, Esther, reacts with horror to the "perpetual marble calm" of a lobotomized young woman named Valerie.^[39] Elliott Baker's 1964 novel and 1966 film version, A Fine Madness, portrays the dehumanizing lobotomy of a womanizing, quarrelsome poet who, in the end, is just as aggressive as ever. The surgeon is depicted as an inhumane crackpot.^[42] The 1982 biopic Frances includes a disturbing scene showing actress Frances Farmer undergoing transorbital lobotomy. The claim^[43] that a lobotomy was performed on Farmer (and that Freeman performed it) has been criticized as having little or no evidence supporting it.^[44][45]

See also

• Frontal lobe injury
• Elliot Valenstein, author of Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness

References

External links

Look up lobotomy in Wiktionary, the free dictionary.

• University of North Carolina Asheville: Lobotomy
• My Lobotomy Radio story
• Psychosurgery.org
• Article on the Lobotomy and its effects: ""Mental cruelty"". The Sunday Times. 2006-02-19. http://www.timesonline.co.uk/tol/life_and_style/article729403.ece?token=null&offset=0. 
• "Lobotomy's back"
• 'My Lobotomy': Howard Dully's Story, co-authored by Charles Fleming
• 'My Lobotomy': Howard Dully's Journey