The rise & fall of the prefrontal lobotomy

Lobotomy (from the Greek lobos, meaning lobes of the brain, and tomos, meaning cut) is a psychosurgical procedure in which the connections the prefrontal cortex and underlying structures are severed, or the frontal cortical tissue is destroyed, the theory being that this leads to the uncoupling of the brain’s emotional centres and the seat of intellect (in the subcortical structures and the frontal cortex, respectively).

The lobotomy was first performed on humans in the 1890s. About half a century later, it was being touted by some as a miracle cure for mental illness, and its use became widespread; during its heyday in the 1940s and ’50s, the lobotomy was performed on some 40,000 patients in the United States, and on around 10,000 in Western Europe. The procedure became popular because there was no alternative, and because it was seen to alleviate several social crises: overcrowding in psychiatric institutions, and the increasing cost of caring for mentally ill patients.

Although psychosurgery has been performed since the dawn of civilization, the origins of the modern lobotomy are found in animal experiments carried out towards the end of the nineteenth century. The German physiologist Friedrich Goltz (1834-1902) performed ablations of the neocortex in dogs, and observed the changes in behaviour that occurred as a result:

I have mentioned that dogs with a large lesion in the anterior part of the brain generally show a change in character in the sense that they become excited and quite apt to become irate. Dogs with large lesions of the occipital lobe on the other hand become sweet and harmless, even when they were quite nasty before.

These findings inspired the physician Gottlieb Burkhardt (1836- ?), the director of a small asylum in Prefargier, Switzerland, to use ablations of the cortex to try and cure his mentally ill patients. In 1890, Burkhardt removed parts of the frontal cortex from 6 of his schizophrenic patients. One of these patients later committed suicide, and another died within one week of his surgery. Thus, although Burkhardt believed that his method had been somewhat successful, he faced strong opposition, and stopped  experimenting with brain surgery.

It was not until the 1930s that lobotomy was again performed on humans. The modern procedure was pioneered at that time by the Portugese neuropsychiatrist Antonio Egas Moniz, a professor at the University of Lisbon Medical School. While attending a frontal lobe symposium in London, Moniz learned of the work of Carlyle Jacobsen and John Fulton, both of whom were experimental neurologists at Yale University.

Jacobsen and Fulton reported that frontal and prefrontal cortical damage in chimpanzees led to a massive reduction in aggression, while complete removal of the frontal cortex led to the inability to induce experimental neuroses in the chimps. Here, they describe the post-operational behaviour of a chimp named “Becky”, who had previously got extremely distressed after making mistakes during the task she had learnt:

The chimpanzee…went to the experimental cage. The usual procedure of baiting the cup and lowering the opaque screen was followed…If the animal made a mistake, it showed no evidence of emotional disturbance but quietly awaited the loading of the cups for the next trial. It was as if the animal had joined the “happiness cult of the Elder Micheaux,” and had placed its burdens on the Lord!

On hearing the presentation by Jacobsen and Fulton, Moniz asked if the surgical procedure would be beneficial for people with otherwise untreatable psychoses. Although the Yale researchers were shocked by the question, Moniz, together with his colleague Almeida Lima, operated on his first patient some three months later.

On November, 12th, 1935, Moniz and Lima performed for the first time what they called a prefrontal leucotomy (“white matter cutting”). The operation was carried out on a female manic depressive patient, and lasted about 30 minutes. The patient was first anaesthetized, and her skull was trepanned on both sides (that is, holes were drilled through the bone). Then, absolute alcohol was injected through the holes in the skull, into the white matter beneath the prefrontal area.

In this way, two of the bundles of nerve fibres connecting the frontal cortex and the thalamus were severed. (The thalamus is a subcortical structure that relays sensory information to the neocortex, and the thalamo-cortical projections are called the corona radiata.) Moniz reported that the patient seemed less anxious and paranoid afterwards, and pronounced the operation a success. Subsequently, he and Lima used a knife, which, when inserted through the holes in skull and moved back and forth within the brain substance would sever the thalamo-cortical connections. They later developed a special wire knife called a leucotome, which had an open steel loop at its end; when closed, the loop severed the nerve tracts within it.

These procedures were “blind” – the exact path of the leucotome could not be determined, so the operations produced mixed results. In some cases, there were improvements in behaviour; in others, there was no noticable difference; and in yet others, the symptoms being treated became markedly worse. In all, Moniz and Lima operated on approximately 50 patients. The best results were obtained in patients with mood disorders, while the treatment was least effective in schizophrenics.

In 1936, Moniz published his findings in medical journals, and travelled to London, where he presented his work to others in the medical community. In 1949, he was shot four times by one of his patients (not one who had been lobotomized); one of the bullets entered his spine and remained lodged there until his death some years later. In the same year as the shooting, Moniz was awarded the Nobel Prize for Medicine, for his innovations in neurosurgery.

The American clinical neurologst Walter Freeman (1895-1972) had been following the work of Moniz closely, and had also attended the symposium on the frontal lobe. It was Freeman who introduced the lobotomoy to the United States, and who would later become the biggest advocate of the technique. With neurosurgeon James Watts, Freeman refined the technique developed by Moniz. They changed the name of the technique to “lobotomy”, to emphasize that it was white and grey matter that was being destroyed.

Walter Freeman (right) and James Watts preparing to perform a lobotomy

The Freeman-Watts Standard Procedure was used for the first time in September 1936. Also known as “the precision method”, this involved inserting a blunt spatula through holes in both sides of the skull; the instrument was moved up and down to sever the thalamo-cortical fibers (above). However, Freeman was unhappy with the new procedure. He considered it to be both time-consuming and messy, and so developed a quicker method, the so-called “ice-pick” lobotomy, which he performed for the first time on January 17th, 1945.

With the patient rendered unconscious by electroshock, an instrument was inserted above the eyeball through the orbit using a hammer. Once inside the brain, the instrument was moved back and forth; this was then repeated on the other side. (The ice-pick lobotomy, named as such because the instrument used resembled the tool with which ice is broken, is therefore also known as the transorbital lobotomy.)

Freeman’s new technique could be performed in about 10 minutes. Because it did not require anaesthesia, it could be performed outside of the clinical setting, and lobotomized patients did not need hospital internment afterwards. Thus, Freeman often performed lobotomies in his Washington D.C. office, much to the horror of Watts, who would later dissociate himself from his former colleague and the procedure.

Freeman happily performed ice-pick lobotomies on anyone who was referred to him. During his career, he would perform almost 3,500 operations. Like the leucotomies performed by Moniz and Lima, those performed by Freeman were blind, and also gave mixed results. Some of his patients could return to work, while others were left in something like a vegetative state.

Most famously, Freeman lobotomized President John F. Kennedy’s sister Rosemary, who was incapacitated by the operation, which was performed on her when she was 23 years of age. And, on December 16th, 1960, Freeman notoriosly performed an ice-pick lobotomy on a 12-year-old boy named Howard Dully, at the behest of Dully’s stepmother, who had grown tired of his defiant behaviour.

My stepmother hated me. I never understood why, but it was clear she’d do anything to get rid of me…If you saw me you’d never know I’d had a lobotomy.

The only thing you’d notice is that I’m very tall and weigh about 350 pounds. But I’ve always felt different – wondered if something’s missing from my soul. I have no memory of the operation, and never had the courage to ask my family about it.

So [recently] I set out on a journey to learn everything I could about my lobotomy…It took me years to get my life together. Through it all I’ve been haunted by questions: ‘Did I do something to deserve this?, Can I ever be normal?’, and, most of all, ‘Why did my dad let this happen?’

Howard Dully during his ice-pick lobotomy, Dec. 16th, 1960. (George Washington University Gelman Library)

Dully’s mother had died when he was 5 years old, and his father subsequently remarried a woman named Lou. Freeman’s notes later revealed that Lou Dully feared her stepson, and described him as “defiant and savage-looking”. According to the notes:

He doesn’t react to either love or punishment. He objects to going to to bed but then sleeps well. He does a good deal of daydreaming and when asked about it says ‘I don’t know.’ He turns the room’s lights on when there is broad daylight outside.

Freeman recorded the events leading up to Dully’s lobotomy:

[Nov. 30, 1960] Mrs. Dully came in for a talk about Howard. Things have gotten much worse and she can barely endure it. I explained to Mrs. Dully that the family should consider the possibility of changing Howard’s personality by means of transorbital lobotomy. Mrs. Dully said it was up to her husband, that I would have to talk with him and make it stick.

[Dec. 3, 1960] Mr. and Mrs. Dully have apparently decided to have Howard operated on. I suggested [they] not tell Howard anything about it.

Following the operation, the notebook reads:

I told Howard what I’d done to him…and he took it without a quiver. He sits quietly, grinning most of the time and offering nothing.

Now in his late fifties, Dully works as a bus driver in California. About 40 years after his lobotomy, he discussed the operation with his father for the first time. He discovered that it was his stepmother who had found Dr. Freeman, after being told by other doctors that there was nothing wrong, and that his father had been manipulated by his second wife and Freeman into allowing the operation to be performed.

It was largely because of Freeman that the lobotomy became so popular during the 1940s and ’50s. He travelled across the U. S., teaching his technique to groups of psychiatrists who were not qualified to perform surgery. Freeman was very much a showman; he often deliberately tried to shock observers by performing two-handed lobotomies, or by performing the operation in a production line manner. (He once lobotomized 25 women in a single day.) Journalists were often present on his “tours” of hospitals, so that his appearance would end up on the front page of the local newspaper; he was also featured in highly popular publications such as Time and Life. Often, these news stories exaggerated the success of lobotomy in alleviating the symptoms of mental illness.

Consequently, the use of lobotomies became widespread. As well as being used to treat the criminally insane, lobotomies were also used to “cure” political dissidents. It was alleged that the procedure was used routinely on prisoners against their will, and the use of lobotomies was strongly criticised on the grounds that it infringed the civil liberties of the patients.

An excellent account of the effects of lobotomy, and of the ethical implications of the use of the procedure, can be found in Ken Kesey’s book One Flew Over the Cuckoo’s Nest. (This was made into a film in 1975, by Milos Forman, who received the Academy Award for Best Director. Jack Nicholson won the award for Best Actor in a Lead Role.)

The use of lobotomies began to decline in the mid- to late-1950s, for several reasons. Firstly, although there had always been critics of the technique, opposition to its use became very fierce. Secondly, and most importantly, phenothiazine-based neuroleptic (anti-psychotic) drugs, such as chlorpromazine, became widely available. These had much the same effect as psychosurgery gone wrong; thus, the surgical method was quickly superseded by the chemical lobotomy.