The History About 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, as well as people who were considered a nuisance by demonstrating behavior characterized as, for example, "moodiness" or "youthful defiance". The patient's informed consent in the modern sense was often not obtained. After the introduction of the antipsychotic chlorpromazine (Thorazine), lobotomies fell out of common use and the procedure has since been characterized "as one of the most barbaric mistakes ever perpetrated by mainstream medicine".

History

In 1890, psychiatrist Gottlieb Burckhardt made one of the first forays into the field of psychosurgery when he removed pieces of the frontal lobes of six patients in a psychiatric hospital in Switzerland. Burckhardt claimed a 50% success rate, but was criticized for the lack of follow-up, and according to one observer, his presentation at a medical conference "made everyone feel ill at ease and encountered harsh comments from colleagues." Emil Kraepelin said that Burckhardt was suggesting "that restless patients could be pacified by scratching away the cerebral cortex."

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", but he ended his research and practice of psychosurgery due to the heavy criticism.

Psychosurgery was not openly attempted again until 1910, when Estonian neurosurgeon Ludvig Puusepp operated on a few patients. Then, in 1935, Portuguese physician and neurologist António Egas Moniz 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). Moniz was given the Nobel Prize for medicine in 1949 for this work.

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 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).

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." 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."

Concerns about lobotomy steadily grew. The USSR banned the procedure in 1950. 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." 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), 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.

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. Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the United States. Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women and including young children.

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.
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, in September 2007.
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 one expert, careful inquiry turns up no such link.

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." 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. 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?"

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."

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. 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. The 1982 biopic Frances includes a disturbing scene showing actress Frances Farmer undergoing transorbital lobotomy. The claim that a lobotomy was performed on Farmer (and that Freeman performed it) has been criticized as having little or no evidence supporting it.