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Orbitoclast, used in transorbital lobotomy
ContextThe lobotomy was one of a series of radical and invasive physical therapies developed in Europe in the first half of the twentieth century. These psychiatric innovations signaled a break with a culture relegating psychiatric patients to asylums, which had prevailed because most serious forms of mental illness were treated only unsatisfactorily by extreme measure, or as unamenable to treatment. These new early twentieth century physical therapies included malarial therapy for general paresis of the insane (1917), barbiturate induced deep sleep therapy (1920), insulin shock therapy (1933), cardiazol shock therapy (1934), and electroconvulsive therapy (1938).
The development of the leucotomy procedure by Moniz in 1936, took place at a time when all of the above therapeutic interventions were extreme and experimental forms of therapy and most posed serious risks to the health of the patients who underwent them. Leucotomy was seen by many psychiatrists as no more severe than therapies such as insulin or cardiazol shock; 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." 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 same patients to resist the increasingly radical and even reckless interventions of asylum doctors.
 Gottlieb BurkhardtIt is commonly accepted that the first systematic attempt at human psychosurgery was conducted by the Swiss psychiatrist Gottlieb Burckhardt in late 1880s. Burckhardt operated on the brains of six patients (one of whom died a few days after the operation) at Préfargier Asylum, cutting out a piece of cerebral cortex. He presented the results at the Berlin Medical Congress and published a report, but the response was hostile and he did no further operations. Early in the 20th century Russian neurologist Vladimir Bekhterev and Estonian neurosurgeon Ludvig Puusepp operated on three patients with mental illness, with discouraging results.
Egas MonizThe development of the leucotomy procedure was the work of 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. Despite having no clinical psychiatric experience and, indeed, little interest in psychiatry, in 1935 at the Hospital Santa Marta in Lisbon, he devised the surgery called prefrontal leucotomy which was carried out under his direction by the neurosurgeon Pedro Almeida Lima. He was also responsible for coining the term psychosurgery. 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). Between November 1935 and February 1936 Moniz and Lima operated on twenty patients, publishing their findings in the same year. Their own assessment was that 35% of the patients improved greatly, 35% improved moderately and that in the remaining 30% there was no change. The patients were aged between 27 and 62 years of age, twelve were female and eight were male. Nine of the patients were diagnosed as suffering from depression, six from schizophrenia, two from panic disorder, and one each from mania, catatonia and manic-depression with the most prominent symptoms being anxiety and agitation. The duration of the illness prior to 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. The post-operative follow-up assessment took place anywhere from one to ten weeks following surgery. The observed complications were less severe than in Burckhardt's sample as there were no deaths or epileptic convulsions and the most cited complication was fever.
The theoretical underpinnings of Moniz's avant garde psychosurgery were largely commensurate with the nineteenth century ones that formed the basis of Burckhardt's theories before him. Although in his later writings he referenced both the neuron theory of Ramón y Cajal and the conditioned reflex of Ivan Pavlov, in essence he simply interpreted this new neurological research in terms of the old psychological theory of associationism. He differed significantly from Burckhardt in that he did not think there was any physical anatomical pathology in the brains of the mentally ill, but rather that their neural pathways were caught in fixed and destructive circuits As he wrote in 1936:
[The] mental 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. A significant advantage of this approach was that, unlike the position adopted by Burckhardt, it was unfalsifiable 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.
Traditionally, the question of why Moniz targeted the frontal lobes in particular has been answered by reference to a presentation by John Fulton and Carlyle Jacobsen at the Second International Congress of Neurology held in London in 1935. Fulton and Carlyle presented two chimpanzees who had undergone frontal lobectomies. The operation had had a pacifying effect on the two primates, who had previously suffered from behavioral disorders. It has been alleged that this provided the impetus and inspiration for Moniz to try the same technique on psychiatric patients. However, as Berrios points out, this conflicts with the fact that Moniz had told his colleague Lima in confidence as early as 1933 of his psychosurgical idea. Nor did he mention Fulton's and Carlyle's presentation as an influence when writing about the procedure in 1936. Indeed, as Kotowicz notes, his attention was drawn more to the case presented by Richard Brickner, at the same conference, of a patient who had had his frontal lobes ablated and, while experiencing a flattening of affect, had suffered no apparent decrease in intellect. Brickner had published on this case in 1932.
Moniz was given the Nobel Prize for medicine in 1949 for this work.
Walter Freemanneurologist and psychiatrist Walter Freeman, who had also attended the London Congress of Neurology in 1935, 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 United States in 1936 at the hospital of George Washington University in Washington. 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 that had 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 from his own kitchen and began testing the idea on grapefruit 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 orbitoclast through the thin layer of bone and into the brain along the plane of the bridge of the nose, around fifteen degrees toward the interhemispherical fissure. The orbitoclast was mallated five centimetres into the frontal lobes, and then pivoted forty 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 two centimetres into the brain, before being pivoted around twenty eight 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 interhemispherical fissure; 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 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). 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 lobotomised in the US.
PrevalenceMost lobotomy procedures were done in the United States, where approximately 40,000 people were lobotomized. In Great Britain, 17,000 lobotomies were performed, and the three Nordic countries of Finland, Norway and Sweden had a combined figure of approximately 9,300 lobotomies. Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the US. Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women. This figure includes young children. In Norway there were 2,500 known lobotomies. In Denmark there were 4,500 known lobotomies, mainly young women, as well as mentally retarded children.
Indications and outcomes: medical literatureAccording to the Psychiatric Dictionary published in 1970:
Prefrontal lobotomy is of value in the following disorders, listed in a descending scale of good results: affective disorders, obsessive-compulsive states, chronic anxiety states and other non-schizophrenic conditions, paranoid schizophrenia, undetermined or mixed type of schizophrenia, catatonic schizophrenia, and hebephrenic and simple schizophrenia. Good results are obtained in about 40 percent of cases, fair results in some 35 percent and poor results in 25 percent are thereabouts. The mortality rate probably does not exceed 3 percent. Greatest improvement is seen in patients whose premorbid personalities were 'normal', cyclothymic, or obsessive compulsive; in patients with superior intelligence and good education; in psychoses with sudden onset and a clinical picture of affective symptoms of depression or anxiety, and with behaviouristic changes such as refusal of food, overactivity, and delusional ideas of a paranoid nature.
Prefrontal lobotomy has also been used successfully to control pain secondary to organic lesions. In this case, the tendency has been to employ unilateral lobotomy, because of the evidence that a lobotomy extensive enough to reduce psychotic symptoms is not required to control pain.According to the same source, prefrontal lobotomy reduces:
anxiety feelings and introspective activities; and feelings of inadequacy and self-consciousness are thereby lessened. Lobotomy reduces the emotional tension associated with hallucinations and does away with the catatonic state. Because nearly all psychosurgical procedures have undesirable side effects, they are ordinarily resorted to only after all other methods have failed. The less disorganized the personality of the patient, the more obvious are post-operative side effects. ...
Convulsive seizures are reported as sequelae of prefrontal lobotomy in 5 to 10 percent of all cases. Such seizures are ordinarily well controlled with the usual anti-convulsive drugs. Post-operative blunting of the personality, apathy, and irresponsibility are the rule rather than the exception. Other side effects include distractibility, childishness, facetiousness, lack of tact or discipline, and post-operative incontinence.
 CriticismAs early as 1944 an author in the Journal of Nervous and Mental Disease 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 lobotomy to be "still too imperfect to enable us, with its aid, to venture on a general offensive against chronic cases of mental disorder" and stating 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: Or the Control and Communication in the Animal and the Machine, said: "[P]refrontal 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 officially 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." By the 1970s, numerous countries had banned the procedure as had several US states. Other forms of psychosurgery continued to be legally practiced in controlled and regulated US centers and in Finland, Sweden, the UK, Spain, India, Belgium and the Netherlands.
In 1977 the US Congress created the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery—including lobotomy techniques—were 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 of lobotomy had generally ceased, but some countries continued to use other forms of psychosurgery. In 2001 there were, for example, 70 operations in Belgium, about 15 in the UK and about 15 a year at Massachusetts General Hospital in Boston, while France had carried out operations on about 5 patients a year in the early 1980s.
- Rosemary Kennedy, sister of President John F. Kennedy, underwent a lobotomy in 1941 at age 23 which left her permanently incapacitated.
- Howard Dully 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 received a literary award in 1951 the day before a scheduled lobotomy was to take place, and it was never performed.
- French Canadian singer Alys Robi underwent a lobotomy and later resumed singing professionally.
- Swedish modernist painter Sigrid Hjertén died following a lobotomy in 1948.
- Playwright Tennessee Williams's older sister Rose received a lobotomy which left her incapacitated for life; the episode is said to have inspired characters and motifs in certain of his works.
Literary and cinematic portrayalsLobotomies 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. In the 1968 film Planet of the Apes, time travelling astronaut Landon (Robert Gunner) is subjected to a lobotomy by Dr. Zaius (Maurice Evans) and rendered catatonic in an effort to shield the truth from the Ape race by covering up the fact that man was once an intelligent being capable of speech. 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. In Unruhe, an episode in the fourth season of The X-Files, a kidnap victim is discovered wandering aimlessly along a road, staring blankly ahead and not responding to any of her surroundings. She is hospitalized and a PET scan reveals that a transorbital lobotomy, done incorrectly, has been performed on her. It is performed on another woman and Scully herself narrowly escapes the procedure. In the 2011 movie Sucker Punch, Babydoll's impending lobotomy is what drives her to try and escape from the Institute . An ice-pick type leucotome forms part of the detail around the "S" of the films title, counterpoised by the final upright of the "H" being a Samurai sword. In [The Simpsons] 2F03, Treehouse of Horror V. Moe is subjected to a full frontal lobotomy after undergoing 'Re-neducation' leaving him drooling and somewhat incapacitated. He keeps the removed piece of brain in a jar.