A brief and sordid history of modern psychosurgery

In 1890 Friederich Golz, a German scientist, reported that when the temporal lobe of the brain was surgically removed from dogs, they became tamer and gentler. Inspired by these results, physician Gottlieb Burkhardt, who was a supervisor of an insane asylum in Switzerland, performed a similar operation in 1892, but this time on humans. He removed parts of the cortex of six seriously disturbed schizophrenic patients. He claimed that some were calmer after the procedure, although in fact two of them died. Unsurprisingly, medical authorities of the time took a dim view of Burkhardt's work and very few psychosurgical procedures of this kind were carried out during the course of the next forty years.

Interest in psychosurgery was rekindled when Carlyle Jacobsen, a scientist working in Yale University, observed that aggressive behavior in chimpanzees sometimes diminished after their frontal and prefrontal cortexes were damaged by means of lobotomy, which means 'lobe cutting'. In a similar experiment, Dr. John Fulton, also of Yale, was unable to provoke experimental neurosis in two chimpanzees after completely removing the frontal lobes of their brains. This was enough to convince Fulton of the effectiveness and usefulness of this type of surgery, and he subsequently became one of the more established and influential proponents of psychosurgery in the United States.

Portuguese neuropsychiatrist Dr. Antônio Egas Moniz heard Fulton speak during a neurological conference in London, and was so impressed with what he heard that he decided to apply a version of the procedure to people suffering from long-term symptoms of mental illness such as obsessive-compulsive disorders and paranoia. In a piece of deductive reasoning which would be laughably facile in most other circumstances, he proposed that since symptoms such as paranoia involved recurring thought patterns, the best way to cut off such thoughts might be to simply interrupt their flow by surgically severing the nerve fibers connecting the frontal and prefrontal cortex to the thalamus, a structure located deep in the brain relaying sensory information to the cortex.

After briefly experimenting with destructive injections of alcohol directly into the brains of patients, Moniz and a neurosurgeon named Dr. Ameida Lima together developed a surgical procedure which they called leukotomy, which means 'white matter cutting', in which holes were drilled in the patient's skull on either side. A flat wire knife known as a leukotome was inserted through each hole and into the brain substance, and then moved from side to side a few times to destroy and sever the nerves.

Moniz reported limited success with this technique, claiming that some patients who had formerly suffered severe depression improved after the surgery, but some patients were not helped by it at all. He himself recommended that leukotomy should only be used as a last resort in cases regarded as otherwise hopeless. In 1936, after Moniz's results were published, leukotomy was taken up in a few centers around the world for a while without much success. The majority of psychiatrists, particularly psychoanalysts, were strenuously opposed to it; Moniz himself was shot in the spine and permanently paralyzed by one of his ex-patients, and thus could no longer practice (can you say 'karma'?); and before long the use of leukotomy had all but ceased.

But psychosurgery was far from dead, and Dr. John Fulton's influence once again entered the story. At the same London conference which Moniz had attended was an American physician and clinical neurologist named Walter Freeman. He too was very impressed with Fulton's results, and later, when he read Moniz's reports of his experiments, he was excited at what he saw as the possibilities of the new treatment. He was determined to try out the new technique on American patients, and with the help of a neurosurgeon named James Watts he carried out the first such operation in 1936.

A few cases were all it took to persuade Freeman and Watts of the effectiveness of leucotomy. Freeman was an ambitious and forceful man, and in spite of suspicion and resistance from most other neurosurgeons, he persevered, eventually gaining some acceptance. He and Watts 'improved' the technique by simple trial and error, and eventually produced a set of guidelines known as the "Freeman-Watts Standard Procedure" which mainly dealt with the insertion of the wire knife, the leukotome, into the brain.

Freeman and Watts traveled the United States performing what they now referred to as lobotomies at as many asylums and hospitals as would allow them. But Freeman was becoming impatient with the length of time which the operation took and the mess that it made. He decided to try a method being used by a neurosurgeon in Italy which involved accessing the brain via the eye orbits rather than by drilling into the skull, but he found that when doing this, his wire knives often broke. His solution to this inconvenience was simple and shocking: he decided to try using an ice-pick instead, and the 'ice-pick lobotomy' was born.

His methodology was simplicity itself. After administering a local anesthetic, he merely applied the ice pick to the skull, knocked it into the brain with a hammer, and then moved it from side to side to sever or destroy the prefrontal lobe. The whole procedure took only a few minutes, and in his zeal Freeman had patients literally standing in line waiting for the ice-pick. He sometimes performed scores of these 'operations' in one day. It is recorded that even experienced, hardened neurosurgeons were fainting at the sight of Freeman at work. It very soon proved to be too much for James Watts as well, who hastily distanced himself from Freeman and his new procedure.

But lobotomy was an idea whose time had come. There was a huge increase in mental illness and asylum admissions after the Second World War, and lobotomies provided a quick and easy method of dealing with this influx. Between 1939 and 1951 more than 18,000 lobotomies were performed in the United States, and tens of thousands more were performed in other countries.

In 1949, Dr. Antônio Egas Moniz's award of the Nobel Prize for Medicine and Physiology in recognition of his creation of the prefrontal leucotomy did much to legitimize the procedure. In the ensuing three years, more lobotomies were performed than in all previous years put together.

Abuse of the procedure became widespread, both in the U.S. and elsewhere. It provided a very quick and cost-effective means of silencing dissent. It was used in Japan on children who behaved badly, or performed poorly at school. It was used by families to deal once and for all with difficult relations. During this time, amateur surgeons performed literally hundreds of lobotomies without even a proper psychiatric evaluation.

Eventually, in spite of Dr. Antônio Egas Moniz's Nobel Prize, the practice of lobotomy began to be seriously questioned and undermined in the early 1950's. A study known as the Columbia-Greystone Clinical Project had already found that the great majority of claims for the success of lobotomy were made by the surgeons themselves, with absolutely no rigorous evidence to support such claims. This coincided with the appearance of new antipsychotic and antidepressive drugs, the first major example of which was Thorazine.

Walter Freeman performed his last ice-pick lobotomy in 1967. It ended in the patient's death, and Freeman was subsequently stripped of his rights to perform any kind of surgery. I have not been able to find even an estimate of how many lobotomies he performed during his career, but given his zeal and the speed of the ice-pick procedure, they almost certainly numbered in the hundreds.

In the 1970s, the United States re-classified psychosurgery, naming it an experimental therapy, a fact which introduced many previously absent safeguards to patients' rights. Most other countries have acted similarly, and lobotomy of any kind is now very rarely performed.

  • 'The History of Lobotomy' at http://www.epub.org.br/cm/n02/historia/lobotomy.htm
  • 'Moniz develops lobotomy for mental illness' at http://www.pbs.org/wgbh/aso/databank/entries/dh35lo.html
  • 'Lobotomy' at http://member.aol.com/MRandDD/lobotomy.htm
  • Freeman at work : http://www.furman.edu/~jearles/general/therapy/page210.htm
  • Freeman's 'toolkit' : http://www.furman.edu/~jearles/general/therapy/page230.htm
  • Patient with two leukotomes in place : http://www.furman.edu/~jearles/general/therapy/page237.htm