The Rise and Fall of Lobotomy
History of Psychiatry Final Essay
Samira
Zolanvari
Dr. Edward Shorter
The Rise and Fall of Lobotomy
Abstract
Psychosurgery,
the neurosurgical treatment of psychiatric disease, has a history dating back
to antiquity, and involves all of the clinical neurosciences. This essay briefy discusses the history of psychosurgery, its
development in the 19th century, and the conditions of its use and abuse in the
20th century. The main focus concerns the (frontal) lobotomy.
The beginning of psychosurgery can be determined by tracing
back to antiquity through the practice of trephination, the procedure of
craniotomy with the cylindrical saw termed the “trephine[1].” There
is literature on trephination for the remedy of neuropsychiatric
symptoms including affective and psychotic disorders can be dated to 1500 BC[2]. Thus, we can conclude that the history of psychosurgery is as
ancient as the recorded history of psychiatric disease itself.
Joanette and
Stemmer write that the initiative of brain surgery as a means of bettering
mental health was born around 1890, when Friederich Golz, a German researcher, surgically removed portions of
his dogs’ temporal lobes, and found the dogs to be calmer and less aggressive
as a result. The surgical performance was quickly patterned after by
Gottlieb Burkhardt, the head of a Swiss mental
institution, who ventured similar surgeries on six of his schizophrenic
patients. The ending result brought about four of them being undeniably
calmer, and two dead[3].
In 1935,
According to Dr. Edward Shorter, it
was Portuguese neurologist Antonio Egaz Moniz of the University of
Lisbon Medical School who really popularized lobotomy. Known to be a very
industrious medical researcher, Moniz had invented
several noteworthy improvements to brain x-ray techniques prior to his efforts
in lobotomy[4]. Moniz was quite an achiever, serving as the Minister of
Foreign Affairs and the Ambassador to
Antonio Egaz
Moniz believed that by severing the nerves that run
from the frontal cortex to the thalamus in psychotic patients who suffered from
repetitive thoughts, this incision would circumvent their problematic recurring
thinking pattern. Together with his colleague Almeida Lima, he devised a
technique involving drilling two small holes on either side of the forehead, inserting
a special surgical knife, and severing the prefrontal cortex from the rest of
the brain. He called it leukotomy, but
this procedure would later become known as lobotomy[6].
Moniz became a celebrated pyschosurgeon
and was awarded the Nobel Prize for his work on lobotomy in 1949. Moniz directed tremendous care in using lobotomy, and
claimed that lobotomy should only be given in cases where everything else had
been tried. Although he was exceedingly renowned for his work, lobotomy was not
a complete success: some of his patients did not even become calmer. Moniz retired early after a former patient paralyzed him by
shooting him in the back[7].
Rodgers perceives that while the Europeans Moniz and
Elliot Valstein argues
that the crucial transformation in the evolution of psychosurgery was the
development of the transorbital frontal lobotomy[11]. Valstein also
remarks that this procedure was rather uncomplicated to perform and was habitually
done by Freeman devoid of the presence of a neurosurgeon. This provoked a rift
between Freeman and
Albert Deutsch asserts that it is
imperative to consider the quandary of psychiatric patients at the time. According
to Deutsch, in 1937, over 400,000 patients lived in approximately 477 American
psychiatric institutions[15]. He also states that over half of the hospital beds in the
Elliot Valstein reports that the lobotomy
started to fall out of favour as the follow-up neurologic sequelae[20] was
manifested. Valstein puts forward that reports in the
scientific and medical literature suggested that the usefulness of the lobotomy
was ambiguous. Furthermore, the clinical indications were rather poorly defined
and its side-effects could be severe: inertia, decreased attention span, unresponsiveness,
inappropriate affect, and disinhibition led to Valstein’s conclusion that the treatment was worse than the
disease. For Valstein, it became evident that many inexpert
practicioners were performing lobotomies in unsterile conditions that further increased the possibility
of serious and sometimes fatal sequelae. Thereafter,
lobotomy was impeded, and, in many countries and states, illegal[21].
Many denounced the practice of simply quieting the patient, rather than curing him/her.
Even so, the procedure was still in use[22].
The decline of the lobotomy was primarily achieved by the introduction of
chlorpromazine in the 1950s, the first effective pharmacologic therapy for
psychosis[23].
After its approval in 1954, it was administered to approximately 2 million
patients in that year alone. The use of psychiatric
medications, the rejection of Freeman's procedure by neurosurgeons, and the
increasing appeal of psychoanalysis led to the ultimate decline of the frontal
lobotomy[24].
Born Rose Marie Kennedy on
The negative image
of the lobotomy entered the popular culture through Ken Kesey's 1962 novel One Flew Over the Cuckoo's
Nest and the movie based on it, in which the rebellious hero becomes
nearly catatonic after undergoing the operation. There have even been cases of celebrities who have undergone
the psychosurgery of lobotomy:[25]
Dr. Barron Lerner suggests that one difficulty we have in assessing the procedure of lobotomy arises from the nature of Freeman's research, since it was highly subjective and did not constitute controlled studies. What Lerner finds to be most disturbing of all is the fact that Freeman’s “decision to perform lobotomies on unwilling patients[26].” However, Lerner does make the claim that lobotomy was functioned as a means for practitioners to develop new remedy for mental disturbances.
Despite the fact
that there was extensive evidence that psychosurgery was not therapeutic,
operations continued unabated for decades. This was because it was
considered unprofessional to criticize another physician in public, so many
doctors who knew that psychosurgery was a farce did not make their opinions
known. This allowed the psychosurgeons to continue unchecked from the late
1930s through the 1970s. In the 1950s, people began getting upset about the
prevalence of lobotomies. Protests began, and serious research supported
the protesters. The general statistics showed roughly a third of lobotomy
patients improved, a third stayed the same, and the last third actually got
worse[27].
The book entitled The Lobotomist, by journalist Jack El-Hai[28], chronicles Freeman's advocacy of the procedure of lobotomy. In exploring the ways in which lobotomy became part of common medical practice, El-Hai raises questions not only about how we should judge the procedure in retrospect, but also about what lobotomy teaches us about last-ditch medical interventions. Among the pieces of evidence stressed by El-Hai are thousands of letters from grateful patients, some even claiming to boast post-operative success such as going on to law school or becoming a doctor.
The first book to evaluate lobotomy, Elliot S. Valenstein's Great and Desperate Cures, was highly critical of Freeman and his operation, which Valenstein saw as providing a cautionary tale about overzealous physicians[29]. Joel Braslow's Mental Ills and Bodily Cures argued that a major motivation for lobotomies was to create "apathetic, indifferent, and docile" patients who would be more compliant than they had been[30]. But Jack Pressman emphasized the importance of evaluating historical events within the context of their own time[31].
Swayze offered a
paper that mentions some important contributory factors that contributed to the
popularity of psychosurgery in the 1940s. Chiefly, there were no alternative
therapies available for chronically institutionalized patients. Second, during
and following World War II there was an alarming increase in the number of
admissions to psychiatric institutions in the
Conclusion
Lobotomy did not prove to be an effective form of psychosurgery. To this day, some people are distressed about lobotomy[35]. Although efforts of Moniz and Freeman were noble, and intentions of practitioners were good, sometimes lobotomies were used as a form of cruel and unusual punishment. Perhaps even in such instances the punisher believed that lobotomy would ultimately cure the criminal. Sometimes, the interventions are the first step toward a successful remedy; in other instances, they prove worthless. Lobotomies may not have been successful, but they did help medical society advance in terms of knowledge. The field of psychiatry itself is new, and lobotomy was once on if its innovations.
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[2] L. Baer, S.L. Rauch, H.T. Ballantine Jr., R. Martuza, R. Cosgrove, E. Cassem, I. Giriunas, P.A. Manzo, C. Dimino and M.A. Jenike, Cingulotomy for intractable obsessive-compulsive disorder: prospective long-term follow-up of 18 patients, Arch. Gen. Psychiatry 52 (1995), pp. 384–392
[3] Y. Joanette, B. Stemmer, G. Assal and H. Whitaker, From theory to practice: the unconventional contribution of Gottlieb Burckhardt to psychosurgery, Brain Lang. 45 (1993), pp. 572–587.
[4] Shorter, E. A History of
Psychiatry: From the Era of the Asylum to the Age of Prozac.
[5] E.S. Valenstein,
The history of psychosurgery. In: S.H. Greenblatt,
Editor, The History of Neurosurgery, AANS,
[6] E.S. Valenstein,
The history of psychosurgery. In: S.H. Greenblatt,
Editor, The History of Neurosurgery, AANS,
[7] E.S. Valenstein,
The history of psychosurgery. In: S.H. Greenblatt,
Editor, The History of Neurosurgery, AANS,
[8] W. Freeman and J.W. Watts, Prefrontal leucotomy in the treatment of mental disorders, South Med. J. 30 (1937), pp. 23–31.
[9] W. Freeman and J.W. Watts, Prefrontal leucotomy in the treatment of mental disorders, South Med. J. 30; 1937. pp. 23–31.
[10] J.E. Rodgers,
Psychosurgery: Damaging the Brain to Save the Mind,
[11] E.S. Valenstein,
The history of psychosurgery. In: S.H. Greenblatt,
Editor, The History of Neurosurgery, AANS,
[12] Valenstein
ES. Great and desperate cures: the rise and decline of psychosurgery and other
radical treatments for mental illness.
[13] Valenstein
ES. Great and desperate cures: the rise and decline of psychosurgery and other
radical treatments for mental illness.
[14] J.E. Rodgers,
Psychosurgery: Damaging the Brain to Save the Mind,
[15] A. Deutsch, The Mentally
Ill in
[16] All currency is based on
[17] E.S. Valenstein,
Great and Desperate Cures, Basic Books,
[18] J.F. Fulton, The Frontal
Lobes: Research Publication for the Association for Research in Nervous and
Mental Disease, Williams & Wilkins,
[19] E.S. Valenstein,
The history of psychosurgery. In: S.H. Greenblatt,
Editor, The History of Neurosurgery, AANS,
[20] Sequela is defined as pathological condition resulting from a disease. It is generally a consequence or result.
[21] E.S. Valenstein,
The history of psychosurgery. In: S.H. Greenblatt,
Editor, The History of Neurosurgery, AANS,
[22] E.S. Valenstein,
The history of psychosurgery. In: S.H. Greenblatt,
Editor, The History of Neurosurgery, AANS,
[23] Shorter, E. A History of
Psychiatry: From the Era of the Asylum to the Age of Prozac.
[24] E.S. Valenstein,
The history of psychosurgery. In: S.H. Greenblatt,
Editor, The History of Neurosurgery, AANS,
[25] E. Shorter. The Kennedy Family and the History of Mental Retardation.
[26] Lerner, Barron. Last-Ditch Medical Therapy — Revisiting Lobotomy, in The
[27] Valenstein
ES. Great and desperate cures: the rise and decline of psychosurgery and other
radical treatments for mental illness.
[28] El-Hai J. The lobotomist: a maverick medical genius and his tragic quest
to rid the world of mental illness.
[29] Valenstein
ES. Great and desperate cures: the rise and decline of psychosurgery and other
radical treatments for mental illness.
[30] Braslow
J. Mental ills and bodily cures: psychiatric treatment in the first half of the
twentieth century.
[31] Pressman JD. Last resort:
psychosurgery and the limits of medicine.
[32] Swayze II, VW: Frontal leukotomy and related psychosurgical procedures in the era before antipsychotics (1935-1954): A historical overview. Am. J. Psychiatry 1995, 152 (4):505-515.
[33] Menninger, WC: Facts and statistics of
significance for psychiatry. Bull. Menninger Clin. 1948, 12:1-25.
[34] Mashour, GA;
Walker, EE;
Martuza, RL Brain Research Reviews [Brain Res. Rev.].
Vol. 48, no. 3, pp. 409-419. Jun 2005.
[35] For example, Christine Johnson, whose grandmother
had a lobotomy in 1954 created a website in order to petition the revocation
of Moniz’ Nobel Prize. She registered the website as
www.psychosurgery.org.