The Rise and Fall of Lobotomy

 

History of Psychiatry Final Essay

 

 

 

 

 

Samira Zolanvari

Dr. Edward Shorter

Friday, December 09, 2005


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, Yale University’s Carlyle Jacobsen undertook frontal and prefrontal lobotomies on chimps, and consequently observed the chimps to being calmer considerably hushed.  Jacobsen’s colleague John Fulton, also at Yale, further experimented on the chimps by attempting to induce “experimental neurosis” in his lobotomized experimental subjects by exposing them to contradictory signals.  Fulton found that they were essentially impervious to the process, according to Joanette and Stemmer.

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 Spain; and he was even one of the individuals of the Treaty of Versailles to endorse a signature, which characterized the end of World War I[5].

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 Lima brought fame to psychosurgery, it was the Americans Freeman and Watts that brought infamy to the discipline. The neurologist Walter Freeman and his neurosurgical colleague James Watts were physicians from the George Washington Medical School. They modified the procedure with the hope that it would “produce more consistent results” than those seen by Moniz and Lima[8].  The modifications yielded a closed method whereby frontal white matter tracts were separated by a leukotome inserted in 1-cm burr-hole along the coronal suture superior to the zygomatic arch[9]. Their initial series of several hundred cases was deemed successful—but not without consequences. The adverse effects of psychosurgical procedures were becoming evident, ranging from post-operative seizure disorders to infections to death[10]. 

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 Watts, for the surgery was frequently imitated by non-surgeons as well as non-physicians. Electroconvulsive treatment (another controversial somatic therapy in psychiatry) was used for anesthesia, and then an instrument resembling an ice pick was inserted into the orbital roof and swept across the prefrontal cortex[12]. Freeman was an enthusiastic promoter of this procedure, and it soon came to be used with indiscretion by physicians without surgical training[13]. Its use became widespread, and was not only enthusiastically promoted, but also enthusiastically received. The remarkable argument, therefore, is not simply the fact that psychosurgery was abused, but also why[14].

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 United States were used by psychiatric patients, and by the 1940s, $1.5 billion dollars[16] was required to minister to mental illness. To further his argument, Deutsch asserts that from 15 million men, 1.8 million were rejected from the armed forces on the count of mental illness, and over 500,000 men were later dismissed for the same reason[17]. Thus, proves Deutsch, mental illness was regarded as an immense burden to society, and the lobotomy provided a way of relieving the heavy costs of the asylums.  Notably, Fulton widely proclaimed that the employment of the lobotomy would bank Americans one million dollars per day in taxes to fund psychiatric institutions. It is also crucial to note that prior to the 1950s there were few effective psychoactive medications for the treatment of mental illness, and the use of the lobotomy often allowed patients to leave asylums and re-enter society[18]. Deutsch points out that “successful cases of lobotomy” were praised in publications such as Time, Reader's Digest, and the New York Times, and he notes that the Nobel Prize of 1949 exceedingly legitimized the psychosurgical procedure. This noted, historians like Valstein view that the lack of effective psychopharmacologic agents, the overcrowded and often sub-par conditions of the asylums, and the large social and financial burden of psychiatric illness all contributed to an environment in which the frontal lobotomy was cordially approved[19].

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 Sept. 13, 1918, in Boston, she was known have had slight retardation. Her retardation may have stemmed from brain damage at birth. But in her own diaries before the lobotomy she chronicled a life of tea dances, dress fittings, trips to Europe and a visit to the Roosevelt White House. Nevertheless, she was seen as a misfit and her father ordered that she undergo a lobotomy at the age of 23.  Rose Marie Kennedy’s lobotomy was performed by Freeman and Watts; Rose Marie’s lobotomy left her completely incapacitated.

 

 
 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 United States[32]. For example, there were 100,000 new admissions to mental institutions and only 67,000 discharges in 1943, and in 1946 nearly one-half of the public hospital beds were devoted to the mentally[33]. Third, prior to 1930, patients continuously hospitalized for 15 years with a diagnosis of manic-depression had a 18% mortality rate due to tuberculosis and other infectious diseases. Thus, the importance of discharging patients from the state institutions was apparent. Another factor, according to many doctors, was that a long stay in a mental institution in itself contributed to the fact that many patients became apathetic[34].

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 



[1] K.W. Alt, C. Jeunesse, C.H. Buitrago-Tellez, R. Wachter, E. Boes and S.L. Pichler, Evidence for stone age cranial surgery, Nature 387 (1997), p. 360.

[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. New York: John Wiley & Sons; 1997.

[5] E.S. Valenstein, The history of psychosurgery. In: S.H. Greenblatt, Editor, The History of Neurosurgery, AANS, Park Ridge; 1997.

[6] E.S. Valenstein, The history of psychosurgery. In: S.H. Greenblatt, Editor, The History of Neurosurgery, AANS, Park Ridge; 1997.

[7] E.S. Valenstein, The history of psychosurgery. In: S.H. Greenblatt, Editor, The History of Neurosurgery, AANS, Park Ridge; 1997

[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, Harper-Collins, New York; 1992.

[11] E.S. Valenstein, The history of psychosurgery. In: S.H. Greenblatt, Editor, The History of Neurosurgery, AANS, Park Ridge; 1997

[12] Valenstein ES. Great and desperate cures: the rise and decline of psychosurgery and other radical treatments for mental illness. New York: Basic Books; 1986.

[13] Valenstein ES. Great and desperate cures: the rise and decline of psychosurgery and other radical treatments for mental illness. New York: Basic Books, 1986.

[14] J.E. Rodgers, Psychosurgery: Damaging the Brain to Save the Mind, Harper-Collins, New York; 1992.

[15] A. Deutsch, The Mentally Ill in America, Doubleday, New York; 1937.

[16] All currency is based on US currency.

[17] E.S. Valenstein, Great and Desperate Cures, Basic Books, New York; 1986.

[18] J.F. Fulton, The Frontal Lobes: Research Publication for the Association for Research in Nervous and Mental Disease, Williams & Wilkins, Baltimore; 1948.

[19] E.S. Valenstein, The history of psychosurgery. In: S.H. Greenblatt, Editor, The History of Neurosurgery, AANS, Park Ridge; 1997.

[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, Park Ridge; 1997.

[22] E.S. Valenstein, The history of psychosurgery. In: S.H. Greenblatt, Editor, The History of Neurosurgery, AANS, Park Ridge; 1997.

[23] Shorter, E. A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons; 1997.

[24] E.S. Valenstein, The history of psychosurgery. In: S.H. Greenblatt, Editor, The History of Neurosurgery, AANS, Park Ridge; 1997.

[25] E. Shorter. The Kennedy Family and the History of Mental Retardation. New York: Temple University Press; 2000.

[26] Lerner, Barron. Last-Ditch Medical Therapy — Revisiting Lobotomy, in The New England Journal of Medicine. Volume 353:119-121; July, 2005.

[27] Valenstein ES. Great and desperate cures: the rise and decline of psychosurgery and other radical treatments for mental illness. New York: Basic Books, 1986.

[28] El-Hai J. The lobotomist: a maverick medical genius and his tragic quest to rid the world of mental illness. New York: Wiley, 2005.

[29] Valenstein ES. Great and desperate cures: the rise and decline of psychosurgery and other radical treatments for mental illness. New York: Basic Books, 1986.

[30] Braslow J. Mental ills and bodily cures: psychiatric treatment in the first half of the twentieth century. Berkeley: University of California Press, 1997.

[31] Pressman JD. Last resort: psychosurgery and the limits of medicine. Cambridge, England: Cambridge University Press, 1998.

[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.