Prefrontal Lobotomy in Popular Psychology

In 1949, Antonio Egas Moniz shared the Nobel Prize in Physiology or Medicine “for his discovery of the therapeutic value of frontal leucotomy.” Frontal leucotomy is better known by its more common name, prefrontal lobotomy. The procedure, which involves severing the connection between the most anterior portions of the frontal lobes and the rest of the brain, was hugely popular as a way of relieving the symptoms of psychotic patients in the United States, where between 40,000 and 50,000 lobotomies were performed by the late 1950s, primarily on patients with schizophrenia and depression. Moniz, a Portuguese neurologist, got the idea from research showing that bilateral frontal lobectomy, severing both frontal lobes, caused excitable chimpanzees to become docile and timid. It seemed that a similar procedure might have similar results in overly excitable (i.e., psychotic) humans. He performed the first prefrontal lobotomy in 1936, using alcohol injection to sever the connections. He later used surgical procedures to accomplish the same goals.

Encouraged by Moniz’s early experiments, the American neurosurgeon Walter Freeman also began performing the procedure on human patients in 1936, and it is through his efforts that the procedure became widespread in the United States. Freeman traveled around the country performing the procedure, at which he had become so efficient that he would frequently lobotomize multiple patients in sequence in hospital hallways. He accomplished this by performing the surgery without an incision. He would first render the patient unconscious with several jolts from an electroshock therapy machine (see Electroconvulsive Therapy). The rest of the procedure involved an icepick-like instrument called a leucotomy, which he would insert through a tear duct (after lifting the eyelid out of the way), breaking through the orbital bone by tapping the instrument with a hammer. He would then push the very sharp tip a short distance into the patient’s frontal lobe and wiggle it back and forth a few times. The procedure would then be repeated in the other eye socket.

Horrendous though this treatment sounds to modern sensibilities, Freeman acted out of a genuine concern for the lives he saw wasted in mental asylums that could be salvaged, if the patients could become capable of living outside the hospital walls without posing a danger to themselves or others. In the days before effective antipsychotic medications, lobotomy seemed a reasonable alternative to what was essentially lifetime incarceration.

Clear data on the actual effectiveness of the procedure are difficult to come by, but even Freeman, the procedure’s most zealous promoter, only claimed good results for 52 percent of his patients, and he provided no clear standard for what constituted an improvement. Along with inducing violent behavior and hallucinations among some patients, the indiscriminate and imprecise cutting would also damage memory, personality, motivation, language use, and many other functions. Patients often had to relearn basic adaptive skills, such as how to eat or use the bathroom. Obesity and epilepsy would sometimes result, and as many as 3 percent died of the procedure. The most high-profile failure among Freeman’s patients was Rosemary Kennedy, sister of the U.S. president, who since her lobotomy in 1941 has required full-time care— although prior to the procedure, she was considered to be only mildly retarded. By the late 1950s, the advent of new, highly effective antipsychotic medications (see Schizophrenia) had begun to render lobotomies obsolete, but Freeman continued to perform the procedure until 1967. His final patient died within three days.

Although prefrontal lobotomies are no longer commonly performed, psychosurgery has begun to make a bit of a comeback, based on remarkably similar reasoning to that which prompted the first wave of popularity. Freeman believed the lobotomy procedure separated the frontal lobes, where judgment and decision-making are localized, from the thalamus, which was believed to be the seat of emotion, of which psychotic patients appeared to have an overabundance. Although his neurological speculations are now known to be wrong in their particulars, a newer procedure that accomplishes essentially what Freeman was attempting is gaining popularity— the cingulotomy.

In a cingulotomy, the cingulate gyrus, which is part of the pathway between the frontal lobes and deeper limbic system structures that govern emotional reactions, is severed. Both obsessive-compulsive disorder (OCD) and depression appear to involve abnormal passage of neurotransmitters along this pathway, and the cingulotomy appears to relieve or even eliminate symptoms. Although the reasons for this are not perfectly understood, the surgery is performed in dramatically different ways from Freeman’s procedure. Modern brain imaging techniques and the use of very precise lasers allow destruction of only the targeted tissue, for example, with no collateral damage of surrounding healthy tissue.

Psychosurgery is still considered primarily a last-resort approach, but this is in part because the modern, vastly more precise version is still burdened by the public perception of Freeman’s legacy. Such popular films as Frances, which traces the effects of a lobotomy on movie star Frances Farmer, have ensured that horrific images of destroyed minds accompany the idea of psychosurgery for many people.

References:

1. El-Hai, J. “The Lobotomist.” Washington Post, January 4, 2001: W16;
2. Todkill, A. M. “The Leucotome.” Canadian Medical Association Journal, 160(6) (1999): 871–874;
3. Wray, H. “Psychosurgery Redux.” U.S. News and World Report, 123(17) (1997): 63–64.