Lost Hospital Series — The Lobotomy

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Every year since 1901, the Nobel Prize has been awarded for achievements in physics, chemistry, physiology or medicine, literature, and for peace. For many, the prize represents the ultimate recognition one can receive in for a lifetime of work.

In 1949, a European doctor won the Nobel Prize for his research and work understanding the human brain.  Dr. Antonio Caetano Deabreau Freire Egas Moniz received the award for discovering the therapeutic value of leucotomy in certain psychoses, more commonly known as the pre-frontal lobotomy.

As early as 1890, German scientist Friederich Golz surgically removed the temporal lobe in dogs, noting that it resulted in a calmer, tamer canine.  In 1892, Swiss physician Gottlieb Burkhardt removed parts of the cortex in six schizophrenic patients, although his work was highly criticized by the medical community.  As a result, very few psychosurgeries were conducted over the next four decades.

In the 1930’s, medicine started to understand the relationship between the temporal and frontal cortex of the human brain in the control of certain emotions, such as aggression. In 1935, Yale University scientist Carlyle Jacobsen observed this connection in chimpanzees after surgically altering their frontal and prefrontal cortex through lobotomy.

Dr. Moniz, at the time professor at the University of Lisbon Medical School, started to perform similar operations to treat psychiatric patients with paranoia and obsessive-compulsive disorders.  Dr. Moniz surgically cut the nerve fibers that connect the frontal and prefrontal cortex to the thalamus (a deep part of the brain responsible for relaying sensory information to the cortex).
Working with a neurosurgeon, Dr. Moniz developed a surgical procedure called “Leukotomy” (white matter cutting). By burrowing several small holes into both sides of the brain, Dr. Moniz and his neurosurgeon could insert a special wire knife and sever accordingly.

Initially, Dr. Moniz’ work was not well received by the medical community, but later revitalized by American physician Walter Freeman. Using Dr. Moniz’ techniques in the United States in 1936, Dr. Freeman was convinced of the procedure’s success, and he lobbied to ensure this practice was embraced by the entire medical community.

Dr. Freeman and another physician ultimately perfected what was to be known as the “Freeman-Watts Standard Procedure, which included a very precise protocol for the insertion of the specialized knife (the “leukotome”) into the brain.

Dr. Freeman convinced the world that the prefrontal lobotomy should be used in mental institutions as a valid therapeutic procedure. Unhappy with the mess the procedure created, however, Dr. Freeman embraced the work of an Italian doctor who had developed a way to enter the frontal lobe through a surgical opening in the roof of the eye orbits.

This method — referred to as “ice-pick lobotomy” — required surgical trepanning by inserting an ice pick through the skin (using a hammer and a single “push” to tap the ice pick and perforate the skin, tissue, bone, and meninges). Although the patient was under local anesthesia, the procedure caused some witnesses, including neurosurgeons and psychiatrists, to faint.

This did not stop the success of lobotomies in the U.S. and around the world. Between 1939 and 1951, more than 18,000 lobotomies were performed in the U.S. and tens of thousands more worldwide. Unfortunately, the procedure was commonly abused as an ordinary means to control behavior and not as a last-resort measure. The identified victims from this surgical procedure included prison inmates, problematic family members, and political opponents.

By 1950, critics of the lobotomy started to gain ground. Scientific evidence in support of the procedure’s success was lacking (about one third of the patients improved, one-third stayed the same, and one-third deteriorated). Given the irreversible damage patients had after the procedure, the medical community needed another option. The eventual use of new antipsychotic and anti-depression medication in the 1950’s provided this alternative, and the use of lobotomies started to decline.

The lobotomy in its original form is now rare, although psychosurgery is still performed in many countries as a last resort to control violent behavior. Indeed, even the Soviet Union outlawed the lobotomy in 1940 (based upon ideological and not humanitarian reasons because it turned “an insane person into an idiot.”). By the 1970s, many U.S. states, as well as numerous other countries, had banned the procedure.

1977 the U.S. Congress created the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate certain allegations that psychosurgery procedures (including the lobotomy) were used in violation of basic human rights. The committee ultimately concluded that in some rare instances (and if properly performed), psychosurgery could have positive effects. Today, psychosurgeries are still practiced, but very rare.

Photographs from ScienceBlogs.comVanguardSculptureServices.com, and NEJM.

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Posted: September 9, 2014

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