Frontal Lobotomy and Medical Ethics

A frontal lobotomy is a psychosurgery that was used in the mid-1900s to treat mental and neurological illnesses, including schizophrenia, bipolar disorder, and epilepsy. It involves severing the nerve pathways from the frontal lobe—the largest section of the brain—from the other lobes.

Frontal lobotomies have always been controversial, even when they were mainstream. The surgery was risky and permanently altered the patient's personality. Many patients died and many more awoke with severe, life-changing side effects and disabilities.

This article discusses the history of lobotomies along with how they worked, why they were used, and what effects they had on patients with mental illness.

History

Lobotomies were part of a wave of new treatments for neurological diseases in the early 20th century, including electroconvulsive therapy (shock therapy).

The 1949 Nobel Prize in Physiology or Medicine went to Portuguese neurologist António Egas Moniz for the controversial procedure’s creation. While others before Dr. Moniz had made attempts at similar surgical procedures, their success was limited and not well-received by the medical community.

Dr. Moniz's lobotomies were initially considered successful. His first 20 lobotomy patients all survived without serious side effects, leading neurosurgeons in Brazil, Italy, and the United States to begin performing lobotomies as well.

Dr. Moniz believed that patients with mental illness had abnormal connections between different regions in their brains, and that severing these "fixed circuits" could help. Part of his inspiration came from a research paper about chimpanzees who were described as calmer and more cooperative after having their frontal lobes removed.

This focus on neural circuits and connectivity, rather than on just one piece of the brain, remains relevant to 21st-century neuroscience.

Lobotomies in the United States

The first lobotomy in America was performed by a neuroscientist named Walter Freeman and a neurosurgeon named James Watts in 1936. The procedure became prevalent in the United States due to their efforts.

The initial procedure had to be done in an operating room, but Dr. Freeman thought this would limit access to the procedure for those in mental institutions who could potentially benefit from a lobotomy.

Freeman came up with a new, more simplified version of the procedure that could be done by doctors in those institutions, without general anesthesia or proper sterilization. Dr. Watts did not agree with these decisions and stopped working with Dr. Freeman in protest.

The lobotomy was a mainstream procedure until it fell out of favor in the mid-1950s. Nonetheless, Dr. Freeman continued to perform the surgery until 1967 when he had his last lobotomy patient, a woman named Helen Mortensen. She died three days after the operation and Freeman was banned from performing lobotomies shortly after.

How Lobotomies Were Done

Two main techniques were used to perform lobotomies. The techniques differed in how the surgeon accessed the patient's brain.

The original lobotomy performed by Dr. Moniz was the prefrontal lobotomy, while Dr. Freeman's version was the transorbital lobotomy.

Prefrontal Lobotomy

A prefrontal lobotomy, also known as a prefrontal leukotomy, was performed in an operation room. The patient was sedated with general anesthesia given to them by an anesthesiologist.

Once the patient was sedated, the surgeon drilled two bur holes in their skull—one on each side of the head above the prefrontal lobes.

Next, the surgeon injected alcohol into the tissues that connect the patient's prefrontal lobes to other parts of their brain, destroying them.

Years later, Dr. Moniz worked with another neurosurgeon named Almeida Lima to develop a needle-like instrument that resembled an ice pick. The instrument, known as a leucotome, had a retractable wire that Moniz would insert through the bur holes to cut through the frontal lobe tissues.

Transorbital Lobotomy

Dr. Freeman's approach was different in several ways. For one, Dr. Freeman intended for the procedure to be done in doctors' offices and mental institutions, rather than an operation room.

Dr. Freeman also used electric shock therapy rather than general anesthesia to sedate patients. This made it easier for the procedure to be done in outpatient settings since an anesthesiologist did not have to be there.

Instead of drilling bur holes through the skull, Dr. Freeman accessed the patient's brain through their eye sockets. During the transorbital lobotomy, he would lift the patient's upper eyelid and point the leucotome against the top of their eye socket.

Next, he would take a mallet and drive the instrument through the bone then five centimeters into the brain. The instrument would be used to remove tracts of brain tissues connecting the prefrontal lobes to the thalamus, a small structure inside the brain that sits just above the brain stem.

Side Effects

Dr. Freeman and Dr. Watts performed their first prefrontal lobotomy on a woman named Alice Hood Hammatt. When she awoke from the procedure, she reported that she felt happy. But six days later, she reported language difficulties, disorientation, and agitation. Nonetheless, Dr. Freeman considered her lobotomy a success.

In 1942, Dr. Freeman and Dr. Watts published their first case study on the effectiveness of their patients' lobotomies. Out of the 200 lobotomies they had done at the time, they reported that 63% of their patients showed improvements after their procedure, 23% had no change in symptoms, and 14% died or had severe complications.

In response to the study, a science writer named Tom Henry reported to the Washington Evening Star that the lobotomy "probably constitutes one of the greatest innovations of this generation."

That said, an estimated three out of every 10 people died from Freeman's transorbital lobotomies. Many more came out of the procedure with permanent brain damage that left them physically and/or cognitively impaired.

Other serious complications caused by lobotomies include:

• Bleeding in the brain
• Epilepsy
• Permanent changes in personality and emotion
• Infection in the brain
• Dementia
  

A Controversial Medical Procedure

To permanently alter another person’s personality was thought by many to overstep the bounds of good medical practice. Many people saw the procedure as a violation of the patients' rights.

In 1950, the Soviet Union banned the practice, saying it was “contrary to the principles of humanity.”

In the United States, lobotomies were featured in many popular works of literature, including Tennessee Williams' "Suddenly, Last Summer" (1957), and Ken Kesey’s "One Flew Over the Cuckoo’s Nest" (1962).

In both novels, lobotomies are represented as frighteningly brutal. In culture and among the general public, the procedure increasingly became viewed as a kind of dehumanizing medical abuse.

In 1977, a special committee of the U.S. Congress investigated whether psychosurgery such as lobotomy was used to restrain individual rights. The conclusion was that properly performed psychosurgery could have positive effects, but only in extremely limited situations.

Unfortunately, by that point, the damage had already been done. Lobotomies were far less frequently used and had been replaced by the rise of psychiatric medications.

Summary

The lobotomy was a type of pscyhosurgery done in the mid-20th century on patients with mental and neurological illnesses, like schizophrenia, bipolar disorder, and epilepsy.

The procedure involved cutting tissues in patients' brains with a tool called a leucotome. In a prefrontal lobotomy, the brain was accessed through two holes the surgeon drilled into the patient's skull. In a transorbital lobotomy, the brain was accessed through the patient's eye sockets.

Lobotomies caused death and devastating effects. Many patients were left with permanent physical, mental, and emotional impairments. In the mid 1900s, lobotomies were largely replaced by psychiatric medicine.

A Word From Verywell

The stormy history of the lobotomy serves to remind modern physicians and patients of the ethical dilemmas that are unique to medicine, particularly neurology.

For the most part, people who performed lobotomies had good intentions to do the right thing for their patients. They were driven by a desire to help that, by today’s standards, may seem misguided and misplaced.