Wednesday, March 2, 2016

Frontal lobotomy

It’s not clear who first quipped “I’d rather have a bottle in front of me than a frontal lobotomy,” but it’s not just a joke. Almost anything would be preferable to a frontal lobotomy. It was a barbarous procedure with catastrophic consequences, and yet it was once widely accepted and even earned a Portuguese doctor a Nobel Prize. In the annals of medical history, it stands out as one of medicine’s biggest mistakes and an example of how disastrously things can go wrong when a treatment is put into widespread use before it has been adequately tested.

A new book by Janet Sternburg, White Matter: A Memoir of Family and Medicine, puts a human face on the suffering of mentally ill patients and their families, and helps us understand why they agreed to lobotomies. It is the affecting story of how her relatives made the difficult but misinformed decision to lobotomize two of her mother’s five siblings, one for schizophrenia and the other for depression, and the consequences of that decision.
She says “even as a child I had a slight awareness, compounded from fear and pity, that something wrong had been done, that it couldn’t be right for people to be this way, expressionless and indifferent to anything around them.” As an adult, she questioned how good, kind people like her aunts could have done this to their siblings, and how they could have authorized a lobotomy on a second family member after they had seen its effects on the first...

In 1935 a Portuguese doctor, Egas Moniz, attended a conference where he learned of an experiment where the frontal lobes of two chimpanzees were removed and they changed from violent and difficult to handle to docile and compliant. It gave him the idea that mental illness in humans might be treated surgically. He devised a leucotome, an instrument for dividing the white matter in the brain, and he experimented on 11 female patients from the Lisbon insane asylum (no informed consent in those days!). He found that they became more docile and seemingly content, just like the chimpanzees. He rushed to publish a paper proclaiming his procedure a success. Several months later, many of his patients relapsed, as did one of the chimpanzees; this follow-up information was not publicized.

An article that re-evaluated Moniz’s research pointed out numerous flaws (for instance, inaccurate description of the technical parameters, lacking angle values and variable depths of insertion)...

Although undesirable effects arose in almost every intervention, they were only described as temporary. These were, in particular, increased temperature, vomiting, bladder and bowel incontinence, diarrhea, and ocular affections such as ptosis and nystagmus, as well as psychological effects such as apathy, akinesia, lethargy, timing and local disorientation, kleptomania, and abnormal sensations of hunger. Moniz did not admit to having detected a decrease in intelligence and memory performance, whereby it is unclear how he could have come to this conclusion.

Moniz displayed unconscionable haste, presenting his results at a conference only 4 weeks after the first operation and publishing them a few weeks later. And other doctors around the world displayed equally ill-advised haste in adopting the operation based on this very preliminary evidence...

In 1949 Egas Moniz was awarded the Nobel Prize in Medicine for his discovery of lobotomy. They called it:
…one of the most important discoveries ever made in psychiatric therapy because through its use a great number of suffering people and total invalids have recovered and have been socially rehabilitated...
He was no longer violent, and the family no longer had to fear him; but he didn’t speak a word, he barely moved, and he didn’t react to anything or anyone. He was incapable of taking care of himself and required constant supervision. He had eruptions of inappropriate sexual behavior with family members. He would do odd things in public like whirling on the sidewalk like a dervish in a slow trance. He even had to be reminded not to swallow food whole without chewing. After 15 years he suddenly recovered the ability to speak but then subjected the family to a surrealistic nonstop flood of fragmented thoughts. He had become “a head without the czar inside.”...

After surgery, she could indeed live alone and care for herself, but she was reduced to a person who would phone her mother with pride to announce that she had made a TV dinner all by herself. She compulsively gulped down any pills she could find and tried to destroy the evidence of what she had done; they couldn’t tell whether she was trying to kill herself or not. She was apathetic and unreactive. Like Bennie, she had been “erased” and turned into a sort of zombie. She had not wanted the operation, but after it was done she never even mentioned it...

Bennie died at the age of 59 in a nursing home. He had been twirling in the hallway until an attendant turned him toward the dining room for lunch. At lunch, he tried to swallow a handful of peanuts all at once and choked to death. That same year, Walter Freeman performed a third lobotomy on one of his earliest patients who had relapsed for the second time. He tore a blood vessel in her brain and she hemorrhaged to death. His surgical privileges were taken away.

There was an increasing backlash against lobotomy, with publicity about prominent victims like JFK’s sister Rosemary, described as “just a bit slow, a bit difficult.” She came out of her lobotomy permanently disabled, paralyzed on one side, incontinent, and unable to speak coherently. She required constant care by a private nurse for the rest of her life...

Sternburg started her investigation with the assumption that the operation turned everyone into zombies, but she learned otherwise: “[It] sometimes provided genuine relief to people who, to my surprise, were able to be aware of their situations, even to compare them with the past and say how much better they were. One trade-off, though, remained constant: the lobotomized remained indifferent.” She describes Bennie as “a person at the farthest reaches of not being at home in the world, in the midst of a tribe that had damaged him and also kept him safe.”

That raises serious philosophical and ethical questions. Is a life without feeling preferable to one spent in torment? Who is to decide? Can psychotic patients give informed consent? In a modern world concerned about terrorism, “the possibility of dehumanizing people is always with us, at least as great a terror.”


  1. Gross D, Schäfer G. Egas Moniz (1874-1955) and the "invention" of modern psychosurgery: a historical and ethical reanalysis under special consideration of Portuguese original sources. Neurosurg Focus. 2011 Feb;30(2):E8.


    The Portuguese neurologist Egas Moniz (1874-1955) is often regarded as the founder of psychosurgery. He performed the first prefrontal leukotomy in 1935—about 75 years ago—with the help of neurosurgeon Almeida Lima (1903–1985) [corrected]. In contrast to the psychosurgical interventions performed by the Swiss psychiatrist Gottlieb Burckhardt (1836-1907), Moniz's interventions on the white brain substance caught great attention worldwide. As a matter of fact, it was this repercussion that led to the award of the Nobel Prize for Medicine in 1949, an award that is still highly controversial today. The goal of the present article is to reconstruct the historical background of the first leukotomies, the tangible expert debate since 1935 on the indication and legitimacy of these interventions, and their contemporary and recent (ethical) evaluation. Special focus will be set on the original Portuguese literature, which has been given too little attention thus far in the English-language literature.

  2. She was a young woman of beauty and grace, but displayed behavioural problems, as she fell behind her success-oriented siblings in academic and sporting life, through a mental disability that was long kept secret. Her father arranged one of the first prefrontal lobotomies for her at age 23, but it failed and left her permanently incapacitated. She spent the rest of her life in an institution in Jefferson, Wisconsin, with minimal contact from her family...

    Placid and easygoing as a child and teenager, the maturing Rosemary Kennedy became increasingly assertive and rebellious. She was also reportedly subject to violent mood swings. Some observers have since attributed this behavior to her difficulties in keeping up with siblings who were expected to perform to high standards, as well as the hormonal surges associated with puberty. In any case, the family had difficulty dealing with her stormy moods and reckless behavior. Rosemary had begun to sneak out at night from the convent school in Washington, D.C. where she was cared for and educated. Her normally placid personality and occasional erratic behavior frustrated her parents who expected all of their children to behave appropriately, be highly goal-oriented, and act competitively. Joseph P. Kennedy, Sr. was especially worried that his daughter's behavior would bring shame and embarrassment upon the family and possibly damage his political career.

    In November 1941, when Rosemary Kennedy was 23, doctors told Joseph P. Kennedy, Sr. that a new neurosurgical procedure, lobotomy, would help calm her mood swings and stop her occasional violent outbursts. (About 80 lobotomies, 80% on women, had been performed in the United States at the time.) He decided that his daughter should have the lobotomy performed; however, he did not inform his wife Rose of this until after the procedure was completed. Rosemary was strapped to the operating table. James W. Watts, who carried out the procedure with Walter Freeman, of Wingdale Psychological and Correctional Facility, described what happened next (as narrated by Ronald Kessler):

    "We went through the top of the head, I think she was awake. She had a mild tranquilizer. I made a surgical incision in the brain through the skull. It was near the front. It was on both sides. We just made a small incision, no more than an inch." The instrument Dr. Watts used looked like a butter knife. He swung it up and down to cut brain tissue. "We put an instrument inside", he said. As Dr. Watts cut, Dr. Freeman put questions to Rosemary. For example, he asked her to recite the Lord's Prayer or sing "God Bless America" or count backwards..... "We made an estimate on how far to cut based on how she responded." ..... When she began to become incoherent, they stopped.

    After the lobotomy, it quickly became apparent that the procedure was not successful. Kennedy's mental capacity diminished to that of a two-year-old child. She could not walk or speak intelligibly and was considered incontinent.

    After the procedure, Rosemary was immediately institutionalized where she remained for the rest of her life. She initially lived for several years at Craig House, a private psychiatric hospital an hour north of New York City.[19] In 1949, she moved to a house in Jefferson, Wisconsin, where she lived for the rest of her life on the grounds of the St. Coletta School for Exceptional Children (formerly known as "St. Coletta Institute for Backward Youth").

  3. By the early 1930s, Egas Moniz had already left his mark on the treatment of the human brain. His method of cerebral angiography allowed physicians to observe cranial blood flow for the first time. But on November 12, 1935, the Portuguese neurologist would attempt something more audacious: a surgery to relieve the suffering caused by severe mental disorders.

    His patient was a 63-year-old woman suffering from hallucinations, severe anxiety and crying spells, insomnia and paranoia (she believed her pharmacist and physician were trying to poison her). Few effective treatments were available for psychiatric patients at the time. Moniz believed that mental disorders were caused by “fixed thoughts” brought on by problems in nerve pathways in the brain’s frontal lobes. Because his hands were distorted by gout, he enlisted his colleague Almeida Lima to assist him with the experimental operation. Lima drilled holes on each side of the woman’s head, inserted a syringe and injected the prefrontal lobe of her brain with pure alcohol, rendering it permanently useless.

    A few months after the procedure, a psychiatrist who examined the patient noted that she still seemed somewhat sad, but that her anxiety and paranoia had decreased significantly. The operation, deemed a success, came to be called a lobotomy...

    Valenstein questions Moniz’s evidence that he cured many of the patients. But overcrowding in U.S. mental institutions made psychiatrists desperate for new treatments, and the lobotomy quickly became part of mainstream medicine. By one estimate, 60,000 lobotomies were performed in the United States between 1936 and 1956 on patients with a variety of diagnoses, such as depression and schizophrenia. Walter J. Freeman, a neurologist at George Washington University, became the procedure’s most enthusiastic practitioner. Freeman eventually developed his own version, the transorbital lobotomy, in which he inserted an ice pick into the brain by way of the patient’s eye socket, then pounded the tool with a mallet, rocking it back and forth to sever nerve fibers...

    Some patients did benefit from the procedure, recovering from previously untreatable depression, anxiety and other conditions. Yet complications included profound apathy, childish or uninhibited behavior and epilepsy. Freeman’s own records suggest that lobotomies killed or worsened the conditions of 14 percent of patients.