It's evening in a mental hospital in Oregon, and there's a struggle happening between a noncompliant patient and the head nurse. The violent patient, however, isn't actually mentally ill; he's a convict named McMurphy who faked insanity so he could finish his sentence in a mental hospital instead of a prison. He's caused a lot of problems in the hospital by encouraging the other patients to stand up to the head nurse's abuses. McMurphy eventually attempts to strangle her because she's partly responsible for the death of another patient.
Because of the violent patient's actions, the head nurse has him committed to a special ward for patients deemed "disturbed." He also undergoes a lobotomy -- an operation in which the connections between the frontal lobes and rest of the brain are severed. The procedure leaves him in a vegetative state. Upon his return to the ward, another patient, Chief, remarks that "There's nothin' in the face. Just like one of those store dummies."
This scene, from the novel "One Flew Over the Cuckoo's Nest" and the subsequent film, was the first time that many people ever heard of a lobotomy. For some, it's still the first thing that comes to mind: an operation on the brain that makes a violent, noncompliant patient calm or even completely unresponsive. In the late 1950s, when Ken Kesey wrote his book, lobotomies were used to treat many different types of mental illnesses, including anxiety, depression and schizophrenia. The procedure was also performed on people who were considered extremely emotional, difficult to handle or simply "moody."
With the wide range of drugs and other types of therapies available to treat severe mental illness today, it's hard to imagine that doctors once thought that such a drastic operation was the way to a cure. As you'll read in this article, it wasn't always much of a cure. Let's start by looking at exactly what goes into performing a lobotomy.
The Way of the Ice Pick
The lobotomy is a type of neurosurgery, or surgery performed on the brain, known as psychosurgery. The idea behind psychosurgery is that severe forms of mental illness can be treated by changing the way that the brain works. Doctors believed that by severing the connections that the frontal lobes, or prefrontal cortex, had to the rest of the brain, they could calm patients' emotions and stabilize their personalities without doing away with their intelligence and motor functions.
The prefrontal cortex serves a number of complex functions in the brain, usually called executive functions. (Higher-level decision making and planning, reasoning and understanding, personality expression, creativity and behaving in a socially acceptable way all fit under this category.) The prefrontal cortex is connected to many other regions of the brain, including the thalamus, which receives and relays sensory signals.
The brain is essentially composed of two different types of matter: gray and white. Gray matter includes the neurons, or brain cells, along with their blood vessels and extensions. White matter comprises the axons, or nerve fibers, that connect the areas of gray matter and carry messages between them through electrical impulses. So a lobotomy was intended to sever the white matter between different areas of gray matter. (Another name for lobotomy, leucotomy, means "slice/cut white" in Greek.)
The first lobotomies were performed in 1935 by Portuguese neurologists Dr. Antonio Egas Moniz and Dr. Almeida Lima. Initially, they drilled holes in the skull on either side of the prefrontal cortex and injected the connecting fibers with alcohol to destroy them. However, this procedure resulted in too many complications, including damage to other parts of the brain. Moniz then decided to use a tool called a leucotome. After drilling holes in the skull, the doctor pressed on the back of the tool, which extended a wire or metal loop inside. By extending and then retracting the leucotome, he could remove cores of white matter.
In 1936, a neurologist and psychiatrist named Dr. Walter Freeman and his partner, Dr. James Watts, began performing lobotomies in the United States. Ten years later, Freeman perfected a new method. Moniz's technique, called a prefrontal lobotomy, required a patient to go under general anesthesia in an operating room. Freeman wanted to find a technique that was faster, more accessible and less expensive, so he decided to get to the prefrontal cortex through the eye sockets instead.
Freeman first practiced on cadavers using an ice pick, which is how his method came to be known as the "ice pick lobotomy." When he began performing the transorbital lobotomy on patients, he used a stronger version of a leucotome that resembled an ice pick, called an orbitoclast. After going through the top of the eye socket, Freeman could enter the brain just by tapping lightly on the orbitoclast with a hammer to break through the thin layer of bone. Then he twirled it to cut through the fibers. After pulling out the orbitoclast, the procedure was repeated on the other side. The transorbital lobotomy took 10 minutes or less.
Because it didn't require drilling through the skull, it could be done by rendering the patient unconscious via electroconvulsive shock. It could also be done by nonsurgeons. Since most mental hospitals didn't have operating rooms or surgeons on staff, this new method made it easier for a patient to get the procedure. Eventually Freeman performed lobotomies as outpatient procedures in his office, in addition to doing them in mental hospitals and teaching other doctors how to do them.
So how well did lobotomies work? It all depends on who you ask. Next, we'll look at the different outcomes of patients who had lobotomies over the years.
Soul Surgery: Successes and Failures in Lobotomy Patients
In the United States, about 50,000 patients were lobotomized, most of them between 1949 and 1956. Dr. Freeman himself performed between 3,500 and 5,000 of them. He called lobotomies "soul surgery" and claimed that they could be used to treat not only schizophrenia, but depression, chronic pain and other mental and physical conditions. Freeman, and other doctors who performed lobotomies, believed that they could relieve suffering. In some cases, they did.
Freeman first performed his transorbital lobotomy on Ellen Ionesco in 1946. She was described as "violently suicidal" by Angelene Forester, her daughter. After Ionesco's lobotomy, Forester says that "it was just peace [...] it was like turning a coin over. That quick. So whatever he did, he did something right" [source: NPR]. Patricia Moen, who was also suicidal, was lobotomized by Freeman in 1962. Afterward, Moen said that she "just started living again." Her husband Glenn was "delighted at the way it turned out."
Not all patients were so happy with life after their lobotomies. Howard Dully was lobotomized by Freeman as a 12-year-old boy in 1960. He wasn't mentally ill; his stepmother wanted to change his personality, which she described as defiant. Dully wasn't told about the operation until afterward. He states that "the surgery damaged me in many ways. But it didn't 'fix' me, or turn me into a robot. So my family put me into an institution" [source: Dully]. Dully claims that he always felt different, like "a freak" and "ashamed." He lived in institutions for 10 years and battled addictions until his 50s.
One of Freeman's most famous failures was the sister of a president. In 1941, Rosemary Kennedy, the sister of John F. Kennedy, was lobotomized at the age of 23. Rosemary was described as a shy and easygoing child, but in her teenage years, she became rebellious and moody. A doctor suggested that a lobotomy could calm Rosemary down. At the time, Freeman had only performed about 60 lobotomies and hadn't yet created his transorbital technique, so he performed a prefrontal lobotomy.
The operation did make Rosemary more manageable, because she was essentially left with the mental capacity of an infant. She couldn't speak intelligibly or control some bodily functions, and she stared into space for hours. Rosemary spent the rest of her life in an institution. Some researchers have claimed that she was mildly mentally disabled before her lobotomy, while others say that she had some form of mental illness. Publicly, Rosemary was described as mentally disabled. Her sister Eunice Kennedy Shriver later helped to found the Special Olympics in her honor.
Other lobotomy patients also experienced negative results. Anita McGee was lobotomized by Freeman in 1953 for postpartum depression. Her daughter Rebecca Welch describes her mother as "there but not there" [source: NPR]. McGee has spent the rest of her life in institutions. Beulah Jones was lobotomized in the late 1940s due to schizophrenia. Her daughter Janice-Jones Thomson stated that afterward, "there was no change in her behavior other than she lost her higher intellect. She could not sit down and read anymore. She could barely write. She had no long-term memory" [source: PBS].
Neurologist Dr. Elliot S. Valenstein has said of lobotomies, "There were some very unpleasant results, very tragic results and some excellent results and a lot in between" [source: Valenstein]. Ironically, the procedure couldn't cure schizophrenics. According to neurosurgeon Dr. Frank Vertosick, "Unlike depression and mania, which are disorders of mood, schizophrenia is a disorder of thought. And what a lobotomy alters is emotional state, not cognitive abilities" [source: Vertosick].
If the results varied so much, then why did lobotomies become the way to treat mental illness? The answer lies in the state of psychiatric care during the time that the lobotomy was popularized.
Psychiatric Care in the 1930s: The Lobotomy's Origins
Although it had come a long way from the days of simply restraining and locking away the mentally ill, psychiatric care in the 1930s was still very limited. There was essentially no treatment for schizophrenic patients, for example. Psychiatrists attempted to treat their symptoms by prescribing drugs like sedatives, which suppressed the patient's nervous system, and trying a number of different mind-body therapies.
Schizophrenics received hydrotherapy in the form of hot or cold baths for hours at a time. There were also a few different types of shock therapy: insulin, Metrazol and electroconvulsive therapy (ECT). All of these therapies induced seizures in patients. Many psychiatrists claimed that these therapies worked by "shocking" patients out of their illness. Others believed that there was a connection between epilepsy and schizophrenia -- a patient who had the former, even if it was induced, couldn't have the latter.
These treatments didn't generally cure schizophrenics, depressives and others of their mental illness; most were in and out of hospitals or ultimately spent their entire lives inside them. In addition, hospitals in the United States were overcrowded -- by 1940, there were around 1 million patients and the population was growing by 80 percent per year [source: Dully]. Conditions were also deteriorating due to a lack of funding during the Great Depression. Public hospitals were understaffed and patients were often left without any kind of treatment. People embraced the idea of a speedy, simple cure and were hopeful that surgery could provide it.
In 1933, two neurologists at Yale Primate Laboratory, Dr. John Fulton and Dr. Carlyle Jacobson, performed experiments on two monkeys named Becky and Lucy. After testing the monkeys' intelligence, the doctors removed half of their brains' frontal lobes and then retested them. They seemed to retain their skills and intelligence. Fulton and Carlyle then removed the other half of the monkeys' frontal lobes. Becky's and Lucy's personalities changed -- they no longer became violent and frustrated when they didn't immediately get their treats after completing a test. The monkeys could still complete the tests, although not quite as well.
Dr. Moniz saw Fulton present his work at a conference in 1935. He saw similarities between the monkeys' behavior prior to their surgery and the behavior of his mentally ill patients. Moniz concluded that he could perform a slightly different operation on people to separate their emotions and thoughts while retaining their intelligence. He and his colleague Dr. Lima performed numerous experiments on cadaver brains before attempting a lobotomy on a live patient. After perfecting his technique, Moniz claimed success -- his lobotomized patients were serene and no longer anxious.
The following year, Moniz shared his findings in medical journals and at conferences, to a mixed reception. Some psychiatrists were very upset at the idea that a surgery that destroyed healthy brain tissue could cure mental illness. Accepting psychosurgery also meant acknowledging that other forms of therapy, such as the growing field of psychoanalysis, may not work.
Still, many psychiatrists and neurologists were intrigued, Dr. Walter Freeman among them. His championing of the surgery eventually included a traveling "lobotomobile," a customized van in which he demonstrated his technique to the press as well as doctors at mental hospitals. He liked to show off by entering both eye sockets at one time with two different orbitoclasts. Critics likened Freeman to an evangelist for the cause, while supporters claimed that getting a lobotomy was as safe and easy as getting a filling at the dentist. When Howard Dully received the records of the lobotomy performed on him as a child, he discovered that it had cost his parents less than $200. Lobotomies cleared overcrowded hospitals, and unlike other psychiatric care, it promised immediate results.
However, the so-called "lobotomy revolution" lasted less than 20 years. Next, we'll look at how it fell out of favor and what's happening with psychosurgery today.
Criticism of Lobotomies
In 1950, a drug named chlorpromazine (sold as Thorazine) was synthesized. This marked the beginning of the end for lobotomies as treatment for mental illness in the United States. Thorazine was the first in a series of antipsychotic drugs, and some have described it as the biggest single advance in the treatment of schizophrenia -- on par with what the discovery of penicillin did for the treatment of infectious diseases.
Criticism of lobotomies had always existed, but concern grew along with its popularity. An editorial in a 1941 issue of the Journal of the American Medical Association read, "No doctor can yet assert that this is or is not a truly worthwhile procedure. The ultimate decision must await the production of more scientific evidence." [source: Diefenbach]. Still, the Nobel Committee selected Dr. Moniz, nominated by Dr. Freeman, for the Nobel Prize in Physiology or Medicine in 1949. However, while popular publications contained stories of Freeman's surgical precision and patients' miraculous recovery, the medical and scientific community discussed the crude nature of the operation and wondered if it could be truly proven as effective.
Eventually this negativity spread to the general press. After the USSR banned lobotomies in 1953, a New York Times article quoted Soviet psychiatrist Dr. Nicolai Oseresky as saying that lobotomies "violate the principles of humanity" and change "an insane person" into "an idiot" during a meeting of the World Federation of Mental Health [source: Laurence]. The article also stated that leading European and American psychiatrists in attendance were inclined to agree. There was never an established scientific basis for lobotomies, and most psychiatrists didn't perform long-term follow-up care for their patients in order to assess its effectiveness.
Some criticism had to do with the relaxed criteria for lobotomies. They were given to criminals, in some cases against their will, in an attempt to "cure" them of their desire to commit crimes. Some battle-fatigued World War II veterans were lobotomized so they could free up space in the hospitals. When patients couldn't consent to the operation themselves, their family members did so, but sometimes the family member was more interested in getting rid of their problem than actually helping the patient. As more stories of abuse and disastrous results became public and antipsychotic drugs got widespread use, lobotomies were all but forgotten.
Freeman continued to perform lobotomies until 1967, when he was banned from operating after last patient (on her third lobotomy -- Dr. Freeman believed in trying until he got it right) died from a brain hemorrhage. He continued to visit his former patients and tout the success of the lobotomy until he died of cancer in 1972.
Although the lobotomy has been banned in several countries (including Moniz's home country of Portugal), it's still performed in limited numbers in several countries today. Often it's used to treat epilepsy. Now known as NMD (neurosurgery for mental disorder), lobotomies are performed in two hospitals in Great Britain as a last resort to treat obsessive-compulsive disorder and severe depression. Those who support it still believe it can be beneficial when all other treatments have failed.
Some doctors in the United States are interested in reviving psychosurgery -- or psychiatric surgery, as some prefer to call it. In 1997, a team of neurosurgeons at Harvard published a report about using MRI to guide doctors in performing cingulotomies to treat mental illness. A cingulotomy involves burning small holes in the cingulate gyrus, an area of the brain though to connect the frontal lobes to the limbic region, involved in emotional behavior. Although there's some evidence that this can work, neurosurgeon Dr. Frank Vertosek points out the public relations problems inherent in any kind of psychosurgery. He also states that most mentally ill patients will respond well to drugs and other therapies, leaving few candidates for surgery even if it did become more widely acceptable.
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More Great Links
- Diefenbach, Gretchen J., et al. "Portrayal of Lobotomy in the Popular Press, 1935-1960." Journal of the History of the Neurosciences, 1999, Vol. 8.http://facstaff.unca.edu/ddiefenb/lobotomy.html
- Dully, Howard. "My Lobotomy." Crown Publishers, 2007.
- "Egas Moniz: Biography." Nobel Lectures, Physiology or Medicine 1942-1962, Elsevier Publishing Company, Amsterdam, 1964.http://nobelprize.org/nobel_prizes/medicine/laureates/1949/moniz-bio.html
- Laurence, William L. "Lobotomy banned in Soviet as cruel." New York Times, August 22, 1953. ProQuest Historical Newspapers 1851-2005.
- Ozarin, Lucy. "The AMA's 1930 Survey of Mental Hospitals." Psychiatric News, June 7, 2002, Vol 37, Number 11.http://pn.psychiatryonline.org/cgi/content/full/37/11/13-b
- "'My Lobotomy': Howard Dully's Journey." All Things Considered, NPR, November 16, 2005.http://www.npr.org/templates/story/story.php?storyId=5014080
- PBS American Experience: The Lobotomisthttp://www.pbs.org/wgbh/amex/lobotomist/
- Shutts, David. "Lobotomy: Resort to the Knife." Van Nostrand Reinhold Company, 1982.
- Toomey, Christine and Steven Young. "Mental Cruelty." The Sunday Times, February 19, 2006.
- Turner, Treavor. "Chlorpromazine: unlocking psychosis." British Medical Journal, January 6, 2007, Volume 334 (supplement 1).http://www.bmj.com/cgi/content/full/334/suppl_1/s7
- Valenstein, Elliot S. "Great and Desperate Cures." Basic Books, 1986.
- Vertosick, Frank T. "Lobotomy's back -- controversial procedure is making a comeback." Discover, October 1997.http://findarticles.com/p/articles/mi_m1511/is_n10_v18/ai_19758746/pg_1