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The lobotomy, a procedure utilized in the early 20^th century for the treatment of schizophrenia and other mental disorders, was widely accepted by scientists without an adequate amount of research and remains a black spot in the history of modern psychosurgery.

On The thirteenth of September, 1848, Phineas P. Gage, the 25-year-old Irish foreman of blasting operations for the Rutland and Burlington Railroad, was preparing the ground to lay tracks in Vermont. The blasting technique involved putting explosive powder and fuse into a hole, covering the hole with sand, then lighting the fuse. Unfortunately, Gage accidentally tamped the powder into the hole before sand was poured in. When the tamping rod struck the powder, it ignited it. The blast drove the rod through Gage’s head like a javelin, the inch-thick shaft entered under his left cheekbone and exited through the top of his head. (Schott, 1997)

Amazingly, Gage was only momentarily dazed. In fact, he remained conscious enough to help get himself to a doctor. The doctor cared for Gage by trying to keep the wounded area clean and bandaged. After a series of near-fatal infections around the embedded rod, Gage recovered. Though the injury left him blind in one eye, the physical wounds to his head eventually healed. His psychic wounds, however, did not. While he retained his speech, memory, and other intellectual faculties, it was observed that his personality had dramatically changed. Previously collected and responsible, he became capricious, and irritable. (The Brain, 1984)

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In 1868, a physician named Harlow from Boston wrote about him: "His equilibrium, or balance, so to speak, between his intellectual faculties and animal propensities seems to have been destroyed. He is fitful, irreverent, indulging in the grossest profanity, which was not previously his custom, manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires."

The injured Phineas, once the most dependable of employees, could not hold a job. He became a derelict, a wanderer, and died in obscurity 13 years after his accident. (Vertosick, 1996)

The case of Phineas Gage became an object of immense medical interest, for it seemed clear, from his somewhat crude experience of psychosurgery, that one could alter the social behavior of the human animal by physically interfering with the frontal lobes of the brain. (Schott, 1997)

The origin of the lobotomy began with Portuguese psychiatrist and surgeon Egas Moniz’s observation at the Second International Neurologic Congress in London. At the Congress, Charles Jacobsen presented work that he and John Fulton had done in bilaterally ablating the prefrontal cortex of two chimpanzees. The animals, "Becky" and "Lucy," had been trained to perform a delayed response task. Becky, in particular, displayed a violent temper when she could not remember which of two cups contained food. (Swayze, 1995) Following lobotomy, the animal made repeated errors without evidence of any emotional response:

Moniz stood up at the end of the lecture and asked, "If the frontal lobe removal prevents the development of experimental neurosis in animals and eliminates frustrational behavior, why would it not be possible to relieve anxiety states in man by surgical means?"

Many attending were shocked to hear it put so frankly, they believed that Moniz was talking about performing the full lobectomy on humans. However a few, including Walter Freeman, were struck by Moniz’s courage. (Schott, 1997)

Attending the conference led Moniz to believe that mental disorders were caused by certain fixed patterns of neurons in the brain, particularly in the frontal lobes. These fixed patterns generated fixed patterns of disturbed thought and behavior. (Noonan, 1989) Moniz’s solution was to surgically destroy these "fixed arrangements of cellular connections that exist in the brain."(Bruno, 1989)

In September 1935, in a Lisbon surgery, Moniz participated in the first controlled attempt to put into practice the ideas raised at the London conference. With the neurosurgeon Almeida Lima, he attempted to perform the first leukotomy, on a female patient. The object of the operation was not to destroy the frontal lobes, but rather to destroy (by injecting alcohol into them) the fibers, the white matter or leukos, which connect the frontal lobes - the area they believed to be the most immediately concerned

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with social behavior - to the main body of the human brain. (Wilkins, 1985) Two trephine openings were made about 3 cm anterior to a vertical line that passed through the base of the tragus bilaterally and 3 cm left and right of the midsagittal line. (Swayze, 1995)

He soon refined this technique by designing a "leukotome," an instrument with a retractable wire loop, which he used to cut six cores in the white matter of each hemisphere. The trephine openings were also moved back 1.0-1.5 cm behind the vertical line described above (Campbell, 1989)

The results were inconclusive. After surgery, the woman was much less agitated and overtly paranoid than she had been before. (Bruno, 1989) But she and the other three patients from the asylum who subsequently underwent the same procedure were also, Moniz admitted, somewhat more apathetic and frankly duller than he had hoped. In addition, they suffered from nausea, sphincter disorders, sluggishness and disorientation. Still, the results were spectacular enough for Moniz to be encouraged. (Schott, 1997)

Although Egas Moniz was the first to use the lobotomy on human subjects, it is important to note that he was not the first to use a neurosurgical approach to the treatment of psychiatric illness. Trepanation began 4,000 - 5,000 years ago in Europe and northern Africa as a treatment for various pathologic conditions. Its use spread to parts of Asia, Melanesia, New Guinea, Tahiti, New Zealand, Siberia, and Abyssinia. The practice was particularly refined in Peru and Bolivia. (Swayze, 1995)

Among those who followed Moniz’s lead, none was more prominent than the neurologist and neurosurgeon team of Walter Freeman and James Watts in the United States. They began performing bilateral frontal leukotomies in 1936, primarily in patients

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with depression. In the ensuing years they did more to promote the use of psychosurgery than anyone else in the world. (Haerer, 1992)

Walter Freeman first met Moniz at the Second Neurological Congress in 1935. Freeman had been impressed by his boldness and began following Moniz’s studies. A year later, when Moniz published the results of his experiments, Freeman requested a

copy of Moniz’s full monograph on the process from its Paris publisher. (Schott, 1997) Freeman had no qualifications as a surgeon. He needed a neurosurgeon as a collaborator so he showed the book to his collegue, James Watts. They ordered from France two of Moniz’s leukotomies, knives specially designed for the operation, and after practicing for a week on brains from the morgue, Freeman and Watts operated on their first living patinet. Watts did the cutting; Freeman navigated. (Noonan, 1989)

The procedure was performed on September 14, 1936 using the Egas Moniz operation. The patient was under avertin narcosis supplemented by gas. Four hours later, after the anesthetic had worn off, her face presented a placid expression, and she admitted that she felt much better. On the following day she was questioned:

Q. Are you content to stay here?

A. Yes

Q. Do you have any of your old fears?

A. No

Q. What were you afraid of?

A. I don’t know. I seem to forget.

Q. Do you remember being upset when you came here?

A. Yes, I was quite upset, wasn’t I?

Q. What was it all about?

A. I don’t know. I seem to have forgotten. It doesn’t seem

important now. (Freeman, 1950)

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Freeman and Watts were thrilled.

A week after surgery, the woman began to behave strangely. She talked incoherently, becoming stuck on certain syllables, repeating them endlessly and hopelessly jumbling up her sentences. She could no longer recite the days of the week, and when she was asked to write, the same repetitions and sad, nonsensical constructions occurred on

paper. A few days later, her speech had largely returned and she went placidly home, showing neither eagerness nor apprehension. (Schott, 1997)

Freeman and Watts tried not to focus on her worsening condition in their book Psychosurgery in the Treatment of Mental Disorders and Intractable Pain,

The two surgeons proceeded to operate on another five patients over the next six weeks, and in November 1936 published a report in which they wrote:

"In all our patients there was a…common denominator of worry, apprehension, anxiety, insomnia and nervous tension, and in all of them these particular symptoms have been relieved to a greater or lesser extent." They further said that in some patients disorientation, confusion, phobias, hallucinations and delusions had been relieved or had altogether disappeared. They concluded by saying the grounds on which they had undertaken the operations – to relieve symptoms that were causing "great distress to the patients and to their families" – and added: "We wish to emphasize that indiscriminate use of the procedure could result in vast harm. Prefrontal (targeted at the parts of the brain

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behind the frontal lobes) leukotomy should at present be reserved for a small group of specially selected cases. Every patient probably loses something by this operation, some spontaneity, some sparkle, some flavor of the personality."

Privately, however, Freeman was not only optimistic but triumphant, Talking about their first patient, he said: "This woman went back home in 10 days, and she is

cured." The "indiscriminate use" he and Watts counseled against would come, despite their warnings; Freeman himself would provide both the means and the motivation for it.

Freeman and Watts decided that leukotomy was an incorrect name for the procedure. It suggested that only the white matter, the leukos, was affected when, in fact, actual nerve cells were also destroyed. Hence, they renamed it the lobotomy. This helped to establish their version of the operation as distinct from that performed by Moniz. (Schott, 1997)

They began to see the limitations of their current technique of operation: eight of their first 20 patients had two operations, and two of these had a third; there were two fatalities. Soon they were trying varied procedures. They experimented with more holes in the top of the head and penetrated deeper. They substituted for the cutting wire of the leukotome a more rigid blade, but found that the blade frequently broke off in the patient’s brain; and, when it could eventually be dragged out, bits of blood vessel and brain tissue came with it. (Noonan, 1989)

Freeman and Watts reported many failures in their early days as they looked for the most efficient operation. They were often disappointed as they experimented with

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different procedures for removing brain tissue. "We learned by experience that the incisions should not be made too far behind the coronal suture, at least in the upper quadrants," they wrote as they explained how cutting the brain too far back from the forehead left the patients inert, incontinent, and with "other indications of severe damage to the frontal lobes." (Freeman, 1950)

By 1938, Freeman decided to change the strategy for attacking the brain. He opted to make the holes in the side of the head, to allow a more direct assault on the white matter. He also changed the instrument to a narrow steel blade, blunt and flat like a butter knife, called a Killian periosteal elevator. In principle, the blunt, thin end of this could be gently pushed through the intervening brain tissue with less risk of tearing the blood vessels. (Schott, 1997)

From this development emerged the "Freeman-Watts standard lobotomy"; or, as they called it, the "precision method." (Time, 1947) After hand-drilling holes on either side of the head which were widened by manually breaking away further bits of the skull, the way would be paved for the knife by the preliminary insertion of a 6 inch cannula, the tubing from a heavy-gauge hypodermic needle. Put in one hole, this would be aimed at the other, on the opposite side of the head. Then the blunt knife would be inserted in the path initially carved by the cannula. Once inside the brain, the blade would be swung in two cutting arcs, destroying the targeted nerve matter. (Freeman, 1950) "It goes through just like soft butter," said Watts. The operation was repeated on the other side of the head. (Schott, 1997)

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Because the technique was "blind" –they could not see what they were doing – it required both men. (Bruno, 1989) Watts manipulated the cannula and blade while Freeman crouched in front of the patient using his knowledge of the internal map of the brain to give Watts instructions. Watts enjoyed "flying on instruments only," as he put it, and became so expert that, as a special trick, he could insert a cannula through a 2 millimeter hole in one side of a patient’s head and thread it through the brain and out of the opposite hole like a shoelace. "That’s pretty dam- dramatic, you know," he once said. "And of course it always impressed spectators." (Schott, 1997)

Having observed that the optimum results were achieved when the lobotomy induced drowsiness and disorientation, Freeman and Watts decided to see if they could use this information to judge how an operation was proceeding; they began to perform lobotomies under local anesthetic. Now they could speak to the patient while cutting the lobe connections and gauge whether they were being successful. They asked patients to sing a song, or to perform arithmetic, and if they could see no signs of disorientation, they chopped away some more until they could.

The following dialog took place during a "standard" lobotomy performed on a thirty-six-year-old man in the summer of 1943. The man had been diagnosed a schizophrenic and, according to the case history, had been ill for about a year.

Psychosurgery began to gain popularity in the United States, though in Europe its acceptance was more limited. Basing their work on the Freeman-Watts system, American neurosurgeons quickly developed a myriad of variations. (It was five years since Moniz’s first operation, and there had still been no long-term study of those who had undergone surgery.) (Time, 1947)

Up until 1945, Freeman had never actually performed a lobotomy himself. (Schott, 1997) He had always worked jointly with Watts, and his surgical experience was limited to performing "spinal taps." (Freeman, 1950) What Freeman really wanted was a version of the operation that could be performed not just by neurosurgeons, but by anyone, anywhere, in a few minutes: an over-the-counter, rapid technique. (Noonan, 1989)

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He had heard of the work of an Italian called Amarro Fiamberti, who had developed a trans-orbital attack on the frontal lobes; one that went in through the skull, directly over the eyeball. He had perforated the orbital plate of the skull behind the eyes, and injected caustic solutions to destroy the brain tissue, but these had sunk down and caused rather severe damage elsewhere. Fiamberti had also punctured the orbital plate directly through the eye sockets and tried to use the original leukotome knife in this method with few good results, and a lot of mess. The potential advantage of such an approach was that it did not require holes to be made in the skull; everything could, in theory, be performed by one individual administering a simple stab through the back of each eye socket into the white matter of the brain. There would be nothing to set up. The patient would be left with nothing worse than black eyes and a splitting headache - plus the usual effects. It would be very easy, very fast, and very cheap. (Schott, 1997)

During the winter of 1945, Freeman tried to develop a trans-orbital approach to lobotomy, practicing on corpses. Watts cooperated, believing that ultimately he would do the surgery, and Freeman would, as usual, navigate. The two men came up against a familiar problem; the instruments they were using were not strong enough to penetrate the orbital bone and kept breaking off inside the head of their experimental corpses. They needed an implement that was slender, sharp, and strong.

One day, mulling over the problem at home, Freeman remembered that the apple corer had been a source of inspiration for Moniz, and began to rummage through the

contents of his kitchen drawers. Soon he found precisely what he was looking for: a cheap, mass-produced ice pick for stabbing pieces of ice off large commercial blocks.

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Normally used for making cold drinks on hot summer days, it now made its debut as an instrument for brain surgery. Freeman put a special hammer-shaped head on the ice pick, which allowed it to be pushed and pulled more easily. It was this instrument that was used in the first trans-orbital lobotomies in America in a procedure that became known as the "ice pick lobotomy." (Freeman, 1950)

Armed with this new weapon, Freeman was convinced that a trans-orbital would be a simple piece of surgery which would not require a neurosurgeon. He decided that he would operate on the first living patient without telling Watts, whom he hoped would be sufficiently impressed to offer his encouragement thereafter. Secretly, he tried his hand on a series of patients, to whom he explained that the technique had been used successfully in Italy for a number of years, which was being quite economical with the truth. He did not dwell on his own lack of surgical experience. He anaesthetized them with three rapid bursts of electric shock. He then drew the upper eyelid away from the eyeball, exposing the tear duct. The sharp point of the ice pick was placed in this, and then, as Freeman put it, " a light tap with a hammer is usually all that is needed to drive the point through the orbital plate." The ice pick was plunged into the brain. When it was about 2 inches inside, Freeman would pull the ice pick about 30 degrees backward, as far as he could without cracking the skull, and then move it up and down at another 20 degree arc, in order to cut the nerves at the base of the frontal lobes. (Campbell, 1989) The procedure took only a few minutes. Freeman’s post-operative advice to relatives was simply, "Buy them some sunglasses." (Schott, 1997)

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By his tenth patient, Freeman felt confident enough to let Watts know what he had been doing. Watts was upset by the brutality of the operation and angrily threatened to break with Freeman if he continued. It was the beginning of the end of their relationship, and within months Watts had left the practice they ran. Freeman, now with an incessant itch for surgery, started to sneak off out of Washington, to mental hospitals in other states where he could practice his technique. He was constantly angered by finding himself given the most deteriorated patients to operate on. He wanted trans-orbital lobotomy to be performed on people just developing signs of mental disorder. (Schott, 1997)

Freeman continued his career without Watts, frequently making "head hunting expeditions" across the US searching for new patients and checking up on old ones. But as the world woke up to the atrocities of lobotomy, Freeman found it increasingly hard to maintain his reputation. (Swayze, 1995) In May 1972, after a brief battle with cancer, he died at 77 years of age, still believing in the integrity of his methods and motives. (Schott, 1997)

Before their split, Freeman and Watts published the results of their operations in

Psychosurgery in the Treatment of Mental Disorders and Intractable Pain.

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The problem with much of their data is that Freeman and Watts never spelled out exactly what they meant by Good, Fair, Poor. They simply state that each case was judged on its own merits, and that a result judged Good in one set of circumstances might be given only Fair, given another set of circumstances. Variables that played a role in their decisions included the diagnosis, the patient’s family situation, the course and duration of the illness, and the period of institutionalization. The most obvious characteristic of their results is the inadequate classifications of Good, Fair, and Poor. (Freeman, 1950) David Noonan states in his book Neuro, " Good, Fair, and Poor define a range too simple and too vague for even a grammar school marking system, never mind a system for measuring the degrees of success of psychosurgery." (Noonan, 1989)

In the 1985 edition of the book Behavioral Neurology, Drs. Jonathan H. Pincus and Gary J. Tucker point out the fundamental flaw of neurosurgery in the early 1900’s. "In many instances," they note, "the selection of patients for frontal lobotomy, the operation and the post-operative evaluation were performed by the same individuals."

After evaluating 617 cases, Freeman and Watts concluded that "Five out of six patients, including both sexes, all ages, and all diagnoses, are considered as improved by prefrontal lobotomy." (In reality, when Freeman and Watts were analyzing their results, their main measure of success was whether or not the patient was able to leave the institution.) The chart above was provided to support their conclusion.

Even though Freeman and Watts put the best possible face on their results, they managed to get only 45% of their cases into the Good category. In their book they state that one hundred of their first five hundred cases (20 percent) had to be considered

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failures. That Freeman and Watts seemed to consider their results acceptable, even something to be proud of, is horrifying.

Freeman and Watts were comfortable enough to think nothing of performing a lobotomy on a four-year-old boy and then listing him as "improved" in spite of the fact that he died of meningitis three weeks after the operation. (In their account of the case, Freeman and Watts note that "Necropsy showed clean healing wounds" in an attempt to escape blame for his death.) They also performed two lobotomies on a six-year-old girl in the space of seven months and three lobotomies on a seventeen-year-old in a year. Though the girl was found to be almost completely withdrawn from her environment four years after surgery, the doctors classified her as "improved" because she was "less troublesome" as a lobotomized ten-year-old than she had been as a disturbed six-year-old. "In spite of her increased speed and strength," they wrote, "she can be more easily managed at home, is beginning to put sentences together and the impulsive, destructive behavior is subsiding." The seventeen-year-old remained in a state hospital, one of their admitted failures. (Noonan, 1989)

Initially, the patients who were operated on suffered predominantly from the affective disorders (involutional depression, involutional melancholia, agitated depression, and the depressive phase of maniac-depressive psychosis), obsessive-compulsive neurosis, hypochondriasis, and various other psychoneuroses. The nature and intensity of clinical symptoms were more important than diagnosis in determining who should undergo surgery. Ultimately, diagnosis per se had little to do with who would receive psychosurgery, as long as the patient was significantly impaired and had not responded to

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more benign treatment and the severity of illness outweighed concerns of major postoperative personality changes. All patients who had a great deal of "emotional tension" with considerable distress, with agitation or suicidal or homicidal tendencies, were considered good candidates for a positive therapeutic outcome.

In the late 1930’s a few patients with schizophrenia were operated on, but none of Moniz’s original seven schizophrenic patients showed remarkable improvement, nor did the 12 schizophrenic patients included in the first 80 operations done by Freeman and Watts. However, interest in the psychosurgical option revived when researchers in Pennsylvania, Minnesota, and Britain, claimed significant improvement following leukotomy in very treatment-refractory schizophrenic patients.

For these reports Freeman and Watts gathered courage to renew word in shizophrenia. Their cautious approach became more excited due to success with previously treatment-refractory patients. Freeman began to believe that persons with schizophrenia could be helped be lobotomy if they were operated on before they showed signs of deteriorating into a withdrawn, apathetic, and avolitional state; but he felt that a patient with deteriorated schizophrenia behaved "the same with or without his frontal lobes."

It was the advent of antipsychotic drugs in the 1950’s that brought an end to the age of psychosurgery. When these drugs were first utilized they were often overprescribed or inappropriately prescribed due to the fact that no one knew exactly how or why they worked. "Each of the major so-called tranquilizers, thorazine and the others, has its own slightly different signature," Scheibel has said. "Some will work on one

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patient, some will work on another. And nobody has the faintest notion. And when I say work, what they do is make life more liveable. They’re not treatments, right? They’re palliatives." (Noonan, 1989)

There was much emotional debate about lobotomy. Critics of psychosurgery charged that emptying the mental hospitals was in fact the main reason the lobotomy became so widespread. (Noonan, 1989) Freeman and Watts were particularly conscious of the situation in the large mental institutions, and several times in their work, they referred to the positive impact psychosurgery could have on these institutions. "As we have stated previously…the problem of the disturbed ward of the state hospital can be all but solved by the performance of prefrontal lobotomy on a large scale," they wrote. They promoted the transorbital lobotomy in particular as a technique ideally suited for use in crowded mental hospitals, "where it is obviously of greatest value." (Freeman, 1950)

The long-term outcome of the lobotomy is uncertain although several follow-up studies were pursued. Tooth and Newton obtained follow-up data on 9,284 of 10,365 patients in England and Wales who had single leukotomy operations between 1942 and 1954. They reported that 41% were recovered or greatly improved, 28% were minimally improved, 25% showed no change, 2% were worse, and 4% died wholly or in part because of the operation. Improvement was more marked in the 2,139 patients with affective illness; 63% were reported as recovered or greatly improved, 19% were minimally improved, 10% showed no change, 2% were worse, and 6% were dead. Of the 6,146 schizophrenic patients, 30% were recovered or greatly improved, 19% were minimally improved, 10% showed no change, 2% were worse, and 3% were dead. From

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these results it can be easily concluded that patients with affective disorders improved more than patients with schizophrenia as was pointed out by Kolb in his review of psychosurgery. Kolb was the first to suggest that those who had undergone psychosurgery did not have a much better long-term outcome than the natural course of the illness. (Swayze, 1995)

Many of the subjects reviewed who were worse after the procedure were found to have loss of social control. This syndrome was characterized by inappropriate and sometimes obscene speech and behavior. (Ballantine, 1989)

Many more studies such as Robin and Macdonald were conducted yielding contradictory results. The control subjects in these studies were not well matched in age, diagnosis or severity of illness. Consequently, they failed to produce a satisfactory assessment of the outcome, and the efficacy of psychosurgery as performed between 1935-1954 remains shrouded in controversy. (Swayze, 1995)

One tragic result of lobotomy is a man referred to as Mr. M. In 1953, Henry M. underwent experimental brain surgery. Two holes were drilled in his head and his hippocampus was removed. When Henry recovered, it was clear that something had gone terribly wrong. He could talk, read, and write. But when asked where he was, or who the people were at his bedside, he did not know. Henry had lost the ability to make memories.

For the past 20 years, Mr. M. has been studied at MIT in Cambridge, Massachusetts. He has a short-term memory of about fifteen minutes but after that he must start over, remaining a prisoner of the immediate present. (Hilts, 1995)

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Mr. M’s case is not unique. After lobotomy many patients scored as they had previously on intelligence tests; however, they were often more forgetful. The patients could recall details of a problem and mistakes made while solving it, but could not put them to use in the correction of further performances. Tissot et al viewed this as a failure to assimilate new material and integrate it with experience. (Adams, 1989)

In conclusion, pychosurgery, as practiced between 1935 and 1960, was a brutal procedure born of ignorance, arrogance, and expediancy. The frontal lobotomy was nothing less than an attempt to "operate" on the minds of the mentally ill. More than 30,000 psychosurgical procedures were performed in the United States (Noonan, 1989) during those years, and in every case the basic rules of surgery were violated because no surgeon who performed the operations knew enough about what he was doing to justify his action. The operations were mutilating stabs in the dark; most of the time the surgeons couldn’t even see the brain tissue they were cutting because they operated through such small openings in the skull. (Freeman, 1950) But that didn’t matter, because it wasn’t the brain they were really operating on anyway. They were operating on the thinking process itself, and on the personality. Because the scientific community was too eager to accept the procedure without any long-term studies or research much irreversible harm was done.

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