What is a lobotomy in psychopathology?

Introduction

The surgical procedure referred to as a lobotomy was initially proposed by physicians who believed that severe emotional and cognitive disturbances were caused by aberrant neural connections in the brain. It was hypothesized that destruction of this abnormal brain tissue could lead to clinical improvements for major psychiatric disturbances. The lobotomy was used, in part, because there were relatively few treatment alternatives to improve the condition of people who suffered from severe psychiatric conditions such as schizophrenia.

Gottlieb Burckhardt, in 1890, is credited as being one of the first surgeons to perform a psychosurgery procedure on mental patients to address symptoms such as agitation and hallucinations. Others, such as Ludvig Puusepp, in 1910, began to operate more specifically on the frontal lobes of the brain to help a group of patients suffering from manic-depression psychosis. The results of the surgeries were mixed, and Puusepp, like Burckhardt, concluded that the dangerous procedure was not worth the risks to patients.

Years later, in 1935, Portuguese physician and neurologist António Egas Moniz, working with surgeon Pedro Almeida Lima, revived the psychosurgery debate by performing a prefrontal leukotomy. This type of lobotomy involved drilling holes on each side of the top of the head, near the frontal areas, and then inserting a leukotome, a needle that contains a small circular wire that can be deployed. Once the leukotome was in position, the wire was released and the instrument was twisted to cut the white matter of the brain, which contains primarily nerve connections from the frontal lobes to other areas of the brain. In 1949, Egas Moniz became the first physician from Portugal to be awarded the Nobel Prize for Physiology or Medicine for his work on the development of the lobotomy.

Movement Away from Prefrontal Leukotomy

One year after Egas Moniz and Lima’s initial prefrontal leukotomy, American physician Walter Jackson Freeman II and surgeon James Watts began to modify the medical procedures. Freeman and Watts did away with the leukotome and started to drill holes on each side of the head, near the temples. A blunt spatula was then inserted and waved toward the top and back and toward the bottom of the head, effectively severing the neural connections between the frontal lobes and the thalamus. This procedure came to be known as the Freeman-Watts standard lobotomy. This procedure was believed to be more precise in its ability to selectively destroy connections between the frontal cortex and the thalamus and to produce better clinical results. However, Freeman still did not like the fact it was a time-consuming surgery that involved drilling into the cranium and required an operating room.

In 1946, Freeman began to popularize a new version of the lobotomy called the transorbital procedure. Although this procedure had its beginnings in Italy in the late 1930s, Freeman altered the way that brain tissue would be destroyed. Freeman’s procedure involved taking a sharp metal instrument (he first used an ice pick) and placing it under the patient’s eyelid. A mallet would then be used to tap the instrument until it broke through the thin bone behind the eye socket. The instrument was then inserted a couple of inches into the head and moved back and forth. Freeman perfected this procedure to the point that he could train another physician to complete it in ten minutes, without the use of a surgical room. This simple transorbital procedure made it possible for lobotomies to be performed on a far larger number of patients. Although Freeman himself performed about thirty-five hundred lobotomies during his career, it is believed that tens of thousands of lobotomies were performed worldwide.

Treatment Effectiveness

Of Egas Moniz’s first twenty patients, fourteen were reported to have recovered or to have substantially improved. The remaining six were believed to have shown some improvement in that they had had more severe symptoms (hallucinations and delusions) before the surgery. Egas Moniz was criticized because he followed his patients for only a few days after the surgery. One follow-up study that was conducted twelve years later revealed that the results were not as positive as initially reported.

Freeman reported that patients, with the exception of those who were suffering from chronic schizophrenia and a limited number of other types of psychosis, generally benefited from the procedure. Follow-up studies have found that it is difficult to determine who will benefit from a lobotomy and what kinds of detrimental effects the procedure will have on emotions and cognition. Also, proselytizers of the procedure overstated the positive outcomes. By the mid-1950s, the introduction of antipsychotic medication such as chlorpromazine (Thorazine) had begun to transform the lives of residential psychiatric patients to the point that lobotomies became seldom used.

Bibliography

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