Snigdhaa Rajvanshi
Psychosurgery, however now a rare form of neurosurgical treatment, is associated with the treatment of psychosis or other mental disorders through the means of surgery. The history of neurosurgery includes various attempts at altering the patient’s mood and different understandings of consciousness. One such attempt came into the limelight in the 1940s when physician and scientist, Walter J Freeman popularized the procedure of Transorbital lobotomy. The following blog post is dedicated to the neurological understanding behind this procedure while also looking at the horrific implications of practicing a procedure that was not supported by the scientific community but popularized by the mainstream media as a revolutionary solution to all mental health problems.
Building upon Moniz’s leucotomy, Walter Freeman, a Yale graduate, and his partner James Watts performed their first “Icepick” lobotomy on
September 4th, 1936. The method
consisted of Freeman forcing an icepick-like instrument called an Orbitoclast
through the back of the eye socket and pierce through the thin bone that separates the prefrontal cortex from the Thalamus. The Orbitoclst would be rotated
bilaterally at different depths (4, 3, and 2cm), to “remove cores of white matter
tracts between prefrontal cortex and Thalamus” (Caruso & Sheehan, 2017).
While Freeman himself did not have knowledge of neuroanatomy, his partner James
Watts provided a neuroanatomical base to the procedure. According to Freeman, the
transorbital lobotomy was a success as it “divorces psychotic ideas from
accompanying emotional components (Allison & Allison, 1954). Many patients
reportedly exhibited less tension and agitation. Freeman particularly noted the
effect of lobotomy on paranoid schizophrenics. While they still continued to have
delusions, they no longer appeared to have “tremendous emotional concern about
it (Allison & Allison, 1954). The authors believed that frontal lobes are
concerned with foresight and insight while the emotional component is supplied
by the Thalamus. By severing the connections between the two, the functions foresight
and insight are obliterated and even upon recovery, they are never as they were
before, leading to a reduced ‘emotional tension’.
As known now, the prefrontal cortex generally responds to complex
sensory stimuli of behavioral relevance. Damage to this area of the brain
would lead to deficits in working memory, poor attention to detail, tendency to
perseverate, difficulty in formulating and perusing goals, a remarkable reduction
in verbal output and lack of spontaneous movement, severe blunting of emotional
responses, and lack of insight (patient usually denies that there is something
wrong with them). More extensive damage to this area can lead to abnormalities
in cortical motor areas, eye movements, ability to talk and patients could also
become incontinent. The individuals who underwent transorbital lobotomy experienced
all of these symptoms on a varying level. While some patients were rendered vegetative
post-procedure, others were left to be an empty shell of their previous selves.
Common postoperative complications also included transcranial hemorrhage,
epilepsy, alterations in affect and personality, brain abscess, dementia, and
death (Caruso & Sheehan, 2017). However, the feeling of apathy that came as
a result of this procedure was viewed by Freeman as a positive instead of a
downside of this method.
Freeman received a lot of backlash from the scientific community
for his use of unethical and unvalidated methods on patients. Even Watts himself
parted ways with Freeman as he deemed the procedure neurologically dangerous.
Freeman rejected various scientific norms to validate his method. He believed
that statistics was a poor medium to convey the changes in the patients following
the lobotomy. Instead, the empirical change of his patients into “placid,
quiet, uncomplaining individuals who showed little concern for their troubles”
was evidence enough for the validity of his methods (Allison & Allison,
1954). He was also reported to have a disregard towards common medical
practices and often failed to sterilize his hands or wear gloves before the procedure
(Day, 2008). As Freeman lost his credibility in the scientific community, his
methods took over the general public rapidly.
By the end of his lifetime, Freeman had performed over 3400
lobotomies. Public acceptance of his methods could be understood by the implication
of the quote printed in The Saturday
Evening Post promoting Freeman’s ideas by saying “a world that once seemed
the abode of misery, cruelty, and hate is now radiant with sunshine and kindness”
(Caruso & Sheehan, 2017). His methods were fast as they could be done in minutes,
did not require ‘bur holes or general anesthesia” (Caruso & Sheehan,
2017) and so easy, that according to Freeman, anyone with an icepick could do
them. Hundreds of patients (often without their fully informed consent), unaware
of the true repercussions of the procedure would visit Freeman for this psychosurgery.
Following his popularity, former American president John F. Kennedy appointed Freeman for his sister who was born with mild learning difficulties and some developmental delays. However, post-procedure, she was left in a near vegetative state and spent the rest of her life in various institutions (Day, 2008). The disapproval by the scientific community and the observed adverse effects of the method caught up with the public impression of Freeman. The same media that once idolized Freeman now served as the catalyst of his downfall. Various popular media performances included patients who were forcefully lobotomized and were depicted to have lost their original lively personality to an apathetic one. The most famous example of the same is Jack Nicholson’s performance in One Flew Over the Cuckoo’s Nest in 1975. Following the introduction of chlorpromazine, Freeman’s practice began to slow, ultimately ending in 1967.
While Freeman’s methods were extremely misguided, his attempts did pave way for the future of psychosurgery and neurological advancement. In 1949, William Scoville pioneered orbital undercutting separating abnormal cortex from normal white matter. Most importantly, Freeman’s technique highlighted the ethical concerns surrounding psychosurgery. In 1981, Gostin proposed ethical standards for psychosurgery including consideration of surgical methods as a last resort following other non-invasive therapeutic methods, insurance of fully informed patient consent by the physician, safety and efficacy of the method ensured by clinical research and the risk of personality change should not outweigh the benefits of the surgery itself (Caruso & Sheehan, 2017). Although Freeman’s transorbital lobotomy marks a dark period of neuroscience that stigmatized psychosurgery in the public eye, it also became a stepping stop for various neurological advancements and a possibility of ethical surgical methods for patients requiring psychiatric care.
References
Allison, H. W., & Allison, S. G. (1954). Personality changes
following transorbital lobotomy. The Journal of Abnormal and Social
Psychology, 49(2), 219–223. https://doi.org/10.1037/h0056490
Caruso, J. P., & Sheehan, J. P. (2017). Psychosurgery, ethics, and
media: a history of Walter Freeman and the lobotomy. Neurosurgical Focus,
43(3), E6. https://doi.org/10.3171/2017.6.focus17257
Day, E. (2008, January 13). He was bad, so they put an ice pick in his
brain... The Guardian; The Guardian. https://www.theguardian.com/science/2008/jan/13/neuroscience.medicalscience
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