Walter Freeman describes his technique

In July 1948 American psychosurgeon Walter Freeman visited the Burden Neurological Institute in Bristol, England, and delivered a lecture on transorbital lobotomy. The paper was published in The Lancet later that year. In this extract he describes his surgical technique.

"We have found that transorbital leucotomy* can be performed satisfactorily in the postconvulsive phase of electro-shock. Electro-shock appears to have a generally disrupting effect on cortical activity, temporarily abolishing the psychotic manifestations and bringing the patient into a brief period of increased adaptability. When leucotomy is also performed, the effects of the electro-shock seem to be at least protracted, and often permanent. A few operations under ordinary anaesthesia have been performed by others, however, and equivalent results are reported. Nevertheless, electro-shock requires so little preparation and is so familiar to the psychiatrist that it seems to be the method of choice.

To maintain the patient in a somewhat prolonged phase of coma, two convulsive doses of electricity are given, the second about one or two minutes after the first convulsion has subsided. After the second convulsion a towel is placed over the patient's nose and mouth to prevent contamination by saliva and nasal secretions. The upper eyelid of the patient is pinched between thumb and finger, bringing it away from the eyeball. The point of the transorbital leucotome is then introduced into the conjunctival sac and moved around against the roof of the orbit until the top of the vault is encountered. The leucotome is brought parallel with the bony ridge of the nose, and its base is tapped lightly with a hammer to drive it through the orbital plate. To aim the leucotome properly the shaft must press rather strongly on the eyeball, but no harm to the globe has been noted except for occasional subscleral haemorrhage.

The transorbital leucotome consists of a tool-steel shaft 12 cm. long and 4 mm. in diameter, tapering for the last 6 cm. to a rather fine point with a slight bevel. Its handle is 7 cm. long and 8 mm. in diameter and equipped with a cross-arm at the base. The shaft is graduated in centimetres, a double line being marked at 7 cm. which is the most frequently used point.

When the leucotome has reached the 4 cm. level, its handle is pushed laterally as far as the margins of the orbit will permit to sever the fibres in the lower portion of the thalamofrontal radiation. It is again returned to mid-position and gently driven to a depth of 7 cm. always in the plane of the bony ridge of the nose. At this depth it is possible, by swinging too far, to lacerate arteries in the depth of fissures on either the medial or the lateral surface of the frontal lobe; and, since the thalamofrontal radiation is a rather narrow band in the region, a movement of only 15-20 degrees laterally and medially is sufficient. When the sweeps of the instrument have been made, it is withdrawn, and moderate pressure is maintained over the eyelids for several minutes to prevent excessive bleeding into the orbit.

Unless the patient is still deeply unconscious, an additional electroconvulsive shock should be administered before the other side is operated on. Patients seem to tolerate multiple convulsions quite well. In view of the refractory period, it is usually necessary to increase the time of passage of the electric current by repeated tripping of the switch until the convulsive threshold is reached. No complications have been encountered in doing this. After the convulsion has subsided, the other side is operated on in the same way." (W Freeman, Transorbital leucotomy, The Lancet, 4 September 1948, 371-373)

Although Freeman had coined the term "lobotomy" some years previously, he (or perhaps the editors of The Lancet) reverted to Moniz's term leucotomy for a British audience.

Monkeys like Becky

The Catalan Culture in New York festival earlier this year included a showing of Joaquim Jordà and Núria Villazán's 1999 film "Monos como Becky" ("Monkeys like Becky"):

"One of the mainstays of the Barcelona School of the 60s, Joaquim Jordà later turned his talents to screenwriting before returning to direction in the 90s. Monkeys Like Becky shows his old subversive spirit still shines brightly. One of the oddest mixtures of reality and fiction recently seen, the film is based on the true story of the Nobel Prize winning Portuguese neurologist Egaz Moniz. In the early 30s, Moniz attended a conference in London in which an American biologist presented a docile, rather charming monkey named Becky; the biologist then showed a film in which Becky was shown to have been formerly a wild, savage beast. The transformation was said to be caused by an incision into the central lobe of the Becky's brain. It dawns on Moniz that such a procedure might prove effective with schizophrenics, and thus the practice of mental lobotomies was born. Using both staged sequences and documentary footage, Jordà and Villazán wryly capture the intersection of science, psychiatry and social control."

The All Movie Guide entry for "Monkeys like Becky" says that director Joaquim Jordà himself underwent a psychosurgical operation. Other reviews say the same about Jôao Maria Pinto, the actor who plays Egas Moniz and one review says that they both had lobotomies, so I don't know what to believe.

Physiologist John Farquar Fulton who, along with psychologist Carlyle Jacobsen, conducted the experiments on Becky claimed to have been the inspiration behind Egas Moniz' decision to operate on mental patients. Here he relates his account in the Alpha Omega Alpha lecture read at the Montreal Neurological Institute, 8 January 1948:

"The operation of frontal lobotomy was introduced as a result of a brief report made at the International Neurological Congress at London in 1935 by Carlyle Jacobsen and myself on behavioral changes which developed in two of our chimpanzees, Becky and Lucy, following bilateral ablation of the frontal association areas. Their story can be briefly told.
In the summer of 1933 we had word from Dr Perrin Long of Johns Hopkins that he wished to dispose of two tame chimpanzees which had been used for the common cold project. He said that they were both accustomed to human beings, having been brought up in the laboratory since their early infancy. The opportunity to use these animals for frontal lobe studies seemed ideal for they could be readily managed. One was a very affectionate animal (Becky) and the other a crotchety old maid who had resisted Dr Long's advances for some three years. Dr Carlyle Jacobsen, who at that time was developing training techniques for a study of the frontal lobe function, took the two animals for a period of intensive training which continued from October, 1933 to March, 1934. The chimpanzees proved ideal subjects, co-operating effectively in all of the training procedures which consited of the delayed-reaction test, problem boxes, and another, more involved, procedure known as the stick-and-platform problem that Dr Malmo has no doubt described to you.
Both animals were operated upon in March, 1934, within a few days of one another, one frontal area being removed in each instance (areas 9, 10, 11, and 12 in the Brodmann scheme). The animals were then tested for another trhee months but no sign of deficit or behavioral change could be detected. In June, the second frontal area was removed from each animal, again within a day or two of one another, and every effort was made to have the lesions both symmetrical and equivalent for each animal. Following this procedure there was no sign of reflex change in either animal and on superficial inspection their cage behaviour did not seem to have altered particularly. On closer scrutiny, however, it was evident that a profound change had occurred, for prior to the second operation both animals showed frustrational behaviour, i.e., when unrewarded after having made the wrong choice in the discrimination test or in the delayed re-action procedure, both animals had temper tantrums and, if unrewarded many times in succession, signs of experimental neurosis became apparent. Following the second operation the animals seemed devoid of emotional expression. If a wrong choice were made, the animal shrugged its shoulders and went on dooing something else - as Jacobsen said picturesquely: "It was as if the animal had joined the happiness cult of the Elder Micheaux and placed its burdens on the Lord." Animals with bilateral ablation also failed the double stick-and-platform test....
Following the paper in which the behavioral changes in our two chimpanzees were described at London in August of 1935, Dr Egaz Moniz of Lisbon arose and put the question that if frontal lobe removal prevents the development of experimental neuroses in animals and eliminates frustrational behaviour, why would it not be feasible to relieve anxiety states in man by surgical means? At the time I was a little startled by the suggestion for I had envisaged a bilateral lobectomy which, though possible, would be a very formidable undertaking in a human being. Dr Moniz, as you are well aware, had other ideas and within a year he had developed his leucotome, carried out leucotomies on some 50 cases and published a book on the subject."

Egas Moniz himself however downplayed the contribution of Becky and Lucy to the development of psychosurgery. In his 1956 account, "How I succeeded in performing the prefrontal leukotomy", he devotes only seven lines to the work of Fulton and Jacobsen in the midst of a wider discussion of experiments on animals and the results of damage to the frontal lobes in humans. There is no mention of the conference in London.

"Vegetables don't cry"

Psychiatrist Eileen Walkenstein describes a lobotomy she witnessed in 1949:

Yes, sadism in medicine and neurosurgery and psychiatry is, alas, still rearing its ugly head and destroying human heads in its wake.
My own introduction to modern neurosurgery occurred in my second or third year in edical school - occurred, literally, in one fell swoop, cutting its way into my own brain and leaving the scar even now, some twenty years later.
I refer to the transorbital lobotomy, otherwise known as the ice pick operation. Techniques of this wounding were perfected to such a degree that all that was required was an ice pick-like instrument - no sutures, no bandages - internal bleeding and destruction of nerve pathways and irrevocable death of brain cells with just a thrust of the ice pick... and all that's evident on the outside are two black eyes - that clear up in time - and memory loss - that doesn't clear up so well... and a state of docile vegetation - that goes on forever. With a flick of the wrist the animal gets changed into a plant - modern alchemy!
My medical school class was invited to see a demonstration of such a transorbital lobotomy, one of the several type of lobotomies. The neurosurgeon, on the staff of a university medical school, stood before the class strutting in a sedate, self-important manner. I remember how good looking and smooth he appeared, a typical Hollywood symbol of the handsome doctor whose patients go ga-ga over him... and how entirely devoid of character he was. He was meticulously groomed, hair perfectly in place, skin very white and smooth shaven - a perfect representative of White Anglo-Saxon America. He wore a suit and tie and looked as if he were addressing a businessmen's luncheon meeting of the Kiwanis Club. After some introductory remarks he opened the door and the nurse and orderly pushed a stretcher into the room. Walking in with them was an attractive young black man, eighteen years old, looking frightened and bewildered. The neurosurgeon paid no attention to him but continued discussing with us how the operation would be conducted, and he seemed proud of the fact that they didn't even need anesthesia for the operation - that knocking the patient out with "a couple of electric shock treatments would be adequate anesthetization". (I guess when you're contemplating slashing up the brain substance, a little cell damage more or less is not too relevant.)
The young black man in wrinkled hospital garb stood cowering in the corner in sharp contrast with the urbane, smooth, self-possessed, polished physician. Finally the doctor turned to the patient, mentioned his diagnosis... Schizophrenic Reaction...and that he was a recent hospital admission... and told him to get up on the stretcher. The young man backed up, his shoulders hunched like a scared cat being attacked by a growling bulldog, his eyes darting this way and that in a futile attempt to seek some way of escape from the inevitable. The nurse and orderly then held his arms, brought him to the stretcher, and somehow managed to get him to lie down on it, shackling his wrists and ankles. The doctor applied the electrodes to the young man's temples, the current was turned on, and the young man's body jerked convulsively for several seconds. The doctor said smoothly, as though nothing had just happened, that he thought he'd give another dose of electric current to be sure he's knocked out completely. Again the current was turned on, again the captured victim was convulsively responding with his entire body to the electricity searing through his brain cells.
(This patient - if he were not poor, not black, not welfare-experimental-animal material - what treatment would then have been meted out to him?... need one ask such an obvious question? What treatment for this young black man had he been in the doctor's own family, for instance? This is the criterion. If you treat me, no matter who I am, in any way different from the way you would treat your family members and colleagues and peers, then you don't deserve to be in a service profession - get out and get into business! In business you treat everyone with equal contempt, independent of their blood realtionship to you - business is business. So get out of the service and helping professions, you doctors, educators, priests, et al. who would dehumanize us - get into the material world - unadulteratedly corrupt - and practice your corruptions on my pocketbook but not of my flesh, my intellect, my spirit!)
I find it very difficult to get back and face that patient who has just had his second electroconvulsive assault. Since leaving him there I have just now busied myself with phone calls, checking my calendar, eating a homemade milk-and-honey popsicle, and just plain vacating for a while. The subsequent scene is so horrible not only in itself but in all its ramifications that I've been avoiding delving in and confronting it.
Well, back again - that patient was, after the second electric shock, completely limp and "anesthetized". (I have never, neither before nor since tha incident, heard of using electricity for anesthesia!) The surgeon then took an instrument from his pocket in a pointedly and overly nonchalant manner and showed the ice-pick-like tool to the class. He then lifted one eyelid of the patient's an stuck the pick up - he made a point of showing that he was having some trouble getting the pick through the skull and into the brain at the first try and he grimaced at the class and said something about the "thickness of the boy's skull". A few of the more obvious racists in the class gave him his anticipated reply by snickering - some of the students, already uncomfortable, had their discomfort increased at this remark. After the pick penetrated the skull, he flicked his wrist back and forth with the pick slashing into the brain substance, severing forever, in an instant, those connections that nature had labored to achieve over millions of years. The Brain-Killer, named Neurosurgeon, repeated the ceremony via the patient's other eye socket.
I was not the only one who gasped at the outrage I had just witnessed. One girl, Dottie, her head probably full of the sterile operative techniques with sterilization of instruments we'd been taught to observe prior to and during the operation, raised her hand and asked about using an unsterilized instrument, to which the surgeon retorted with a pretty-boy smile: "Well, I didn't wipe it on my bootstrap."
Who was there to raise the bigger question - by what right had this surgeon, knowing almsot nothing about the patient except that he was black, eighteen, on welfare, and a new hospital admission, butchered this young man's brain for the education of a class of young doctors-to-be. Who were all those responsible for all the steps required to bring that patient's brain in contact with that butcher's ice pick?
The show was over - the showman strutted in front of the room, titillated at his own performance - at the suave, nonchalant way he imposed a gruesome spectacle on a class of horrified doctors-to-be.
The young man, never to be whole again, lying stretchered out before us, was wheeled out of the room, out of most of our lives. He will always be a part of mine - seared forever in my brain, in my guts.
May, as Goethe promised, the pain be halved now that I've shared it with you...may the load of it be lighter for me. It will never be lighter for that young man - he is beyond weights and measures - beyond the pain of butcheries - vegetables don't cry.

"Vegetables don't cry" was published in Blue jolts (true stories from the cuckoo's nest), edited by Charles Steir, New Republic Books, Washington DC, 1978.

The New York Times on DBS

Vera Hassner Sharav of the Alliance for Human Research Protection criticises a recent New York Times Magazine article on Deep Brain Stimulation:

"The surgical implant has been tested in 12 severely depressed patients in an uncontrolled trial —with no placebo comparator. This is the sole basis for the claim made that this treatment works in 8 out of 12 treatment resistant patients. In the “success” case example of the article, Deanna Benjamin, a 41 year old former nurse who underwent the experimental surgical implantation, she continues to take a combination of powerful drugs—the antidepressant, Effexor and antipsychotic, Seroquel...

As has been documented by science writer, Robert Whitaker, no matter how radical or unsubstantiated the claims, whenever psychiatry has launched a new treatment—such as, lobotomy, insulin coma, electro-shock, new generation antidepressants (SSRIs), second generation neuroleptics (‘atypical antipsychotics’)—the uncritical press, most especially The New York Times—enthusiastically endorsed every one of them. Indeed, the Times has a long record of allowing its pages to be used by medically licensed salesmen who, in true snake oil sales tradition, were in the business of selling hope rather than scientifically proven safe and effective treatments."

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