Psychosurgery of the Frontal Lobes
During World War I, soldiers with prefrontal lobe damage retained normal motor abilities, language skills, and sense perception, but often became blunted. They lost motivation and had difficulty making decisions. Similar observations were made of subjects of early psychosurgery. Between the 1930s and 1970s, more than 100,000 people underwent frontal lobotomy—surgical lesions to “cure” the “mentally ill.” A common type was performed in the prefrontal areas (near or in the OFC). Lobotomy patients became passive and easily managed by clinicians. However, they experienced loss of initiative and motivation, they became infantile and socially maladjusted, and their personalities changed permanently. The treatment is no longer deemed capable of restoring normal function by the American Medical Association. With the invention in 1950 of the first antipsychotic drug, chlorpromazine, and others that followed, psychosurgery rapidly decreased in popularity.
The idea that mental illness is a brain disorder has roots in ancient cultures that practiced trepanation (boring holes into the skull) to release evil spirits. This idea— that something is wrong with what’s inside the head of a mentally ill—was explored at the beginning of the twentieth century. Pioneering surgeons during the first half of the twentieth century assumed mental illness could be localized within the brain and cut out. Neurologists commonly believed the mind could be localized to the frontal lobes. However, nothing was found—neuroanatomically speaking—that could explain mental illness. The frontal lobes looked the same in mentally ill patients as they did in other people. This was a disappointment to the medical community, who pursued another line of research based on theoretical reflections from philosophy and early neurological research.
The medical community shifted to viewing the brain as a widely distributed associative machine. Philosophers such as David Hume and John Locke had argued that our flow of perceptions, ideas, thoughts, thinking, and mental life, on the whole, ought to be viewed as operating on mechanical principles of association. These philosophers ascribed little to the mind in terms of innate cognitive machinery.
Cajal viewed the physical basis of the mind as neural networks. He believed it was in the connections, chemistry, and organization of these that the workings of the mind could be found, including thoughts, experiences, and consciousness. Cajal translated philosophical associationism to a biological form based on associative paths between brain cells. The cognitive machinery of the mind was still seen as being based on principles of associations, but at the neural level, in the biology of the brain. Cajal’s biological associationism was explored, as physicians failed to go beyond gross functional localization to understand the biological machinery of the mind and possible defects relating thereto. Perhaps the right way to understand the mind was as a huge network of connections. In this view, a mental disorder would be a distributed connective disorder rather than an anatomically localized malfunction. Mental disease was now increasingly seen as a neural signaling imbalance.
If mental disease was a neural signaling imbalance, perhaps there was a way to rebalance things. Physicians tried this through various methods of shocking the brain. One method was to repeatedly administer electric jolts to the head until patients were rendered unconscious (one or more times). Another approach was to administer drugs that caused patients to experience horrific convulsions. Sometimes these convulsions were so strong that patients suffered bone fractures. Many died, particularly from electric shock therapy. The survivors became docile and manage- able—at least until the symptoms returned.
For many physicians, it became clear that shock therapy was no cure for mental disease. Shock therapy could, at best, provide a means to temporarily make patients more manageable. The associationist approach to mental disease seemed to many physicians to be right, but shock-treated patients’ symptoms returned (violent behavior, suicidal tendencies, obsessive behaviors, and so on). The physicians now sought more permanent solutions through psychosurgery. Instead of trying to create a neural balance through shock, physicians sought to do it by operating on the brain’s neural network in chosen areas. If mental disease was a neural imbalance and the mind resided in the frontal lobes, then perhaps one could prune connections within the frontal lobes to restore harmony. Egas Moniz (1874-1955) and Walter J. Freeman II (1895-1972) attempted this as they tragically pioneered frontal lobot- omy psychosurgery (El-Hai 2005).
In the late 1930s, Freeman declared substantial progress on the problem of mental illness, for which he had long sought a cure. Like many neurologists of his time, he saw mental illnesses as wholly neural. He spent countless hours in St. Elizabeth’s morgue (in Washington, DC), dissecting the brains of diseased mental patients, but found no abnormalities. In 1936, he stumbled on the work of Moniz, a Portuguese neurologist who, aided by a surgeon, operated on 20 mental patients with “obsessive fixed ideas.” Lacking adequate clinical credentials, Moniz ordered a procedure where the frontal lobes were lesioned. First, holes were drilled in the skull, and then a twisted wire was pushed through them and rotated inside the brain—the first frontal lobotomy. Researchers of mental disease had noticed that World War I soldiers with frontal lobe damage became docile. This was enough for Moniz to try his psychosurgery, and he claimed that five of the 20 patients in the group were “cured.”
Freeman’s encounter with Moniz’s work was pivotal. Freeman too had psychosurgery ideas. Freeman thought the thalamus was the emotional center of the brain and, inspired by Moniz, instructed an assistant to sever connections between it and the cortex in the frontal lobes of patients in mental wards at St. Elizabeth’s. First, holes were drilled in the skull, then scalpel cuts were made inside the frontal lobes, severing connections with the thalamus. Freeman, like Moniz, lacked adequate surgical credentials and relied on assistance. The operations rendered patients docile and “manageable” at first, but within months, symptoms reappeared.
Undeterred, Freeman proceeded to operate on the same patients one or two more times, but now they were given only local anesthesia and remained conscious. Freeman asked them questions during the operations to judge lesion effects, as his assistant surgeon made incisions. He would, for example, ask them to count backward, cite the names of presidents, sing a song, or recite the Lord’s Prayer. After multiple operations on 12 patients, he believed he had succeeded in curing mental illness. However, his idea of “curing” was not what we would equate with the meaning of the word. Freeman thought he was successful if his patients behaved in a nonagitated manner. The patients could therefore be discharged but typically became immobilized, childlike, cognitively impaired, and socially lost. The patients’ personalities had been radically altered.
The medical community was outraged but would not publicly criticize a medical doctor, and Freeman continued to convince the press of his success. The New York Times called his procedure a “surgery of the soul” and stated that it was history making. Freeman tried a new procedure that required no anesthesia and no operating room, and could be performed in a matter of minutes. It was a simple enough procedure that Freeman and others without surgical training could perform it. Freeman would lift the eyelid and jam an ice pick in through the upper part of the orb of the eye, on the side of the nose, with a hammer. He would wiggle it, withdraw it, and repeat the procedure on the other side. The whole thing took 5 min. This procedure is now known as a transorbital lobotomy—a form of frontal lobotomy. Freeman once did 25 such lobotomies in one day; another physician’s record was 75. In 1941, John F. Kennedy’s sister Rosemary received Freeman’s treatment. She never spoke coherently again, became incontinent, and spent long periods staring at walls.
In 1949, 5000 lobotomies were performed by Freeman and other physicians in the USA. By 1951, more than 20,000 had been performed. Lobotomies were now a standard procedure at the highest-ranked institutions, such as the Mayo Clinic and John Hopkins. Moniz was awarded the Nobel Prize in the same year for his work on frontal lobotomies. However, lobotomy evaluations in the mid-1950s revealed their failure. The American Medical Association was now of the position that Freeman’s lobotomies were as effective for curing mental disease as a “bullet to the brain.” Freeman continued his work after moving to California, where he expanded his practice to young adults and “difficult” children. He held that he could change their personalities for the better. Today we would classify some of his patients as having had attention deficit disorder. His last lobotomy was performed at the Berkeley General Hospital. The operation caused the patient to hemorrhage and die. This outcome was not the first of its kind. Frontal lobotomies are still performed to this day, albeit rarely and in a modified form.
Frontal Lobe Summary
The frontal lobes support our mental life as autonomously acting beings, capable of reasoning and making decisions based on logic, intuition, and emotion. Damage to them may result in a wide range of emotional, motivational, cognitive, and motor problems.
-  Further reading: El-Hai (2005), Dully and Fleming (2007), and Kessler (1996).