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More than one way to skin a cat

By Allison Xantha Miller | Issue #21

How did doctors perform lobotomies? Where did they cut, and with what? Elliot Valenstein describes several types of lobotomies in Great and Desperate Cures. (See our interview.) Here are some of the most significant procedures.

Prefrontal leucotomy, a.k.a. core operation (1935)
After experimenting with cadavers, the Portuguese neurologist Egas Moniz had his partner and former student Almeida Lima drill holes in the top of a patient’s skull and inject alcohol into the frontal lobe. Beginning with their eighth patient, Moniz used a specially made instrument called a leucotome, from the Greek leuco (white matter) and tome (knife). Lima poked it into the brain to the desired depth, then activated a retractable wire loop and twisted the instrument so that a "core" was cut. At first Moniz had two holes drilled into both sides of the top of the head. When the results were less than satisfactory, he gradually increased the number of holes to six on each side. The leucotome had an unfortunate tendency to break off in the patient’s brain, a problem that bedeviled later surgeons.

Open lobotomy (1937)
The surgeon drilled holes into the top of the skull as usual, but also shone a light inside and used a speculum to expose the brain, which he then cut with a scalpel. The advantage was that neurosurgeons could actually see what they were cutting and avoid major blood vessels, thereby decreasing the risk that the patient would bleed to death. Yet it was in many respects the same crude procedure as the core operation. In 1943, J.L. Poppen modified the technique by inserting a suction tube to remove more brain tissue.

Standard lobotomy (1939) [ pictured below]
Dissatisfied with the imprecision of the core operation and its frequent complications (the leucotome breaking off in the brain, for instance), Walter Freeman and James Watts designed a "precision operation" later known as the Freeman-Watts standard lobotomy. They drilled a hole on each side of the head and stuck an instrument in each hole to clear a path for a thin spatula. They then then pulled the spatula upward so that the blade was pushed downward inside the brain. The spatula was removed, the area rinsed, and the spatula reinserted but pushed downward this time so that the upper area of the brain was cut. Freeman and Watts found that a successful lobotomy usually produced "drowsiness and disorientation," writes Valenstein, so "whenever possible, they operated under local anesthesia, talking to the patient, asking questions, and getting the patient to perform tasks such as singing or subtracting sevens from one hundred. . . . If they observed no signs of drowsiness and disorientation, they often destroyed a larger area."

Transorbital lobotomy (1946)
Walter Freeman adapted transorbital lobotomy as a simpler operation. It required neither a neurosurgeon, an anesthesiologist, nor extensive postoperative care. It was thus perfectly suited for state hospitals, where resources were increasingly scarce. Freeman used electroshock to induce unconsciousness. Instead of drilling into the side of the skull, he got into the brain through the eye socket using a stylus modeled after an ice pick. Then, as he wrote to his son, he made "the lateral cut by swinging the thing from side to side." The whole procedure could be completed in ten minutes.

Above top: Transorbital lobotomy patient with two orbiclasts in place. Above bottom: Once the orbiclasts were removed, the patient’s blood was injected into her brain to destroy brain tissue in regions where the orbiclast couldn’t reach.

Prefrontal lobectomy (1948)
Some neurosurgeons took another tack and made lobotomy more complicated by removing a significant chunk of the frontal lobe. A team at the University of Minnesota believed that lobectomy offered a number of advantages: Because the surgeons actually opened the skull, they could clearly see the brain tissue and blood vessels. They also could be sure they were inflicting enough brain damage so as not to require a second lobotomy: "If the expected result does not follow," they wrote, "one is not in doubt about the extent of the operation."