Between 1951 and 1960, over seven hundred brain operations called frontal lobotomy were carried out on psychiatric patients at the Richmond Hospital in Dublin. At the time many doctors considered it a crude procedure but now it seems unbelievably so. Two holes were drilled in the front of the head and brain tissue then severed or cored out with an instrument resembling a butter knife. The aim was to detach part or all of both frontal lobes from the rest of the brain, and so break the nerve ‘circuits’ that were believed responsible for mental illness. In Dublin the patients came from all walks of life. There was a veterinary surgeon with severe obsessive-compulsive disorder and a housewife with ‘psychotic’ depression. Frontal lobotomy was offered and accepted by a man found criminally insane after dashing his child against a fireplace. Remarkably, there were several priests of unknown diagnosis: their subsequent care in closed orders and poor records making further investigation virtually impossible.

Most patients came from St. Brendan’s Hospital, but also private nursing homes in Bray and north County Dublin. Usually two operations were done every Saturday morning, the neurosurgeon paid fifteen guineas a case by the Department of Health. Egas Moniz, the Portuguese neurologist who won the Nobel Prize in 1948 for pioneering frontal lobotomy died fifty years ago last December. His discovery was hailed by the Nobel Committee as the greatest breakthrough in mental healthcare in over half a century. Now the operation is considered an aberration, an example of what happens when doctors run amuck. Like Randle McMurphy in Kevin Kasey’s One Flew Over The Cuckoo’s Nest, most patients are believed to have been victims -antisocial but sound – who were lobotomised by medical apparatchiks as a means of social control. Moniz is now likened with Nazi war criminals and attempts have been made to strip him posthumously of his prize.

Frontal lobotomy was carried out on over twenty five thousand patients worldwide between 1948 and 1960, the majority in the U.S.A. Although most patients were poor and confined to state mental hospitals they came from the wealthy and professional classes too. Rose Kennedy, sister of JFK, is perhaps the best known, but there was also Tennessee William’s sister (another Rose) and the Hollywood actress Francis Farmer. It was viewed then as a final resort for an overwhelming problem. Before World War II, psychiatric patients occupied 55% of all hospital beds in America, most held in State institutions where the average patient to staff ratio was 200:1. In Europe the situation was only marginally better. Mental hospitals were frequently places of Dantesque horror; once entered there was virtually no hope of release. In the May 1946 issue of Life Magazine, Albert Meisel’s pictorial essay ‘Bedlam’ revealed another version of Belsen at home to a population already jaded by war crimes. Photographs showed naked and malnourished figures, some physically restrained, staring at the viewer from dank, dungeon-like wards. In addition, just as One Flew over the Cuckoo’s Nest summoned widespread criticism for lobotomy in 1975, so another film of a popular book, Mary Jane Ward’s “The Snake Pit” moved a population to demand improvements in mental healthcare in 1948.

Before lobotomy there was no effective drugs and Psychoanalysis, though of profound interest, was little more than a parlour specialty for the middle class, (even Freud himself acknowledged that it was applicable only to some of the neuroses). For the severe depressives, schizophrenics, syphilitics and psychopaths who crammed the public institutions, there was already a strange repertoire of accepted physical therapies. Patients might be deliberately put in insulin coma for weeks at a time, or convulsions induced – sometimes with such ferocity that joints were dislocated and limbs broken. In St. Brendan’s Hospital in Dublin it was common practice to subdue unruly patients by strangling them with a coiled up, damp towel until they fainted.When treatment inevitably failed staff turned to the padded cell, the straightjacket and handcuffs – a patient’s fate no different whether from the professional classes or a homeless victim of the depression.Enter Egas Moniz at sixty. An extraordinary savant of a man (see below), he had already had a previous discovery rejected by the Nobel committee and craved recognition. At an international congress in London, he heard Carlysle Jacobson of Yale talk of a female Chimpanzee who had parts of her frontal lobes removed. Normally aggressive and unco-operative, after surgery she had become placid and “almost cheerful” as if she had joined a “happiness cult”. Moniz returned to his native Lisbon and within a year had lobotomised twenty patients. The preparation for his first human case could not have been more casual: a brain was brought up from the morgue and, with his assistant looking over his shoulder, he practised his technique by inserting a writing pen through the cortex from various angles. His monograph on lobotomy received favourable reviews by a medical community that was receptive to any treatment that could make a difference. Respected hospitals reported early and dramatic successes and as interest in lobotomy grew, articles in the New York Times, Harpers and Life attracted the attention of patients and relatives.

By 1950, the operation was being performed in all European countries except Germany and forty-eight States in the USA. Even sceptical physicians working in mental hospitals described how patients previously tortured by suicidal obsessions became light hearted, even jocular and others, incarcerated for years, were eventually sent home.A measure of the respectability lobotomy gained is provided by the Catholic sponsored group of theologians, physicians and scientists at the Centre d’Etudes Laennec in France, who in 1954 concluded that “at present it would be possible to count in thousands the number of lobotomised people who owe to this operation the fact that they lead a normal socio-professional life”

In Dublin the lobotomies were performed by a neurosurgeon who is now 92 and a former President of the Royal College of Surgeons. All cases were selected by consultant psychiatrists and after surgery were returned to their care for careful follow-up. Sir Wyliie McKissock, probably the most eminent neurosurgeons in London carried out two thousand alone. A peripatetic lobotomist he drove on his weekends off around the nursing homes and mental institution on the Sussex coast. At each stop as many as nine or ten patients would be lined up for an operation that usually took only about ten minutes. McKissock had never met them beforehand, and driving back to London would be just as oblivious as to their outcomes.

In America it was not uncommon for a family to bring a disturbed relative, a depressed wife say or a paranoid teenager, to the office of whoever in the city was advertising their services as a lobotomist – a neurosurgeon possibly, but just as easily a neurologist or psychiatrist with no surgical training. The most cavalier, and by far the most notorious lobotomist was Professor Walter Freeman of Washington. A physician rather than a surgeon he developed the so-called ‘Ice-Pick lobotomy’, which entailed driving an ice pick through the roof of the eye socket with a mallet. The barbarity of the operation was masked by its impressive title –Trans- orbital leucotomy: it had the advantage, which would be appreciated by politicians today, that it could be carried out in an outpatient clinic. (In fact Freeman once performed the operation in a Motel Room).

With popularity came a lack of discrimination and lobotomy was eventually tried out on virtually all types of mental illness. Whilst it could be seen to improve some patients with severe obsessions, it made no impact on those with schizophrenia or personality disorder who made up over half of the hospital population. It also became evident that a major drawback of the operation was a dulling of personality – patients appeared happier but lacked zest and the character traits that gave them their individuality. As the numbers increased more serious complications were recorded, but for many psychiatrists taking risks even for small improvements was still better than banishing a patient to a state institution for the rest of his life. There were always critics, notably Loyal Davis the neurosurgeon father of Nancy Regan, but by the early 1960s the brain operation had become obsolete anyway. In 1955 a new antipsychotic drug Chlorpromazine, introduced by Smith Kline and French, was to revolutionise Psychiatry. Its remarkable pacifying effect in a wide range of psychotic conditions led to the first ever decline in the hospital population. The last lobotomy in Dublin was performed in 1960.In our present climate of Fitness to Practice hearings and medical regulation, it has been suggested that Moniz might more appropriately have faced the Nuremberg ‘Doctor’s trials (which also deliberated in 1948) rather than the Nobel Prize Committee. We wince at the idea of irreversible brain damage being used as a therapeutic option, especially when informed consent must have often been academic.

We choose to forget that many of the surgical treatments we now take for granted (e.g. heart transplants) were once untested and seemed impossibly desperate. And Moniz was by no means the first (or last) physician to be motivated primarily by personal aggrandizement. To confuse the issue further, a large prospective study from Veterans Administration hospitals in 1955 indicated that lobotomy did exhibit statistically significant improvements when compared to control populations. It also found that after discharge, patients made a better social adjustment in the community. For fifteen years or so after his death, Moniz’s reputation as a great medical pioneer waned. As chlorpromazine was accepted without question so lobotomy was denigrated with the publication of more and more reports of complications. An easy target in the culturally liberal 1970s, the operation was at the polar opposite to the ant-psychiatry doctrines of R.D. Laing, and was regularly portrayed in books and films as a means of mass control. (Though ironically, Soviet doctors were among the most vociferous critics of lobotomy and it was never adopted in Russia.) The unpalatable truth – that lobotomy though dreadful helped many people who would otherwise have been incarcerated in appalling institutions – will never be enough to salvage Moniz’s reputation. Nor will the scientific validation of a Nobel Prize. In contrast to the new reversible surgical treatments for depression that are being tried in some centres (using deeply placed brain electrodes), Moniz’s operation will always be seen as a crude assault on the human mind. Perhaps so, but it should be remembered that in the end it was a new drug, and not public revulsion or a political awakening that ended the era of frontal lobotomy.