What Does Lobotomized Mean? The History of Lobotomy in the U.S.

Literally, to be lobotomized is to have undergone a lobotomy: brain surgery that cut the white-matter connections between the prefrontal cortex and the thalamus^[2]. U.S. physicians performed roughly 60,000 of these operations between 1936 and 1956, many of them at psychiatric institutions^[2].

Most patients had psychosis, obsessive-compulsive disorder, or intractable pain^[6], and many would today fall under the definition of serious mental illness. For how common these conditions are among U.S. adults today, see the national mental health statistics.

In everyday slang, “lobotomized” describes someone who seems dazed, blank, or emotionally flat. The image traces back to the “post-leucotomy syndrome” clinicians described in many patients: apathy, emotional blunting, and disinhibition^[4]. The slang use is figurative and involves no surgery.

The Portuguese neurologist Egas Moniz introduced the operation late in 1935^[1]. His first report covered 20 patients: 35% had complete relief, 35% improved without full relief, and 30% did not improve^[2]. Moniz shared the 1949 Nobel Prize in Physiology or Medicine for the leucotomy^[4].

In 1936, neurologist Walter Freeman and neurosurgeon James Watts performed the first U.S. lobotomy at George Washington University on Alice Hood Hammatt, a woman diagnosed with agitated depression^[2]. The night before surgery she tried to withdraw her consent^[2].

About two months later, Freeman began calling the operation a “lobotomy” instead of a “leucotomy”^[2]. The new name stressed that the surgery targeted the frontal lobes and set their work apart from Moniz’s^[2]. In practice, “leucotomy” (or “leukotomy”) and “lobotomy” describe the same family of operations.

The transorbital “ice pick” lobotomy

Freeman later adapted a transorbital approach that reached the frontal lobes through the thin bone above the eye socket with an icepick-shaped instrument called an orbitoclast^[2]. It needed no drilled holes or general anesthesia, so Freeman, who was not a surgeon, could perform it in an office^[2].

Watts objected to the method and to Freeman’s lack of sterile technique, and the partnership ended^[2]. By 1948 Freeman was demonstrating the transorbital operation at a Veterans Administration hospital in Tuskegee, Alabama, over objections from VA neurosurgical consultants^[2].

No national registry tracked lobotomies, so every total is an estimate. The best contemporary count comes from a National Institute of Mental Health survey: about 10,000 people in the United States had undergone lobotomy or a related frontal-lobe operation by the end of 1949^[1]. The number of operations had risen every year for the five years before that^[1].

Counts climbed quickly: a 1951 review counted more than 2,000 U.S. lobotomies by March 1947, about 5,000 by June 1948, and more than 10,000 by October 1949^[7].

Later historians put the U.S. total at approximately 60,000 between 1936 and 1956, some performed in makeshift operating rooms outside hospitals^[2]. Another review describes “tens of thousands” of transorbital procedures across America and parts of Europe over nearly two decades^[4]. The majority of prefrontal leucotomies worldwide were performed in the United States^[8].

Freeman personally performed more than 3,000 prefrontal and transorbital lobotomies^[2]. In 1957 he published a follow-up of 3,000 of his patients spanning 1936 to 1956^[9].

Who was lobotomized

Patients were mostly people with psychosis, obsessive-compulsive disorder, or intractable pain, and the operation spread to the United Kingdom, Europe, Russia, Japan and China^[6]. Records from one California hospital show who bore the burden: Stockton State Hospital performed 245 lobotomies on 232 patients between 1947 and 1954, and 205 of them (84%) were on women^[2].

That imbalance existed even though Stockton had more male patients and more men were diagnosed with schizophrenia, then a primary indication^[2]. Chart reviews found that the need to “maintain order” on the ward was a common reason for recommending the operation^[2].

Results varied widely, and the surgeons who performed the operations reported most of them. In their first series of about 200 patients, published in 1942, Freeman and Watts reported that 63% improved, 23% showed no change, and 14% suffered severe postoperative deficits or died^[2].

Documented complications included brain hemorrhage, epilepsy, brain abscess, dementia, changes in personality and emotion, and death^[2]. Reviews of early techniques also list infection and seizures^[10].

A 1954 study of 538 transorbital lobotomy patients in Texas state hospitals found that 57% improved and 43% did not^[11]. Fifty-three percent left the hospital afterward, but only 31% were still out of the hospital when the study was written^[11].

Freeman’s own 1957 follow-up reported that 70% of patients with schizophrenia, 80% with affective disorders, and 90% with psychoneurotic disorders were living outside the hospital 5 to 10 years after prefrontal lobotomy^[9]. He also found the rate was twice as high among private patients as among state hospital patients^[9]. These were his own uncontrolled data.

Well-known cases

Rosemary Kennedy, sister of President John F. Kennedy, was lobotomized by Freeman and Watts^[2]. Afterward she was severely disabled and lived in an institution for the rest of her life^[2]. Rose Williams, sister of playwright Tennessee Williams, was lobotomized after a schizophrenia diagnosis and also spent her life institutionalized^[2].

Consent was not always obtained. Some institutionalized or incapacitated patients were operated on without informed consent, and prisoners may have been lobotomized to change behavior rather than to treat mental illness^[4].

No single fatality rate exists, because deaths were recorded differently from one hospital and case series to the next. In the Texas transorbital series, fatalities amounted to 2% of 538 patients^[11]. Freeman and Watts’s 1942 figure of 14% combined deaths with severe deficits and did not separate them^[2].

Deaths also occurred outside published series. One of Freeman’s transorbital patients hemorrhaged and died while Freeman posed for a photograph during the procedure^[2]. As late as 1977, a federal commission was still recommending a national system to collect data on every psychosurgical operation, which suggests no complete national count existed^[5].

Was a lobotomy painful?

Hammatt, the first U.S. patient, was sedated and given general anesthesia for her prefrontal operation, and struggled as it was given^[2]. For the transorbital version, Freeman made patients unconscious with a portable electroshock machine in place of anesthesia^[2]. That required no anesthetist, surgeon, or proper sterile technique^[4].

Little direct evidence records what patients felt afterward. Hammatt developed temporary language difficulties, disorientation, and agitation six days after her operation^[2].

Medication, more than any single scandal, ended the lobotomy era^[4]. Chlorpromazine reached North American psychiatry in 1954 and was marketed in the United States as Thorazine^[3]. It offered an effective non-surgical treatment for severe aggression and psychosis, and psychosurgery fell out of favor^[4].

The effect showed up hospital by hospital. Stockton State Hospital ended its lobotomy program after chlorpromazine and reserpine arrived^[2]. Professional criticism of underreported adverse events, and of procedures done by non-neurosurgeons in unsuitable settings, added pressure^[4].

Public opinion turned as well. Tennessee Williams’s play Suddenly, Last Summer (1958), Sylvia Plath’s The Bell Jar (1963), and the 1975 film One Flew Over the Cuckoo’s Nest, which won 5 major Academy Awards, all depicted lobotomized patients as diminished or controlled^[2].

Freeman kept operating into the late 1960s: his last transorbital patient, Helen Mortensen, died 3 days after her operation in 1967^[2].

Abroad, the Soviet Union banned prefrontal leucotomy, and China stopped the operation for ideological reasons after the Soviet ban^[8]. In the United States, the controversy helped shape the National Research Act of 1974 and the Belmont Report, which set out principles of informed consent^[4].

The main federal review of the question stopped short of a ban. In 1977 the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research reviewed the evidence and did not recommend a total ban^[5]. It concluded that at least tentative evidence showed some forms of psychosurgery could have significant therapeutic value^[5].

The commission’s eight recommendations instead required specially approved institutional review boards, informed consent, and court approval for prisoners, involuntarily committed patients, and children^[5]. It also stated that psychosurgery should never be performed over a patient’s objection and that using it for institutional or social control is not appropriate^[5].

The Freeman-era lobotomy is no longer practiced in the United States^[2]. Modern psychiatric neurosurgery uses small, precisely targeted stereotactic lesions, and cingulotomy is the most commonly performed psychosurgical procedure in North America^[4]. Anterior capsulotomy is used for obsessive-compulsive disorder, and cingulotomy has been used for OCD and treatment-resistant depression^[4].

Deep brain stimulation, which modulates brain circuits without destroying tissue, has partly replaced lesioning^[2][4]. On February 10, 2009, the FDA approved a humanitarian device exemption for deep brain stimulation in adults with chronic, severe, treatment-resistant OCD who have not responded to at least three SSRIs^[12]. As of a 2019 review, OCD was the only psychiatric disorder for which deep brain stimulation had FDA approval, under that exemption^[4].