Why doctors used to think drilling into people's skulls could treat mental illness

• Lobotomies used to be a horrific way that doctors tried to treat patients with mental illness.
• Doctors thought those with mental illness had abnormal neural connections so severing them may help.

Howard Dully got a lobotomy at age 12.

"By some miracle, it didn't turn me into a zombie, or crush my spirit, or kill me," he told NPR in 2005 as an adult. "But it did affect me deeply."

Lobotomies are one of the most criticized medical procedures in history.

For some — including Dully, who received his procedure from famed lobotomy advocate Walter Freeman — they did more harm than good.

"Freeman's operation was supposed to relieve suffering. In my case, it did just the opposite," Dully told NPR.

Different doctors performed lobotomies differently, but one of the primary approaches was to drill a hole in the side of the skull to access the brain. You can see an example of this in a video from the National Institutes of Health.

What is a lobotomy?

A lobotomy, aka leucotomy, is a surgical procedure that severs neural connections in the prefrontal cortex, the area of the brain that controls cognitive function.

In the mid-20th century, some scientists believed people with mental illnesses had abnormal neural connections that caused their symptoms. So interrupting nerve fibers that connected the prefrontal cortex to other parts of the brain was thought to be therapeutic.

Lobotomies were performed starting in the mid-1930s and throughout the '40s to treat everything from schizophrenia, depression, and anxiety to ulcerative colitis and intractable pain.

They were also a solution for overcrowded psychiatric institutions to treat and discharge patients to keep costs down.

But lobotomies often caused more problems — and sometimes resulted in epilepsy, personality defects, chronic headaches, seizures, permanent disability, or even death.

By the 1950s, lobotomies were on their way out, but not before doctors performed over 40,000 of them in the US alone.

The first lobotomy that started it all

António Egas Moniz introduced the modern lobotomy in Portugal in the mid-1930s. His first patient was a 63-year-old woman with depression, anxiety, paranoia, hallucinations, and insomnia.

Two months after the procedure, a different psychiatrist evaluated the woman and reported that "the patient's anxiety and restlessness had declined rapidly," researchers recounted in the Singapore Medical Journal.

Lobotomies, which the Nobel Committee at the time considered one of the most important discoveries ever made in psychiatric medicine, spread to Europe and North America, where scientists developed their own modifications.

As a result, lobotomies had a variety of techniques, and two primary methods among them were the open method and the transorbital method, said Mical Raz, professor of history at the University of Rochester and author of the book "The Lobotomy Letters: The Making of American Psychosurgery".

With the open method, the surgeon made an opening in the skull with drilling tools, like a surgical instrument with a cylindrical blade called a trephine, to reach the brain.

The transorbital method involved insertion instruments — like an orbitoclast for breaking through the thin layer of bone — through the patient's eye sockets.

What was wrong with lobotomies

It's impossible to know how many lobotomies, if any, were truly successful in treating patients' mental health conditions because of doctors' questionable definition for what "success" looked like.

"Psychiatric outcomes were — and often still are — judged by patients' reintegration and functioning in society," Raz said.

For example, Freeman, the American neurologist who introduced and popularized lobotomy in the US, partly based the success of his procedures on the patients' social adjustment after the operation rather than their psychiatric situation.

It didn't matter if a schizophrenic patient continued to have hallucinations and delusions. The lobotomy was considered a success as long as they were able to work or manage a household.

Moreover, the popular press was said to publish articles sensationalizing so-called successful procedures. Meanwhile, the scientific literature largely lacked critical analysis and objective documentation of patients' variable reactions to lobotomies.

A couple of experts also brought attention to how lobotomies only seemed to make it easier for caregivers to manage their patients, questioning its benefit as a medical treatment.

In addition, some patients were lobotomized without informed consent.

Why surgeons stopped performing lobotomies

It wasn't until the discovery of the first antipsychotic drug, chlorpromazine, that the use of lobotomies started to die down.

By 1954, about 2 million patients in the US had already received chlorpromazine, ushering in the era of medications as psychiatric treatment.

"Lobotomies were replaced by the advent of effective psychiatric drugs, which enabled behavioral control of difficult patients and made the drastic step of lobotomy seem unnecessary," Raz said.

Drugs were also often the safer, cheaper, and more effective option compared to lobotomy.

Although some lobotomies were still performed worldwide — albeit in much lower frequency — up until the 1970s, Raz said the 1950s was essentially the end of the lobotomy era.

The last known lobotomy in the US occurred in 1967, which resulted in the patient's death.

Today, lobotomies remain legal in the US, but regulations vary across states. Some states like California and Tennessee have heavy restrictions, but others like Colorado and Delaware have little to no regulations, researchers documented in a survey.