1Department of Psychology, Louisiana State
University, Baton Rouge, LA, 2Department of Mass Communication,
University of North Carolina at Asheville, NC
The first scientific report of lobotomy applied as a psychosurgical treatment for sever mental disorders was written by the Portuguese neurologist Egas Moniz in 1936. This study was published less than a year after the first lobotomy had been performed with a human subject, and stimulated experimentation in psychosurgery around the world (Diering & Bell, 1991). A modified version of the Moniz procedure called a 'prefrontal lobotomy' was quickly introduced to the United States by a neurologist named Walter Freeman, and his associate, neurosurgeon James Watts. Although the exact number of lobotomies performed in the United States is not known, two surveys indicated that the number of lobotomy operations increased dramatically in the years immediately following its introduction, and the rate of surgeries per year did not decline until the 1950s. (Limburg, 1951; Kramer, 1954). Historical reviews have outlined the prominent social influences which contributed to the rise and subsequent decline of lobotomy (e.g., Valenstein, 1986; Swaze, 1995), although no source of which we are aware has operationalized or tested the influence of these factors.
It has been proposed that biased popular press coverage was one factor which stimulated interest in lobotomy, thus contributing to its widespread adoption. Valenstein (1986), for example indicated, 'it was … generally known that many patients were referred … as a result of all the publicity' (p. 160). In addition, there are some specific examples of anecdotal reports that popular press articles prompted persons in the general public to consider lobotomy as a treatment option for themselves or loved ones. One man wrote a story about seeking treatment with lobotomy after his wife had read about the procedure in the popular press (Dannecker, 1942). Crossley (1993) cited an example of one family who wrote to the medical Superintendent of the North Wales Hospital:
At the same time that lobotomy was being promoted in the popular press, the procedure was being severely criticized by some members of the medical establishment. During a scientific discussion on lobotomy published in the Journal of Nervous and Mental Disease in 1938, A. A. Brill attacked the scientific validity of outcome results presented to date, stating, 'I feel that there is absolutely no reason why we should be in any way impressed by the seriousness of these presentations' (p. 233). In 1941, a panel discussion held at a meeting of the American Medical Association concluded that lobotomy should be considered an experimental procedure (W. Freeman et al., 1941). The 1941 American Medical Association panel also issued a warning about several negative effects on personality including apathy inappropriate social behavior, and lack of initiative (i.e., the frontal lobe syndrome). Therefore, negative information about lobotomy was available in the early years of press coverage.
The goal of this paper is to review the portrayal of lobotomy in magazine and newspaper articles from 1935 to 1960, in an effort to assess if biased popular press reporting may have contributed to the use of lobotomy. This goal was accomplished by analyzing the content of articles across time. Specifically it was hypothesized that (1) the content of early articles would be positive in tone, and become more negative in tone over time. (2) The number of benefits attributed to lobotomy would start out high in number, and decrease over time, and (3) the number of negative side effects reported would start out low in number and increase over time.
Popular press articles were selected from both magazine and newspaper sources between the years 1935 and 1960. The Readers Guide to Periodical Literature is the standard and accepted reference for popular press magazines, and was used in the present study to generate the sample of relevant magazine articles. The New York Times is known as the American "newspaper of record," and newspaper articles were selected from the New York Times Index.2 The final Sample consisted of 42 magazine articles and 34 newspaper articles.3
A quantitative analysis was conducted in order to objectively evaluate specific content elements relevant to the three hypotheses. Each article was randomly distributed to two different coders for quantitative review.4 Coders were asked to rate the overall tone of the article in its presentation of lobotomy on a five-point scale (1 = very negative; 2 = somewhat negative; 3 = neutral; 4 = somewhat positive; 5 = very positive).5 In cases where there was disagreement in rating, the mean of the coder's scores was entered into data analysis Coders where also asked to identify benefits and negative side effects of lobotomy mentioned in the article. The average number of benefits and negative side effects mentioned per article was entered into data analysis.
A qualitative content analysis is also presented in order to place the quantitative findings into an historical context. For the purpose of qualitative analysis, articles were sorted by year into historically meaningful time-blocks All articles were then carefully reread in time sequence by two of the current authors, with special attention given to identification of themes relevant to the present hypotheses (e.g., portrayal of benefits of lobotomy). Illustrative examples of theme content were then selected for inclusion in the narrative. Historical background information was also integrated where appropriate.
FINDINGS: QUANTITATIVE ANALYSIS
Correlational analyses with the full sample of articles6 were conducted using the Spearman rank order statistic due to the use of ordinal data in the analyses. In order to test the first hypothesis, article tone was correlated with year of publication. This analysis was statistically significant and in the expected direction (rs = - .47, p <. 001). Examination of figure 17 indicates that the earliest articles received positive ratings of tone and became rated as more negative over time. Hypothesis number two was tested by correlating the number of benefits listed per article with year of publication. This analysis was also statistically significant and in the expected direction (rs = -.41, p < .001), indicating that the number of benefits from lobotomy (e.g., the alleviation of psychological distress, the ability of the person to leave the hospital the ability for the person to function in society and be gainfully employed) mentioned per article started high in number, and decreased in number with time (see Fig. 2). A third analysis correlating the number of negative side effects mentioned per article with year of publication was conducted to test hypothesis three. This correlation was not statistically significant (rs = .12, p > .05), suggesting that there was not a consistent pattern for the reporting of negative side effects over time. However, as illustrated in Figure 3, there appears to be a trend in the data consistent with the present hypotheses, especially in the early years. Therefore a post-hoc analysis which included only articles published between 1935 and 1955 (n=68) was conducted correlating the number of negative side effects mentioned per article with year of publication. This correlation was statistically significant and in the expected direction (rs = .22, p < .05). This finding indicates that there was a significant increase in the reporting of negative side effects up until the year 1955. Perhaps this trend was diminished between the years 1955 and 1960 because lobotomy had already lost favor in mainstream medical practice by this time, thus eliminating the need to enumerate negative side effects of the procedure.
FINDINGS: QUALITATIVE ANALYSIS
The Early Years: 1935-1944
The first articles on lobotomy were brief accounts of medical papers or conference presentations, with longer, more detailed articles appearing in 1941. In addition, several popular press articles were prompted by the publication of Freeman and Watts' book Psychosurgery in 1942, which outlined the theory supporting the use of lobotomy. Early popular press publications were generally positive in tone, and there were specific examples of biased and misleading portrayals.
FIGURE 1 Correlation between article tone and year of publication.
One example of misrepresentation in the press was the description of the lobotomy operation itself. Prefrontal lobotomy was performed by burring holes into a patient's skull, and then using a knife to destroy fibers connecting the frontal lobe with the rest of the brain. This was a relatively crude and ‘blind’ procedure, during which the surgeon was largely unable to see the area of brain being destroyed. However, the press described steps in the operation as precise. For example an article which appeared in Time quoted Walter Freeman describing the manipulation of the leucotome millimeter by millimeter (Lobotomy, 1936). Kaempffert (1941), in a Saturday Evening Post article entitled "Turning the Mind Inside Out" wrote that 'the psychosurgeon… cuts at exactly the right angle in exactly the right plane' (p. 18). Later in the same article, Kaempffert created an analogy of the psychosurgeon to a watchmaker, all the while indicating to the audience that the operation is one of delicate precision.
Figure 2. Correlation between the number of benefits from lobotomy listed per article and year of publication.
Mounting Controversy: 1945-1954
There was a burgeoning of popular press articles written on lobotomy between the years 1945 and 1954. During this time period, there was a trend toward more balanced reporting. Articles began to express the need to examine evidence and weigh the pros and cons of the operation. Kurt Goldstein (1950) wrote an article for Scientific American in which he cautioned against the widespread use of lobotomy. Specifically, he asserted, 'it is of supreme importance to investigate whether the claims of the optimistic advocates of the operation correspond to the facts' (p. 45). After presenting some of his own data on the loss of abstract abilities, he conveyed a moderate position, stating, 'it is certainly an exaggeration to refer to all lobotomized patients as "human vegetables", as one author has done. Yet the results are serious enough to give us considerable concern' (p.47).
Another excellent example of balanced reporting was a feature article in the Saturday Evening Post entitled "The Operation Of Last Resort" (Wallace 1951). This article reviewed the development of the lobotomy technique, as well as the controversy. The author outlined the positions of advocates, critics and those who took a middle ground by encouraging the procedure in rare cases, but discouraging indiscriminate use. In addition, a detailed account of one personal life before and after a lobotomy was presented. This story illustrated for the audience the complex issues involved in weighing the various arguments. For example, the author asked, 'in trying to determine if an operation has been good or bad, what measuring stick or standard will be used to judge?’ (p.24). In the end, the audience is urged to consider the issues thoughtfully and asked, 'what would you have done?' (p. 95).
Another trend that emerged during this period was an increase in decisively negative press. In 1949 Newsweek published: "Lobotomy Disappointment," reporting on a scientific meeting, which, 'ended with severe criticism of the treatment' (p.51). The Chief criticisms listed in this article were that Lobotomy was being used indiscriminately, that there was not enough scientific evidence to support widespread use, and that the procedure did more to help caretakers than patients. Similar sentiments were outlined in several New York Times articles published that same year (e.g., L. Freeman, 1949a; Mental Aid Found, 1949; Plumb, 1949).
Articles voicing the opinions of critics in the scientific community usually focused on the potential for post-operative changes in intelligence and personality. Science Digest reported information from two scientific articles that ‘sounded a warning’ about the negative effects of prefrontal lobotomy on intelligence measures (Surgery for Psychotics, 1947, p. 34). Popular press articles also featured research suggesting lobotomy resulted in problems with abstraction ability (Kaempffert, 1948) and planning ability (Planning ability impaired, 1947). A New York Times article discussed personality changes which accompanied lobotomy (personality Shift, 1947). Freeman and Watts themselves published a scientific article on personality changes after lobotomy, and this was also reported in the popular press (L. Freeman, 1949b).
Interestingly, during this time period there were far fewer attempts to write about personality changes as a benefit, and in fact, there was instead a relative increase in the sensationalizing of this negative side effect. For example, the article "Personality Shift" (1947), quoted a family who believed their loved one 'has lost her soul' as a result of lobotomy (p. 51). Gumpert (1948) quoted one doctor, 'the operation may produce a human vegetable', and this doctor also referred to lobotomy as 'rape of the soul' (p. 518). A very critical New York Times article was entitled "Lobotomy Banned in Soviet as Cruel" This article indicated that doctors in the Soviet Union concluded, the procedure is ‘contrary to the principles of humanity,' and, 'through lobotomy' an insane person is changed into an idiot' (Laurence, 1953, p. 13).
Despite the introduction of more balanced reporting in the popular press, the number of lobotomies performed continued to grow (Valenstein, 1986). There are several possible reasons for this inconsistency. First, just as the criticisms began to mount heavily against lobotomy, the procedure was given impetus by the scientific establishment in 1949 when Egas Moniz was awarded the Nobel Prize for medicine for developing the technique. The award was reported in two New York Times articles, one of which appeared on the front page. Given the prestige of the award, it is not surprising that Lobotomy was portrayed positively. For example, one article referred to lobotomy as 'revolutionary' (Zurich, Lisbon Brain Specialists, 1949, p. 1), and the other noted, 'the sensational operation justified itself. Hypochondriacs no longer thought they were going to die, would be suicides found life acceptable, sufferers from persecution complexes forgot the machinations of imaginary conspirators' (Explorers of the Brain, 1949, p. IV 8). There was no mention in either article of controversy, criticism, or potential risk.
In addition, lobotomy may have continued gaining acceptance because innovative uses and variations of the procedure were promoted in the popular press. Several articles featured stories about lobotomy being used to cure criminal behavior (e.g., Kill or Cure, 1946; Ruch, 1946; Crime Cure, 1947; Parole is Denied, 1952). Lobotomy was also reported as a treatment for pain (e.g., Body Pain is Ended, 1948; Laurence, 1951). Moreover, as criticisms of standard lobotomy mounted, successes using modified procedures were reported with new fervor. The most significant innovation was the 'transorbital lobotomy', which was introduced by Walter Freeman in 1945, and widely reported in the press by 1948 (e.g., 10 Minute Brain Operation, 1948; Pierced Brains, 1948). While the prefrontal lobotomy was performed using a knife placed through holes burred into the temporal regions of the patients' skull; the transorbital lobotomy used an ice pick like instrument hammered into the brain through the orbital plate above the eye socket. Transorbital lobotomy was introduced as a faster, safer method, which could be conducted on an outpatient basis. In several articles, Freeman cited the negative side effects of the prefrontal lobotomy to promote his new method, which he suggested did not have as many negative side effects (e.g., L Freeman, 1950; Looking Backward, 1953). In addition, Freeman promoted the transorbital lobotomy as an alternative procedure, which could be performed by psychiatrists as well as neurosurgeons. James Watts strongly disagreed with this latter claim by Freeman, and ended his association with Freeman as a result.
It was also during this time period that Freeman began advocating intervention early in the course of the disease, because he came to believe that lobotomy was not therapeutic if performed after significant mental deterioration had occurred. A Time article entitled "Mass Lobotomies" (1952) emphasized this point in the following quotation: 'Dr. Freeman, who once said, " I won't touch them unless they are faced with disability or suicide", now believes that "it is safer to operate than to wait" (pp. 86-87). Freeman also advocated using transorbital lobotomy on a larger scale and with more lenient patient selection criteria. For example, the New York Times reported that Freeman recommended relaxed criteria for lobotomy be used in V.A. hospitals (V.A. Urged to Widen, 1950).
Transorbital lobotomy also gained favor in institutional settings as a tool to settle difficult patients and to empty overcrowded state hospitals. An article published in Newsweek reported, the operation had made the mental patients… much easier to care for in the institutions' (Surgery for Insanity, 1952, p. 100). Another article began, ' a brain operation is so simple that 15 can be done in one and one half-hours may help to clear the "back" wards of our mental hospitals"' (Ice Pick Operation, 1950, p. 24). The New York Times reported an article under the headline "Ice Pick" surgery is tried in masse: West Virginia conducts tests of brain operation to bar impulses to misbehave' (1952, p. 61). The article described how within weeks 228 lobotomies were performed by Walter Freeman. In fact, Freeman was on a crusade, traveling across the country to hospitals to perform operations and teach his technique. It is because of Freeman's promotion of transorbital lobotomy, in part waged through the popular press, that Valenstein (1986) concluded, 'virtually all of the transorbital lobotomies in the United States can be traced to the influence of one man - Walter Freeman' (p.229).
The Decline 1955-1960
The introduction of Chlorpromazine in 1954 provided a non invasive alternative treatment for severe mental illness. Drug therapy became the new hope for a desperate public, and lobotomy, as well as other somatic therapies (e.g., insulin coma), rapidly lost favor. There were only a few popular press articles published on lobotomy during this period. Some articles contrasted lobotomy with newer brain surgery techniques (e.g., Deep in the Brain, 1955; Pfeiffer, 1955; New Lobotomy Used, 1958), and a few attacked the procedure (e.g., Neurologist Hits Psychosurgery, 1956; Williams, 1957). One New York Times article reported that research using a control group, a methodological consideration that had been absent in many previous investigations, found no superior effects of lobotomy (Lobotomy scored in schizophrenia, 1957).
The only feature-length article on lobotomy published during this period presented a retrospective, and recounted Walter Freeman's 'dramatic half million-mile journey… to check personally on the patients who had once been operated upon by himself and Dr. Watts' (Did their Minds Clear?, 1958, p.48). Not surprisingly the article reported that Freeman still advocated the procedure. While it is unlikely that this one article made a significant impact on public opinion in 1958, it is evidence that Freeman continued to be an avid promoter of lobotomy until the very end.
Both the quantitative and qualitative analyses support the conclusion that early popular press articles on lobotomy were positively biased. The quantitative analyses indicated that the average tone of articles remained positive until the 1950s, the number of benefits of lobotomy listed per article was highest in the early years, and the number of negative side effects listed per article started low in number and increased with time (at least until the mid-1950s). In addition, the qualitative analysis uncovered many instances of misrepresentation and sensationalized reporting in the early years. The portrayals of lobotomy remained positive despite the availability of opposing viewpoints in the medical community, which provided a basis for balanced coverage. Although early publications were biased with positive portrayals, the reporting styles became increasingly balanced, and eventually negatively balanced, through time. These findings are consistent with observations presented by Valenstein (1986), and lend further support to the theory that early uncritical press coverage may have been one factor in the rapid acceptance and wide spread use of lobotomy.
Of course this is not to suggest that popular press portrayals were the only, or even the primary, factor facilitating the use of lobotomy. It is more likely that there was a complex and interactive relationship of popular press portrayals with other social, personal, medical, and economic forces creating the environment in which the proliferation of lobotomy could take place (see Valenstein, 1986; Swaze, 1995 for reviews). Valenstein (1986) proposed that similar influences prompted biased portrayals of medical innovations in the contemporary press, such as new treatments for AIDS and Alzheimer's Disease (p. 292). Therefore, results of the present study may provide more than a curious historical review.
Indeed, perhaps a cautionary lesson can be learned
from the history of lobotomy. The hallmark of scientific discovery is objective
and controlled experimentation with replication that creates a dynamic
process evolving through time. However, as illustrated by the present study,
this process does not occur in a vacuum. For example, medical research
is propelled in part by public needs, and at times, public desperation.
However, as happened in the case of lobotomy, competition in the media
to break dramatic stories can combine with fame seeking by persons in the
medical community to create a symbiotic relationship which serves the media
and the physicians, but not necessarily the public interest. This is a
situation where human emotion undermines the foundation of the scientific
process leading to a rush to press without justification, and stimulating
public interest, without adequate information. It is true that with time
the full story of lobotomy was known, but by then it was already too late
for untold thousands of people who had undergone this irreversible procedure.
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