The lobotomy was designed to cut tissue connecting the prefrontal cortex to the thalamus. Since transorbital lobotomies are not guided or visualized if any way, they’re basically cutting blind into brain tissue.
It should be obvious why a tiny slip could have drastically different outcomes for differing patients. They’re slicing the brain, and can’t see where they’re slicing.
Typically, an ice pick (or instrument very closely resembling one) was hammered just between your eye and nose until it pierced through the skull. Once past a certain point, the surgeon would sweep the pick across the prefrontal cortex region (the area almost directly behind your forehead) and essentially cut off all tissue connections with that part of your brain and the rest of it.
The prefrontal cortex is where it was decided that mental and psychiatric disorders presented. By severing that connection it allowed the patient to lose the ‘crazy’ part of their brain.
The procedure did have several successful outcomes in the beginning and was rapidly adapted as good science. Patients with severe disorders were immediately well behaved and civilized people again.
Mental hospitals began to perform the procedures in mass, often without patient or family consent and with little proper pre-surgical analysis. It resulted in many people becoming brain dead and losing significant brain function as not all brain disorders lie within the prefrontal cortex. Rather significant cognitive function does.
The practice of lobotomy was deeply divisive in the field of psychiatry. Many doctors regarded it as risky and ineffective and it was banned at many psychiatric hospitals, including the home hospital of Walter Freeman.
The "Ideal Result"
But more importantly, while modern psychosurgery can effectively treat some psychological disorders, lobotomies didn’t “cure” anybody. So were so many performed? The late medical historian Jack Pressman explained it best by saying (I’m paraphrasing here) that lobotomies transformed people into individuals who were physiologically and psychologically different than they had been before and that those changes were then interpreted as being a “true medical benefit”. Nobody was cured with a lobotomy. They just became psychologically different people and that that met treatment goals enough to be considered a win, or at least neutral.
The chief personality/psychological difference that was interpreted as a cure was manageability. So you would see reduced aggression, more compliability with nurses/doctors/family instructions, less outwardly extreme behaviors – all the things that challenged families and care providers. It’s really hard for us, decades later, to fully appreciate the challenges care providers faced before the development of psychopharmaceuticals. State hospitals were over capacity, psychiatrists were in short supply, and other than the shock therapies (insulin, electrical, and cardiazol), there wasn’t much available to “treat” mental illnesses. All doctors and families could do was to be reactionary and just manage symptoms. And lobotomies allowed them to do that better. Even at the time, many doctors knew that lobotomy wasn’t a rescue, it was more of a salvage. But in the absence of anything else, salvage appeared (to them) to be better than anything else they could do.
Until psychopharmaceuticals were developed. The entire psychiatric community rapidly jumped ship once an actual rescue was available, a rescue that was not permanent and didn’t involve brain damage. Lobotomies had been tapering off anyway as the scientific community made advances in neurophysiology.
First and foremost, an “ideal result” was a patient that could go home. That was the #1 goal for patients undergoing lobotomy – get them functioning well enough to be cared for by loved ones at home. So an ideal patient had reduced aggression, no longer self-injured, and no longer presented a risk for suicide. They showed less outward signs of psychosis and/or mood disruption. Some doctors, like Freeman, were convinced that the patient was cured and went right back to their normal lives. That was unusual. The ideal patient could go home, be cared for by loved ones, and be functional. They could dress and feed themselves, they could help out at home, or sometimes take low-functional jobs. Importantly, the ideal patient still had a personality. They weren’t who they were before, but they weren’t a zombie; they were still someone. And getting them home helped with the overcrowding seen at most public mental hospitals at the time.
Even if they could never be discharged, the ideal patient was calm and manageable in the mental hospital. They followed directions, no longer showed agitation, and no longer presented a risk to themselves, other patients, and care providers.
So the outcome was never a total cure, and many doctors knew that. The outcome was a change in who they were, and the change made them appear outwardly better and be more easily managed. And this salvage operation was in use because that’s really all they had in terms of permanence. Once a non-invasive, non-surgical option became available, lobotomy all but disappeared.