A lobotomy was a surgical procedure that severed nerve connections in the front of the brain, and it was performed in two main ways depending on the era. The earliest version required drilling holes in the skull, while the later, more widely known version involved inserting a thin metal instrument through the eye socket. Both methods targeted the white matter fibers connecting the prefrontal cortex to the rest of the brain, with the goal of disrupting emotional and behavioral circuits in patients with severe psychiatric conditions.
The Original Moniz Method
The first lobotomies were developed in the mid-1930s by Portuguese neurologist António Egas Moniz, who called the procedure a “prefrontal leucotomy.” Working with surgeon Almeida Lima, Moniz designed a specialized instrument called a leucotome: a needle-like device with a retractable wire loop at its tip. A surgeon would drill two small holes, called burr holes, into the skull on either side of the forehead. The leucotome was then inserted through these openings and guided into the posterior portion of the frontal lobe. Once in position, the wire loop was extended and rotated, physically tearing through the white matter fibers that connected the prefrontal cortex to deeper brain structures.
In his earliest attempts, before the leucotome was developed, Moniz used a cruder approach: injecting pure alcohol directly into the frontal lobe tissue to destroy it. This was quickly abandoned in favor of the leucotome, which allowed slightly more control over where the damage occurred. Moniz received the Nobel Prize in Physiology or Medicine in 1949 for this work, a decision that remains controversial.
The Transorbital “Ice Pick” Procedure
American neurologist Walter Freeman dramatically simplified the procedure in the late 1940s by eliminating the need for an operating room entirely. His transorbital lobotomy used an instrument called an orbitoclast, essentially a modified ice pick. The patient was rendered unconscious, often through electroconvulsive shock rather than conventional anesthesia. Freeman would then lift the patient’s eyelid, position the pointed tip of the orbitoclast above the eyeball, and place it against the thin bone at the back of the eye socket.
A small mallet was used to tap the orbitoclast through that thin layer of bone, which separates the eye sockets from the frontal lobes. Once the instrument pierced through into brain tissue, Freeman would sweep it back and forth in several directions to sever the nerve connections running to and from the prefrontal cortex. The procedure was then repeated on the other side. The entire process took less than 10 minutes and left no visible surgical scars, only two black eyes that faded within days.
The speed and simplicity of this approach was precisely what made it so widely adopted, and so dangerous. Freeman performed the procedure in his office, in state hospitals, and even from his personal van as he traveled the country. No neurosurgical training was required, and the lack of precision meant the extent of brain damage varied enormously from patient to patient.
What the Procedure Actually Destroyed
The brain’s prefrontal cortex doesn’t work in isolation. It communicates with deeper structures through bundles of white matter, the long nerve fibers that carry signals between regions. A lobotomy severed many of these pathways indiscriminately. Key connections that were damaged included fibers running between the prefrontal cortex and the thalamus (a relay station that filters sensory and emotional information), the amygdala (which processes fear and emotional memory), and the anterior cingulate cortex (involved in decision-making and emotional regulation).
By cutting these connections, the procedure disrupted the brain’s ability to integrate emotion with thought and planning. This is why lobotomized patients often appeared calmer or less agitated. But the same disconnection also flattened personality, dulled motivation, and impaired judgment. The procedure didn’t treat the underlying condition so much as it blunted the brain’s capacity to express it.
What Happened to Patients Afterward
A long-term follow-up study of lobotomy patients found that 91% developed what researchers classified as a “personality defect,” a broad term covering emotional blunting, loss of initiative, impaired social behavior, and reduced ability to plan or think abstractly. About 12% developed epilepsy as a direct complication. Some patients were unable to care for themselves for the rest of their lives. Others regained enough function to live independently but described feeling fundamentally different, as though something essential about who they were had been removed.
The severity of these outcomes depended largely on how much tissue was destroyed, which varied because the procedure was performed essentially blind. Surgeons had no imaging to guide them. They relied on anatomical landmarks and physical feel, meaning two patients undergoing the same procedure could end up with very different amounts of brain damage.
Who Received Lobotomies
During the 1940s and 1950s, lobotomies were performed on patients with a wide range of psychiatric diagnoses, including schizophrenia, severe depression, anxiety disorders, and obsessive-compulsive disorder. In practice, the procedure was often used on patients who were considered difficult to manage in overcrowded state psychiatric institutions. Women and minorities were disproportionately represented. An estimated 40,000 to 50,000 lobotomies were performed in the United States alone before the procedure fell out of favor in the mid-1950s, largely because the first effective psychiatric medications became available.
How Modern Procedures Differ
Lobotomy as Freeman and Moniz practiced it no longer exists. However, a small number of highly targeted brain surgeries are still performed for psychiatric conditions that have resisted every other treatment. These modern procedures, including cingulotomy and capsulotomy, use precise imaging and stereotactic guidance to create tiny, controlled lesions in specific brain pathways. The target areas are millimeters wide rather than the broad swaths of tissue destroyed by a lobotomy.
These surgeries are reserved for patients with severe, treatment-resistant obsessive-compulsive disorder or depression who have failed years of medication and therapy. The outcomes are significantly better than historical lobotomies, with meaningful improvement in a subset of patients and far fewer personality changes. The difference comes down to precision: modern neurosurgeons can see exactly where they’re operating and limit damage to the smallest possible area, something that was impossible with an ice pick and a mallet.