Abstract
In Poland, there were 176 cases of prefrontal leucotomy performed by Moniz’s method between 1947 and 1951. There were also several cases in which alternative psychosurgical techniques were used: prefrontal topectomy by Bilikiewicz and colleagues, and prefrontal topischemia by Ziemnowicz. This article analyses the following: publications by Choróbski, who performed lobotomy in Poland, and by Korzeniowski, who assessed its short-term results; a report by Bornsztajn, who reviewed general results of the method; and clinical research by Broszkiewicz and by Konieczyńska, who assessed Polish patients in terms of long-term results of lobotomy. Negative clinical evaluation of lobotomy led to its abandonment in Poland, a decision strengthened by a regulation that forbade lobotomy in the USSR and impacted Polish psychiatry.
Introduction
Lobotomy performed in Poland is rarely examined in a historical context. Even recent publications concerning new psychosurgical methods used in this country disregard the fact that prefrontal lobotomy was carried out here (Harat et al., 2004; see also Anon., 2004). Since the 1970s, there has been only one publication with a primary focus on lobotomy in Poland, describing the topic schematically within a limited space (Kujawski, 2012). The last thorough analysis of prefrontal lobotomy in Poland was undertaken by Konieczyńska (1976). This study was a follow-up analysis of a selected group of patients who had lobotomies in 1947–51. Later articles concerning major figures involved in lobotomy – Jerzy Choróbski and Lucjan Korzeniowski – rarely raise the issue of their use of lobotomy. For instance, two articles about Korzeniowski by Pużyński (1985, 1995) do not mention his involvement in lobotomy, although a complete list of Korzeniowski’s works in Pużyński (1985) includes his articles about leucotomy. Pużyński must have known about the surgical procedures since he supervised Konieczyńska’s doctoral dissertation. Similarly, a recent article about Choróbski barely mentions his involvement in lobotomy (Bidziński, 2008). The present article aims to partially fill the existing gap, although the subject definitely requires further investigations.
As noted by Ploumpidis, Tsiamis and Poulakou-Rebelakou (2015), lobotomy in different countries each had its own history, depending on local circumstances. Recent publications describe the local context of the procedure in certain countries (Kotowicz, 2008; Ögren & Sandlund, 2005; Ploumpidis et al., 2015; Salminem, 2011; Tranøy and Blomberg, 2005; Zalashik and Davidovitch, 2006). The history of lobotomy in Poland may bear superficial resemblance to its history in Norway, in terms of a sanitization of biographies of people involved in the procedure (Tranøy and Blomberg, 2005). However, there is a significant difference between the two countries since Polish physicians involved in lobotomy never tried to conceal the fact that the procedure was carried out in their country. The ‘sanitization’ of their biographies occurred in later, historical articles. The reasons why the information about lobotomy did not reach a wider audience were the relatively short period when the operations were performed, the low number of lobotomized patients and the lack of practitioners’ interest in the procedure. Polish physicians turned away from lobotomy also because of the political situation. Poland was influenced by the USSR which prohibited lobotomy. For several decades, Polish society was also isolated from Anglo-Saxon countries in which lobotomy was widely discussed.
Polish psychiatry in the nineteenth and twentieth centuries
It is frequently mentioned that the popularity of lobotomy in the USA was due to the lack of an alternative method of treatment rather than a strong belief that lobotomy was an ideal cure for mental diseases. Also, the cost of the operation was low, and it was relatively easy to perform due to the imprecise method of cutting the cerebral tissue blindly, without the use of imaging techniques. In addition, the conditions in mental institutions were horrific (Valenstein, 2010: 176–7). It is therefore important to analyse conditions of Polish psychiatry prior to the introduction of lobotomy.
Psychiatry in partitioned Polish lands
During the period when Polish territory was partitioned into three neighbouring states (1795–1918), the conditions in psychiatric wards differed between the regions. The situation was best in the Prussian region; there were 9000 beds in hospitals for the mentally ill, which was equivalent to 1 bed per 450 inhabitants. In the territories of Prussian partition (which were later regained by Poland in 1919–20), there were 26 institutions for the mentally ill before 1914. In Greater Poland, Silesia and Pomerania (then Prussian territories; now in Poland), the standards of medical care for the mentally ill were among the highest in Europe at that time (Bilikiewicz and Gallus, 1962: 161). Before World War I, good medical care was provided both for Germans and Poles living on this territory (p. 174). The territories annexed by Austria and Russia were less well served. Up to 1914, the Austrian region had only 11 institutions for the mentally ill, providing 1500 beds, i.e. 1 bed per 5500 inhabitants (p. 152). The methods of treatment were quite progressive (pp. 153–5). In 1902, territories annexed by Russia had 88 institutions for the mentally ill with 6051 beds, i.e. 1 bed per 1724 inhabitants, but most of these places were available in Warsaw (pp.127–8). In these territories, medical care was highly inadequate; it was at quite a low level and inconsistent with medical knowledge of that time (p. 127). In eastern regions annexed by Russia and Austria, the situation was catastrophic, and five provinces (Nowogródek, Polesie, Stanisławów, Tarnopol and Wołyń voivodeships – now territories mostly in Belarus and Ukraine) did not have any beds available (p. 129).
One of the greatest challenges to be faced when Poland regained its independence in 1918 was the problem of providing medical care for all inhabitants of the newly established country. Many institutions were destroyed or closed down, especially on territories that were reclaimed from Russian annexation (pp. 178–9). Most psychiatric institutions were located in the former Prussian territory. They were also the best equipped and provided the highest numbers of places available for patients. Therefore, mentally ill patients were constantly redistributed from eastern regions to western parts of the country. With great effort, Poland widely introduced new forms of psychiatric treatment and implemented uniform regulations. In 1937–39, after 20 years of independence, there were 17,000 places for people with mental illness in Polish institutions, which amounted to 1 bed per 2000 inhabitants. There were only 270 psychiatrists in Poland, which amounted to 1 psychiatrist for every 120 mentally ill patients (p. 181). These conditions were not sufficient to provide the best psychiatric treatment. Later, World War II proved to be even worse for Polish psychiatry.
World War II – extermination of the mentally ill by Nazis
World War II was a traumatic experience for Polish people, and affected mentally-ill patients (Nasierowski, 2012: 14). Nazis propagated the idea of ‘life unworthy of life’ (lebensunwertes Leben) and believed the mentally ill, mentally handicapped, psychopaths, and children who cause problems should be put to death (Bilikiewicz and Gallus, 1962: 245). The most widely known cases are the exterminations of mentally-ill patients from hospitals in Owsińska near Poznań, in ‘Dziekanka’ near Gniezno, in Kościań, in Warta and Kochanówka near Łódź, and in Gostynin. The patients were exterminated in a gas chamber in Fort VII in Poznań, in gas vans, and in other places (Wardzyńska, 2012). The extermination of the mentally ill by Nazis also took place in the eastern parts of Poland between 1941 and 1944 when Germany was at war with the USSR (Hohendorf, 2012). It is estimated that around 20,000 Polish mentally ill patients were murdered by German occupants during World War II (Nasierowski, 2015: 454).
Death rates were also high among medical staff, especially physicians. Due to the actions of German and Russian occupants, Poland lost approximately 8500 physicians and dentists, which was 48.6% of all those registered before World War II (p. 454). Out of 270 psychiatrists who worked in Poland before the war, 138 (51.1%) were lost: 72 were killed (26.7%), 13 committed suicide (4.8%), 27 (9.8%) died, and some disappeared in uncertain circumstances (Ilnicki, 2012: 189). The extermination was part of Nazi and Soviet plans to exterminate the Polish intelligentsia (Bilikiewicz and Gallus, 1962: 247; Ilnicki, 2012: 189; Nasierowski, 2015: 454).
The destruction of Poland’s cultural heritage was extensive and included its material and cultural values. During the war, Poland lost the majority of its technical, industrial, medical and scientific equipment, as well as written sources. There were 110 psychiatric institutions in 1939, but only around a dozen survived World War II. The number of places available for mentally-ill patients decreased from 17,000 just before the war to 7500 just after the war (Bilikiewicz and Gallus, 1962: 247).
In 1947, Poland had 24 million inhabitants with only 13,500 places in psychiatric institutions and 60 or 80 psychiatrists according to various sources (Bilikiewicz and Gallus, 1962: 248; Nasierowski, 2016: 586, quoting Gallus, 1947, and Korzeniowski, 1948). In this difficult situation, a great effort was needed to provide adequate medical care for Polish citizens. Most larger cities started to open institutions that offered consultations and medical care for the mentally ill. Many pre-war hospitals and institutions were rebuilt. New legal regulations helped to re-organize psychiatric treatment (p. 249). Special attention was also given to the education of new medical staff.
It seems that the atrocities of the war and the reorganizing spirit in a country that had recently reclaimed its independence made Polish medical staff especially sensitive to any treatment that might cause harm to mentally-ill patients. The effect of World War II in creating a negative opinion of lobotomy can be seen, for example, in the Israeli physician, Mark Dvorzarsky: he associated the procedure with the malpractice of Nazi physicians who conducted cruel experiments on concentration camp prisoners. Dvorzarsky stated that lobotomy had no scientific basis, so it was more of an experiment than a therapy, and posed a risk of evolving into a new form of punishment (Zalashik and Davidovitch, 2006: 101). War experiences might have had the same effect on Polish medical staff; the procedure was quickly abandoned in Poland. The specific historical context and the psychiatric assessment of lobotomy results played a significant role in the rejection of the procedure. A further factor was the introduction of regulations forbidding lobotomy in the USSR. Any theoretical scientific considerations probably played a secondary role.
The beginnings of lobotomy in Poland after World War II
Lobotomy in Poland was practised between 1947 and 1951 (Broszkiewicz, 1954, 1955; Konieczyńska, 1976). The first nine operations were carried out at the Department of Neurosurgery in Warsaw, where the first patient was lobotomized on 25 October 1947, and the second and the third patients on 17 November 1947. The remaining six operations were carried out in 1948, with the last on 8 November (Korzeniowski, 1948: 73–88). These first lobotomies were performed by Jerzy Choróbski (1902–86), a Polish surgeon who was regarded as the father of Polish neurosurgery. The results of the treatment were evaluated by the psychiatrist Lucjan Korzeniowski, who assessed the mental conditions of the patients. He had begun his career in psychiatry under the supervision of Jan Mazurkiewicz in the 1920s; after World War II, he started to cooperate with Choróbski (Korzeniowski, 1948: 44; Pużyński, 1985: 2).
All nine operations were performed by the Moniz method (Korzeniowski, 1948: 59; Korzeniowski and Choróbski, 1949: 532). It consisted in cutting the white matter of both frontal lobes. The lobes were treated separately through a symmetrical trepanation hole on each side of the skull. Each hole was located on a line perpendicular to the zygomatic arch − 6 cm above the arch; the line crossed the zygomatic arch 3 cm away from the external margin of the orbit. Having cut the dura matter, the operator put a blunt instrument 4–5 centimetres deep into the frontal lobe, then cut off the white matter in four quadrants by careful movements of the instrument in the directions of the calvaria and the base of skull. In order to avoid damage to blood vessels, it was advisable not to cross the boundary of the lesser wings of the sphenoid bone (Korzeniowski, 1948: 59; Korzeniowski and Choróbski, 1949: 532).
Moniz had introduced such operations, performed by means of a leucotome, and the name of the method was ‘leucotomy’, 1 a specific type of lobotomy, i.e. destroying the frontal lobes and their connections (Shorter, 1997/2005: 249). The leucotome was ‘a small apparatus’ designed by Moniz to perform leucotomy (Moniz, 1948/1974: 159). Freeman and Watts (1950: 31) described it thus: ‘The Moniz leucotome consists of a cannula, and a trocar armed with a cutting blade near its tip. The tip of the cannula is closed, but there is a slit over its distal end, through which, when a stilet is pressed, the cutting blade protrudes to a distance of 5 mm.’ It is not certain if Choróbski used this original leucotome designed by Moniz, since Korzeniowski (1948: 59) refers only to the use of a ‘blunt instrument’. However, the technique of making trepanation holes in specific locations on the skull and destroying the white matter by rotating an instrument inserted through these holes is characteristic for Moniz’s leucotomy.
Choróbski was a leading figure in Polish neurosurgery, and contributed significantly to the development of this medical speciality in Poland. Educated at the Faculty of Medicine of the Jagiellonian University in Krakow, he underwent much training abroad; in 1930 and 1933, he worked in Montreal, where he was supervised by Wilder Penfield (Bidziński, 2008: 168). This may be particularly important in connection with performing lobotomy, since Penfield described frontal gyrectomy (in Latin: gyrectomia frontalis) that resembled prefrontal topectomy (in Latin: topectomia praefrontalis) carried out by Pool (Ziemnowicz, 1951: 1474). In 1932 Choróbski worked in Chicago under the supervision of Loyal Davis (Bidziński, 2008: 168). He had a good command of German, French and English, and was well acquainted with achievements in international neurosurgery. He participated in many international conferences, and the international cooperation was also reinforced by frequent visits of specialists from abroad who came to Choróbski’s hospital in Poland to give lectures and perform operations (p. 169). This involvement in international neurosurgical society might well have encouraged him to carry out lobotomy, which was considered to be an innovative procedure in the 1940s. Choróbski also performed other operations that consisted of removing a part of the neocortex. For instance, he excised a part of the sensory cortex in a case of phantom pains in 1953, and a fragment of the motor cortex in a case of Parkinson’s disease in 1958. He also carried out hemispherectomy in an epileptic (pp. 170–1). In general, Choróbski was the first neurosurgeon in Poland to perform the majority of neurosurgeries that were popular at that time (p. 170), and lobotomy was no exception.
Choróbski’s student, Bidziński (2008: 171), mentioned that Choróbski performed leucotomy for the first time in 1942, but gave no additional details of the purpose and place of the operation. If this piece of information is true, the operation probably did not take place in Poland since Korzeniowski (1948), who described patients lobotomized by Choróbski, reported that the first leucotomies in Poland were performed between 1947 and 1948. The relatively late introduction of lobotomy in Poland may be attributed to difficult conditions during World War II, making it impossible to introduce new methods of treatment earlier. A similar reason for a late start to lobotomy operations was identified, for example, in Finland (Salminem, 2011: 116).
Having analysed results of leucotomy in nine patients (eight suffering from schizophrenia and one from epilepsy), Korzeniowski and Choróbski stated that five of them were able to leave the hospital and return to their families. Because the assessment was made only a short time after the leucotomy (3 months), they acknowledged that the improvement they observed in their patients could not be treated as a final diagnosis and a permanent state (Korzeniowski and Choróbski, 1949: 534). In general, they observed significant improvement in three cases, moderate improvement in two cases, no improvement in one case, deterioration in one case, death directly caused by the operation in one case, and death due to other causes in one case (p. 534).
Korzeniowski and Choróbski claimed that, after the operation, aggression disappeared in all six patients in which it had been present before the leucotomy. The researchers found this result especially important since they believed the aggression had been the basic symptom that had made it impossible for patients to live in society. Autism disappeared in four cases; in one case it diminished significantly. Hallucinations, which were present in five patients before leucotomy, were present only in three patients after the procedure. All five patients who suffered from delusions before the operations stopped experiencing them after leucotomy. All four patients who had suffered from dissociation were also relieved from this symptom. Attitude towards the family improved in four cases, all except one showing significant change. On the other hand, Korzeniowski and Choróbski observed side-effects of leucotomy in some patients, such as memory, attention and initiative disorders, sexual arousal, infections caused by bedsores, urinary incontinence, hemiplegia, and death due to a haemorrhage into the ventricles (p. 534). The authors emphasized that leucotomy primarily eliminated features that had made patients unable to function in society: autism, negativism, aggression and a hostile attitude towards one’s family (p. 533).
Korzeniowski (1948: 61) also stressed the necessity of re-educating patients after the operation, since they suffered from memory and attention disorders and deterioration of all intellectual functions. He indicated that, in order to recover, patients should return to the family home rather than stay in a mental institution (p. 61; Korzeniowski and Choróbski, 1949: 533). Korzeniowski believed that being within the family was a better environment for teaching a patient proper behaviour and social skills. Therefore, during the process of selecting patients for lobotomy, it was important to assess their families (Korzeniowski, 1948: 61).
Korzeniowski supported a general belief that leucotomy could give positive results in patients for whom other treatments were ineffective. Instead of being doomed to stay in hospitals for the mentally ill for the rest of their lives, some patients could return to their family homes (p. 58). In general, leucotomy was recommended in: schizophrenia, melancholia, delusions, obsessions, epilepsy, pain in metastasis and phantom pains (Korzeniowski, 1948: 58), and in anxiety in psychoses of the elderly people (Korzeniowski and Choróbski, 1949: 532).
Korzeniowski and Choróbski concluded that leucotomy constituted significant progress in treating mental illnesses. They believed that only white matter connections would have been cut if the procedure had been carried out with visual guidance, thereby limiting negative side effects. They suggested that visual guidance by means of imaging technologies could help the operator to cut the cerebral tissue more precisely. Korzeniowski and Choróbski claimed that results achieved through leucotomy should be used in research on the physiology and physiopathology of the brain. They also encouraged further research that would compare symptoms before and after leucotomy (Korzeniowski and Choróbski, 1949: 535).
Theoretical justifications for lobotomy
Korzeniowski’s explanations of lobotomy were inspired both by Moniz’s approach and Freeman’s ideas, but the exact mechanism of the operation is not easy to pinpoint. In his account of the nine patients lobotomized by Choróbski, Korzeniowski (1948) claimed that lobotomy removed emotional responses present before the operation. This explanation resembles the view of Freeman and Watts (1939: 535–6) that lobotomy is efficient because it reduces the intensity of the emotions invested in ideas. They believed that cerebral pathways between the frontal lobes and the thalamus regulated the emotional aspect of ideas, and therefore cutting off these pathways would bring about therapeutic results (Freeman and Watts, 1950: 547; Valenstein, 2010: 167–8, 171). Freeman used anatomical studies to support this view. Experiments on monkeys carried out by the neurosurgeon A. Earl Walker demonstrated that the prefrontal area is connected with the dorsomedial thalamus. Studies by the neuroanatomist C. Judson Herrick showed that cognition and emotions involve combined activity of the frontal lobes and the medial area of the thalamus. These results, which suggested that ideas become dynamically empowered by emotions, were used by Freeman as an explanation of and justification for lobotomy (Valenstein, 2010: 168).
However, Korzeniowski (1948: 50) stressed that the elimination of excessive emotionality and motor excitement is a palliative procedure and does not deal with the cause of an illness. Korzeniowski and Choróbski (1949: 531) were aware that leucotomy did not cure a disease but merely diminished its symptoms, and they also stressed that it was a treatment of last resort, acceptable only if all other methods had proved to be ineffective.
When discussing the circumstances of introducing lobotomy in Poland, Korzeniowski and Choróbski (p. 531) referred to an experiment on chimpanzees by Jacobsen. The extraction of the polar parts of the frontal lobes allegedly eliminated symptoms of excitement and irritation in the animals. Korzeniowski and Choróbski also referred to a case of a mentally-ill female patient in a mental hospital in Tworki, who attempted to commit a suicide; after shooting through her two frontal lobes, she underwent changes that were interpreted as a clinical improvement.
Korzeniowski (1948: 52) acknowledged that the frontal lobes were crucial for solving abstract issues and new or complex problems. He also quoted Kleist’s observations concerning lesions of the frontal lobes, gathered during examination of skull injuries during World War I. Kleist drew attention to aphasia, intellectual impairment and changes in personality, which he observed after frontal lobe lesions (Kleist (1937), quoted by Korzeniowski, 1948: 53–5). The frontal lobes were believed to perform a decisive role in controlling behaviour, rational planning and in inhibiting direct urges (Russell (1948), quoted by Korzeniowski, 1948: 52).
Korzeniowski knew that lobotomy destroyed connections between the frontal lobes and subcortical centres: the thalamus and hypothalamus (Korzeniowski, 1948: 45–9). He quoted Le Gros Clark and W.R. Russell, according to whom the frontal lobes were involved in controlling and processing emotional stimuli coming from the thalamus and the hypothalamus (pp. 50–2). Korzeniowski and Choróbski (1949: 531) believed that destroying the connections between the frontal lobes and subcortical regions might cut off the frontal lobes from an affective drive, and thus leucotomy would reduce psychomotoric agitation. On the basis of these observations, Korzeniowski concluded that leucotomy could be especially efficient when patients suffered from excessive emotional experiences. The procedure was believed to be ineffective in cases when patients were already emotionally dull, with reduced emotional responses (Korzeniowski, 1948: 54–5, 58). On the other hand, injury to the frontal lobes eliminated their inhibitory role on temporal-parietal lobes and basal nuclei. The uninhibited activity of the lower structures was responsible for more direct, lively and automatic behavioural responses that might lead to weakness of will, lying, making jokes, stealing and infidelity (Kleist (1937), quoted by Korzeniowski, 1948: 54–5).
The line of argument presented by Korzeniowski follows Freeman’s explanations of the mechanism of lobotomy. However, Korzeniowski and Choróbski also quoted Moniz’s views according to which leucotomy eliminated fixed and persistent connections, thereby eliminating mannerism and stereotypical behaviour (Korzeniowski and Choróbski, 1949: 531). Moniz believed that mental illnesses result from fixed neural pathways that generate abnormally stabilized thoughts. He tried to support his belief by research carried out by Ramón y Cajal, although the latter did not study the relation between brain states and mental states at all (Moniz, 1948/1974: 158–159; Valenstein, 2010: 97–8). In a similar fashion, Moniz tried to use Pavlov’s studies in order to support his new psychosurgical method, although he failed to indicate what exactly the link was between prefrontal leucotomy and Pavlovian theory. Moniz’s arguments were considered poorly constructed and unable to give a proper support for lobotomy (p. 80). Historical analysis makes it even more evident that there was no connection between Pavlov’s studies on conditioned reflexes and Moniz’s claim that the brain establishes new associations when pathologically fixed ones are allegedly eliminated. The lack of any theoretical connection is evident in the light of the prohibition of lobotomy in the USSR on the basis of the conflict between lobotomy and Pavlov’s theory (pp. 98–9).
Berrios stresses that lobotomy was based on the theoretical assumption that damage to a particular cerebral region would eliminate some undesired form of behaviour without releasing some other forms of behaviour that would be equally or even more undesirable. This assumption behind lobotomy was in strict opposition to the hierarchical models of the brain, which were propounded by John Hughlings Jackson, among others (Berrios, 1997: 77). Jackson’s theory inspired Jan Mazurkiewicz, one of the prominent Polish psychiatrists of the first half of the twentieth century. Although Mazurkiewicz’s theory could be used against lobotomy, the theory was criticized in Poland for ideological reasons from the late 1940s to the mid- 1950s. Political changes after World War II made Mazurkiewicz’s tenets unpopular among some Polish psychiatrists because they were incompatible with Pavlov’s ideas. An example can be found in a discussion of Mazurkiewicz’s views by Andrzej Jus. His political engagement during the time of Soviet control over Poland made him reject Mazurkiewicz’s psychiatry (Nasierowski, 2016: 593–8). Mazurkiewicz followed Jacksonian views on the hierarchical organization of the nervous system; the primary function of the cortex was to inhibit the activity of lower neural mechanisms (Jus, 1955: 318). Jus emphasized Mazurkiewicz’s belief that many mental illnesses developed when the frontal cortex lost its control of other cortical regions; when this happened, morbid symptoms developed, such as delirium and hallucinations. Yet, instead of using this argument against lobotomy, Jus rejected Mazurkiewicz’s theory; he claimed that this trend in Mazurkiewicz’s thought made it similar to the psychomorphologism advocated by the lobotomists Freeman and Watts (p. 319).
Another Polish psychiatrist – Ewa Broszkiewicz – who was politically engaged during Soviet control (Orwid and Bomba, 2000: 1032) – also indicated that prefrontal lobotomy was a procedure rooted in psychomorphologism, which was associated with mechanistic materialism. Psychomorphologism assumed that anatomical structure was the main determinant of mental life. Specific regions were responsible for specific mental functions, independently from environmental stimuli of various kinds and intensity. In psychomorphologism, mental illness was treated as an illness of the brain; in other words, psychomorphologism claimed that mental illness resulted from anatomical changes in cell structures (Broszkiewicz, 1955: 367–368).
In contrast to psychomorphologism, Pavlov believed in dynamic localization of neural processes. He thought that higher mental functions resulted from the activity of the entire brain: various cerebral structures were connected in many dynamic systems due to processes that constantly changed and cooperated (p. 368).
In general, Polish psychiatrists who discussed lobotomy indicated connections between Mazurkiewicz’s thoughts and some Western theories that were criticized in the USSR for ideological reasons. Simultaneously, lobotomy was also rejected by Soviet psychiatrists as based on a Western psychomorphologist approach to brain functions. Jus (1955: 320–1) indicated that, despite its physiological orientation, Mazurkiewicz’s theory was too speculative on many points to be accepted in the materialist psychiatry of the USSR. The fact that Mazurkiewicz followed Jackson’s theory – against lobotomy – does not seem to be a decisive factor for a negative approach towards lobotomy in Poland. The main reasons stemmed from the political atmosphere and clinical assessment of changes present in lobotomized patients.
An innovative Polish method: Ziemnowicz’s prefrontal topischemia
In 1950–1, a new method called prefrontal topischemia (in Latin: topischaemia praefrontalis) was introduced by Stanisław Ziemnowicz. He was a neurosurgeon acquainted with Choróbski, who supervised him in the Department of Neurosurgery in a Warsaw hospital between 1939 and 1940. When inventing the new method, Ziemnowicz was working independently in Gdańsk (Wroński and Jarmundowicz, 2009: 14). The procedure involved destroying the cortex by constant or temporal stopping of the blood supply to the Brodmann areas 9, 10 and sometimes 46. The method was used in cases of severe psychoses and pain in terminal stages of cancer (Ziemnowicz, 1951: 1475). It was believed to leave intact the cortico-thalamic, cortico-hypothalamic and cortico-cortical connections, and was said not to lead to undesired changes in a patient’s personality (p. 1475). In this respect, his method gave better results than lobotomy and leucotomy, since the latter often led to negative changes in personality.
Earlier, Bilikiewicz, Nowicki and Sedlaczek-Komorowski (1950) had described two cases after prefrontal topectomy was carried out by Nowicki. They stressed that topectomy was less radical than lobotomy, but their description of the results achieved was rather sceptical concerning changes in psychiatric profile. Ziemnowicz (1952: 883) claimed that his method was better than topectomy, since topischemia was a more subtle method that decreased the risk of early post-operative complications such as haemorrhage and haematoma and late post-operative complications such as epilepsy. In general, he described topischemia as more selective and subtle than other earlier techniques (Ziemnowicz, 1951: 1475; 1952: 883).
Ziemnowicz (1951: 1476) stressed that psychosurgical methods should be used only in severe incurable cases when all other methods of treatment proved to be ineffective. He recommended his method in cases of extreme pain in cancer when its cause was impossible to eliminate, when there was a risk of suicide because of pain, when pain could be eliminated only by means of narcotic drugs and when the main illness of the patient allowed him/her to survive more than four weeks after the operation (Ziemnowicz, 1952: 883). In his 1952 article, Ziemnowicz described five patients on whom he performed topischemia: four with cancer and one with a false diagnosis of a cancer. One patient with cancer underwent only a temporal ischaemia, so her cortex was not damaged and she was not fully released from her pain. In all other cases, the pain disappeared or at least did not cause any noticeable suffering. Three patients with cancer died shortly (1 day to 4 months) after the operation due to the main illness. One patient survived with a significant improvement since the diagnosis of cancer proved to be false – this patient managed to recover from a severe inflammation of the bladder (pp. 883–6). The later progress in a fifth patient with a cancer, who showed an improvement after the operation, is not known (p. 886).
Ziemnowicz stressed that topischemia did not eliminate pain as such, but eliminated or significantly diminished consciousness of pain (p. 886). Therefore, after topischemia, patients did not suffer from pain, although sometimes they were aware of it for very brief moments (p. 886). He also emphasized that topischemia did not cause other undesired changes in the mental life of the patients, in contrast to other psychosurgical procedures such as lobotomy and leucotomy (p. 888).
Ziemnowicz (1951: 1477) claimed that the positive results achieved by psychosurgery could be explained on the grounds of Pavlovian theory. He also suggested that Pavlov’s theory, together with Kleist’s observations, encouraged Moniz and Lima to start psychosurgical treatment of psychoses (p. 1472).
Topischemia was an innovative Polish procedure that could eliminate more severe psychosurgical operations in patients suffering from pain. The lack of interest in psychosurgery in Poland and the automatic acceptance of Soviet regulations against lobotomy led to the method being abandoned.
The political setting – Pavlovian sessions in the USSR
After World War II, Poland was under the influence of the USSR, and this political situation had a great impact on Polish psychiatry. After Stalin rose to power in the 1930s, scientific research in the USSR was highly controlled by politicians (Windholz, 1999: 333). In 1950, the USSR Academy of Sciences and the USSR Academy of Medical Sciences organized a Scientific Session in Moscow, held from 28 June to 4 July. During this meeting it was officially stated that Soviet psychiatry should follow Pavlov’s materialistic theory of the higher nervous system activity (p. 331). Furthermore, the session established that annual scientific conferences should be organized to discuss issues related to Pavlovian physiology and pathology of the highest nervous activity (p. 332). Consequently, in 1951 (11–15 October) there was a session on ‘Physiological Teachings of the Academician I.P. Pavlov on Psychiatry and Neuropathology’ in Moscow. Some of leading psychiatrists were accused of erring in their theoretical approaches that differed from Pavlovian teaching. The accused specialists acknowledged their alleged errors and promised to follow the only proper path of materialist psychiatry. Among the accused psychiatrists were Gilarovsky, Gurevich, Sereisky and Shmarian (p. 333–41).
Shmarian, Gurevich and Gilarovsky believed that various regions of the brain have different functions. Consequently, various symptoms appearing in schizophrenia were thought to be a result of the malfunctioning of different parts of the brain: frontal, temporal and occipital lobes (Windholz, 1999: 335–7). These views were often associated with psychomorphologism. They were interpreted as opposing Pavlovian theory that supported a dynamic localization of functions in the brain (p. 341). During the Pavlovian meeting in Moscow, the accused psychiatrists not only agreed to change their theoretical views so that they complied with Pavlov’s theory, but they also rejected methods of treatment such as lobotomy and electroshock therapy (pp. 337, 339, 342). These events had a significant impact on psychiatry, not only in the USSR but also in Poland in the early 1950s. The political influence on science and philosophy in Poland during this period makes it difficult to analyse the theoretical approach of Polish psychiatrists to lobotomy.
Broszkiewicz who supported the Pavlovian theory in psychiatry claimed that for several years lobotomy was practised in Poland, despite a simultaneous reorientation to Pavlov-inspired psychiatry. The first Pavlovian session in the USSR, which began in June 1950, had an effect on the practice of psychiatry in Poland, but 176 lobotomy procedures took place in Poland between 1947 and 1951 (Broszkiewicz, 1955: 374).
In September 1951, during the 26th Convention of the Polish Psychiatric Association, psychiatrists Stryjeński and Falkowski put forward a motion concerning lobotomy. This motion did not result from any discussion during this convention and it did not inspire any new discussion. The motion stated:
The Convention of the Polish Psychiatric Association claims that using prefrontal lobotomy and other surgical procedures in psychiatric hospitals as a hospital treatment should be prevented. In cases in which lobotomy or other surgical treatment is proposed, it is necessary to obtain an acceptance from the voivodeship specialist in psychiatry or from one of psychiatric teaching hospitals. (Protocol from 26th Convention of the Polish Psychiatric Association, 29–30 September 1951, quoted by Broszkiewicz, 1955: 376)
A total of 52 members voted in favour of the motion, and 2 members abstained (Broszkiewicz, 1955: 376). As observed later by Broszkiewicz, the motion might give the impression that it was mainly intended to lead to a more careful selection of patients for lobotomy rather than to a complete abandonment of the method (p. 376). However, the new regulation put an end to practising lobotomy in Poland.
Critical assessment of lobotomy in Poland
Bornsztajn’s opinion
Several months before the introduction of new regulations, lobotomy was severely criticised by Maurycy Bornsztajn, a renowned psychiatrist and psychoanalyst, who was initially interested in neurology. As a young physician, he worked in Germany under the supervision of Mendel and Oppenheim in Berlin, and later with Kraepelin in Monachium. On returning to Poland, he first worked with the neurologist Edward Flatau, but later he became a director of the Department of Psychiatry in the Jewish hospital (the Czyste hospital) in Warsaw (Jarosz, 1985: 307). Bornsztajn introduced to the literature a new diagnostic category: ‘somatopsychic schizophrenia’ (Nasierowski, 2015: 450).
In April 1951, Maurycy Bornsztajn gave a lecture at the meeting of Warsaw Section of the Polish Psychiatric Association, which was later published in a leading Polish journal Neurologia, Neurochirurgia i Psychiatria Polska (Bornsztajn, 1951). Bornsztajn did not conduct any experiments on lobotomy, but based his analysis on the results achieved by others. He read literature on lobotomy, including three articles by psychiatrist Barahona Fernandes from Lisbon, neuropathologist Walter Freeman from Washington and brain anatomist A. Meyer from London, based on their lectures during the International Congress of Psychiatry in Paris in September 1950. Bornsztajn also analysed the results of research on lobotomy by French authors – Pierre Wertheimer, Durand, Kammerer, Boitelle and others – and severely criticized the method (pp. 55–6). He claimed that all researchers obtained similar results, which were sufficient to judge the procedure in a definitively negative way; in spite of this, the researchers still concentrated on technical improvements of the method instead of abandoning it completely (p. 56).
Bornsztajn criticized the use of lobotomy in severe illnesses, such as schizophrenia, and also in milder cases, such as neurosis (pp. 57, 63). He drew attention to a complete change in personality after lobotomy. Although lobotomized patients stopped suffering from pains and fears, the overall change was not positive. Bornsztajn pointed out that the post-operative social adjustment of patients, which was often described by lobotomists as an improvement, usually appeared at the cost of the pre-operative personality of the patient, and therefore the adjustment was very superficial (p. 61). He said the behaviour of lobotomized patients was like that of chronic patients in advanced stages of schizophrenia, when they lose interest in their morbid symptoms, such as hallucinations, and become shallow and obtuse (pp. 61, 64). Bornsztajn suggested that the good mood of lobotomized patients mainly resulted from their intellectual impairment. Their social adjustment was mostly to current circumstances, on a very low level (p. 62).
Bornsztajn’s strong criticism of lobotomy as a procedure that should not be performed under any circumstances was in clear contrast to medical approaches in other countries. Although lobotomy was criticized by many Americans, even its strongest opponent – the Chicago psychoanalyst Roy Grinker – claimed that lobotomy could be performed on old patients who have no other possibilities than to live in state hospitals (Valenstein, 2010: 186).
Bornsztajn criticized the materialist-mechanistic orientation on which, he believed, the faith in lobotomy was based (Bornsztajn, 1951: 66). He showed similarities between psychosurgical approaches and old theories of Gall’s phrenology that emphasized strong connections between specific mental functions and particular neuroanatomic structures (p. 66). He stressed that in psychiatry we should aim at understanding the mechanism of an illness and its possible treatment before any new method of therapy was implemented (p. 66).
Bornsztajn also quoted two articles by Professor Gilarovsky (1950) from Moscow, which appeared in Soviet medical journals (Bornsztajn, 1951: 64), although obviously without mentioning the circumstances in which Gilarovsky was forced to adjust his views so that they agreed with the Soviet regime. However, an editorial footnote to Bornsztajn’s article mentioned the new regulation introduced by the USSR Ministry of Health on 9 December 1950, forbidding the use of lobotomy in neural and mental illnesses (p. 64n).
Broszkiewicz’s follow-up studies of lobotomized patients
In 1955, Ewa Broszkiewicz analysed patients who underwent lobotomy in Poland in 1947–51. From documentation received from neurosurgical centres that carried out prefrontal leucotomy in Poland, she established that 176 patients were operated on: 113 women and 63 men. The operations were done at six centres: on 101 patients in the Nursing Home for the Nervously and Mentally Ill (now The Provincial Neuropsychiatric Hospital) in Kościan, on 29 in the Department of Neurosurgery at the Medical University of Warsaw, on 24 in the Department of Neurosurgery at the Medical University in Krakow, on 9 in a psychiatric department of a hospital in Radom, on 12 in the Department of Neurosurgery at the Medical University in Wrocław, on 1 in the State Institute of Psychiatry and Neurology in Pruszków (now the Institute of Psychiatry and Neurology in Warsaw). In the time of Broszkiewicz’s assessment, patients were aged 20–69 years (Broszkiewicz, 1955: 299–300). Broszkiewicz managed to get information about 166 patients (in 10 cases there was no medical documentation in the archives). From the 166 patients, 144 were still alive in the time of her research (Broszkiewicz, 1954: 43–4).
In the first part of her research, these 144 patients who underwent leucotomy in Poland and their families were asked to fill in questionnaires designed to gather information about the patient’s condition after the operation. On the basis of this information, Broszkiewicz selected: patients who returned home after leaving hospital and worked in any profession; patients who were described as having improved after lobotomy in the opinion of their family; and patients who were still in a hospital but were described by the staff as calmer and better adapted to the environment. These cases seemed to be most interesting for her further examination since she wanted to analyse those patients who could be described as ‘cured and improved’, according to American authors (Broszkiewicz, 1955: 300–1). Consequently, she conducted hospital research on 27 patients and an ambulatory research on 18 patients. These 45 patients seemed to be in the best condition on the basis of questionnaires (Broszkiewicz, 1954: 44).
Broszkiewicz stated that among the 45 patients analysed, she did not find any one who could be described as ‘cured’. A few were described as ‘improved’; this was because some symptoms that had been more troublesome for society decreased, while other symptoms caused by the operation were less troublesome (Broszkiewicz, 1955: 301).
Broszkiewicz emphasized that, although patients left an institution and returned home, they did not necessarily improve, which was a common interpretation among lobotomists. Among all 144 patients examined in Poland, 60% remained in an institution, and 40% went home. However, in the latter cases, families often noticed no improvement or even clearly stated that the patient’s condition deteriorated after the operation. The main factor in deciding whether the patient returned home was the family’s level of patience and indulgence or positive feelings towards the patient rather than the patient’s condition itself (p. 301). Among the 27 patients that Broszkiewicz examined in her hospital research, 24 were living at home. After the examination, only 17 returned home, and the other 7 were hospitalized, mainly due to Broszkiewicz’s intervention; she claimed that some patients who were tolerated by their families definitely required hospitalization (p. 301).
The 27 patients examined by Broszkiewicz were classified into four groups. The first group consisted of 14 patients who deteriorated after lobotomy. In the second group of five patients, results were positive, but only in comparison with other cases rather than in an absolute sense. The third group of three patients exhibited temporary disappearance of morbid symptoms and their later reappearance. The last group of five patients were lobotomized for reasons other than schizophrenia (p. 301).
Broszkiewicz reported that before the operation the majority of patients were barely examined at all. They were not subjected to proper alternative treatment for a sufficient period of time. Hospital documents did not present descriptions of pre-morbid personality or any other medical history. Psychiatric examinations and observations were so incomplete that it was difficult to grasp the psychopathological picture and the process of an illness on the basis of hospital documents. Even just before the operation, patients were not examined carefully. Medical staff did not state the exact reasons for deciding to do a lobotomy, and decisions were often made without enough thought. Similarly, post-operative examinations and observations were not conducted in detail; 2–3 weeks after the operation, examination of patients became as superficial as for other patients suffering from chronic illnesses (p. 303), despite the extraordinary treatment they were subjected to. Broszkiewicz stressed that, even if directly after World War II medical staff were not able to examine patients thoroughly, this situation should have improved in the following years, and especially before the operation (p. 302).
Broszkiewicz stated that certain symptoms were present to various degrees in almost all patients examined after lobotomy. First, patients became apathetic and passive. Usually they did not work at all. If they did work, which they did reluctantly and badly, then qualifications required for their new job were lower than before the operation. They lacked ambition, initiative and plans for their future. Second, they became frivolous and unconcerned. They were emotionally indifferent and not interested in family matters, social or cultural issues. Their only interests concerned concrete, practical matters related to themselves (food, clothes, personal objects) or to their closest surroundings. Many patients had an increased appetite. They showed lack of criticism, suggestiveness, sometimes boasting, and were prone to be jealous, lying, spiteful and sadistic. The majority of patients manifested excessive sexual arousal and lack of shame, which was sometimes associated with coprolalia. Third, patients had difficulties in learning; they learnt reluctantly; they could not concentrate; they easily became tired. They showed significant memory disorders, consisting in difficulties in registering and recollecting experienced and learned facts. They were often disoriented in space and especially in time. Most patients were in a serene mood, some were telling jokes. Sometimes, however, they were depressed and had suicidal thoughts or tendencies. Some were talkative; they had difficulties in changing the topic of conversation and tended to prolong their talk by adding insignificant details (p. 350).
Symptoms of schizophrenia that disappeared or decreased, temporarily or permanently, after lobotomy included motor agitation, anxiety and fugal reactions. However, these symptoms disappeared only in some patients – in others they continued to be present or even increased (p. 351).
Broszkiewicz emphasized the importance of Korzeniowski’s research on nine patients lobotomized in the Department of Neurosurgery in Warsaw, since they were the first patients who underwent this type of operation in Poland. She stressed that Korzeniowski was the only psychiatrist who tried to evaluate the clinical conditions of these patients. However, Broszkiewicz also mentioned some shortcomings of his research, and said his conclusions on the results of lobotomy were too optimistic (p. 370). He observed the patients for a relatively short time, ranging from six days in some cases to a maximum of four months in others. Broszkiewicz observed that Korzeniowski should have carried out another evaluation of the patients’ conditions later (p. 371), and she seems to have done her own research in order to fill in this gap. Another drawback of Korzeniowski’s research was that he observed patients predominantly in hospital conditions; only one patient was seen at home. This fact had an important implication for his evaluation: he concentrated mainly on psychiatric tests and artificial tasks unrelated to everyday life, but gave very little information about patients’ adaptation to society, i.e. concerning their work or existence in a community.
Broszkiewicz’s main criticism of Korzeniowski’s reports was the fact that, from such brief observations, he was not able to draw far-reaching conclusions about patients’ supposed improvements. She claimed that he did not present any patient who would be truly capable of independent existence or of returning to society, and that he merely observed in some patients the disappearance of symptoms that were difficult for the hospital medical staff to handle. These shortcomings were especially significant, considering that no other Polish psychiatrist examined the lobotomized patients in their early stage after lobotomy (pp. 372–3).
Konieczyńska’s follow-up studies of lobotomized patients
In the 1970s, a psychiatrist Zuzanna Konieczyńska examined a group of people who underwent prefrontal leucotomy in Poland in the period 1947–51. She managed to get information about 92 patients out of 176 who had been previously lobotomized. Of these, 36 had died, including eight for reasons directly connected with the surgery: cerebral haemorrhage, extradural and subdural haematoma, encephalitis and meningitis. In the case of the other 28 patients who died later, it was impossible to establish any connections between the causes of death and the operation (Konieczyńska, 1976: 163). Among 56 patients still surviving at the time of the research, the majority (50 patients) had been operated on because of schizophrenia, i.e. approximately 90%. Among the remaining six patients, four had the operation because of epilepsy, one because of intellectual disability and one because of general paresis (p. 163). This group of 56 patients was very heterogeneous in terms of age, education, the onset of an illness before the operation, the age at which the operation was performed, and psychopathological profile (pp. 163–4). Like Broszkiewicz, Konieczyńska stressed that it was not possible to find the exact reasons why decisions to operate were made. The only common features for all patients analysed were that they had been subjected to prefrontal lobotomy and then examined more than 20 years later (p. 164). Because of the heterogeneity of the analysed patients, Konieczyńska emphasized that descriptions of individual cases might be more valuable than any final generalizations. Nonetheless, she made some conclusions on the basis of her analysis of 49 patients who had been operated on because of schizophrenia; one case in the sample of 50 was excluded from the analysis since he underwent only a right-sided lobotomy (p. 164).
In the cases analysed, the period of hospitalization before the surgery was relatively short, ranging from 3 months to 5 years, but in half the cases it was 3 years or less. After lobotomy, 19 patients (38.7%) spent all their time in a hospital or in other institutions for the mentally ill; 14 lived at home all the time, but half of them should have been treated in a hospital because of constant psychotic symptoms and behaviour that made any adaptation impossible. When the research was done, 18 patients were at home, but half of them required hospitalization. Of the remaining 31 patients who were analysed in a hospital or another institution, seven patients were able to live at home if suitable care was provided. In the light of these data, it was possible to state that whether a patient was hospitalized or lived at home was only partially dependent on the psychiatric profile of the patient. It was also greatly influenced by other complex factors, such as family situation, their tolerance and emotional attitude towards the patient, the course of the illness, etc. (pp. 164–5).
The patients analysed were divided into three groups in terms of the course of their illness after the lobotomy: a group with a positive outcome (12.3% of the patients analysed), a group with a remitting-relapsing (i.e. waxing and waning) course (16.3%) and a group with a continuous course (61.2%) (p. 166).
In the first group, the psychotic symptoms disappeared after lobotomy and did not return. However, Konieczyńska stressed that it was doubtful if the cause of remission was lobotomy, since the symptoms disappeared at various times – up to several years after the operation. Moreover, although acute psychotic symptoms disappeared, other symptoms still predominated in the group for many years: problems with concentration, memory disorders, emotional indifference, diminished activity and initiative, decrease in interests and judgement, lack of plans for the future, isolation from society, no interest in their own fate. Only one person was fully active and independent for almost the entire period since lobotomy. The rest of the patients required some amount of care. A very important feature in this group was the dynamics of changes in the clinical profile of some patients after the surgery. During several years after the lobotomy, some patients were inactive and lacked any initiative; later this state improved, and one patient even recovered to lead a full life (p. 166). Konieczyńska associated the initial stage after lobotomy with an organic injury to the central nervous system, which recovered in following years (p. 167).
In patients who displayed features of remitting-relapsing course of the illness, there were no significant changes in psychopathological symptoms during periods of relapse. In some cases, however, periods of relapse were prolonged. Moreover, in such cases, both periods of relapse and of remission were characterized by more pronounced psychopathological symptoms, such as decrease in activity, initiative and interests, isolation from society, and emotional indifference. At the time of Konieczyńska’s research, all patients required some care, and none was capable of living alone. Only one patient had been fully independent, had worked professionally and supported his family for several years (p. 167).
The majority of patients examined displayed features of a continuous course of the illness; they isolated themselves from society, lost their grip on reality, became inactive, abandoned their interests, and enclosed themselves in an internal world of their own experiences (pp. 167–8). After lobotomy, only a few of these patients worked. Their activities were stereotypical and limited to simple physical work, usually carried out under the supervision of other people. The majority of these patients required constant care. None was capable of a sufficiently independent existence, and several who were living at home when examined, in fact required hospital treatment. They had managed to stay at home only because of the help from their families, who were very attentive and tolerant towards the patients’ abnormal behaviour (p. 168).
Because of insufficient data, it was impossible to classify 10.2% of the patients examined, in terms of the character of the illness after lobotomy. However, their state at the time of examination, as well as data collected on the level of their adaptation to society, indicated that they did not significantly differ from patients with a continuous course of the disease (p. 168). Therefore, 71.4% of examined patients were seriously damaged, which made them incapable of any kind of relatively independent life (p. 168).
Apart from the group with a positive course after lobotomy, in which acute psychopathological symptoms disappeared, the only changes in psychopathological profile displayed by all groups after the surgery was the disappearance of depressive symptoms such as decreased mood, suicidal thoughts and tendencies. These symptoms also disappeared in one patient who underwent a right-sided lobotomy, but the symptoms returned after several years (pp. 168–9).
On the basis of her observations, Konieczyńska drew the following conclusions. In the group she examined, changes in the type of the course of the illness and changes in psychopathological profile occurred, to a great extent, independently from the prefrontal lobotomy. Except for some tendency to change to a worse course of illness, no other correlations were observed (p. 169). Konieczyńska stressed that improvement after lobotomy, which occurred in a small percentage of cases reported by some researchers, could be attributed to a spontaneous remission rather than any positive effect of the surgery (p. 169). This statement was supported by the fact that factors considered to be prognostically positive in schizophrenia were also prognostically positive in lobotomized patients (pp. 169–70). In general, after lobotomy the illnesses in the patients examined tended to develop in a more negative way in comparison with the period before surgery (pp. 170–1).
Konieczyńska concluded that prefrontal lobotomy did not have a positive effect on schizophrenia, and 25 years after surgery, psychotic symptoms were still present in 87.7% patients. In the remaining patients, the symptoms disappeared, but it was impossible to prove that this was due to surgery rather than spontaneous remission (p. 180). Only one person had become fully socially adapted (p. 180). Likewise, there was no positive influence of lobotomy in cases of epilepsy, either in terms of behavioural disorders or in terms of the kind and frequency of attacks (p. 181).
A difficult and unresolved problem for Konieczyńska was the distinguishing of symptoms of chronic schizophrenia from those of organic cerebral injury (p. 171). Almost all patients exhibited features that could be associated with psycho-organic syndrome, such as euphoria, instability, labile affect, irritability, verbosity, and viscosity of thinking, but it was impossible to indicate that it was caused by lobotomy (pp. 171–9). Those patients who did not have psycho-organic syndrome diagnosed might still suffer from psycho-organic injury because it was impossible to differentiate symptoms of chronic schizophrenia from psycho-organic ones, either in clinical observations or in psychological tests (p. 180).
Conclusions
The material presented here on the history of lobotomy in Poland shows that the most important factor influencing the attitude of researchers to this method was the analysis of clinical psychiatric symptoms rather than theoretical orientation. Bornsztajn and Broszkiewicz came from different theoretical backgrounds concerning psychopathology: the first was an advocate of psychoanalysis, whereas the latter supported behaviourism backed by Pavlovian theory. Yet they both severely criticized lobotomy for dramatic changes in the personalities of lobotomized patients. On the other hand, Ziemnowicz, who supported the same Pavlovian approach in psychiatry as Broszkiewicz, had a positive attitude to psychosurgery and introduced topischemia.
What is symptomatic of difficulties in establishing a link between theoretical orientation of Polish physicians and their attitude towards lobotomy is Broszkiewicz’s disbelief that anyone could try to base a blind, harmful procedure such as lobotomy on any truly scientific, physiological and humanitarian theory, and simultaneously support this theory (Broszkiewicz, 1955: 375). The analysis of theoretical justifications for lobotomy is especially difficult in Poland because Pavlov’s theory could not be criticized in a country under Soviet influence. Thus, Pavlovian theory was quoted at will, either in support or against a given procedure, depending on a researcher’s individual opinion on psychosurgery. In 1976, when Polish psychiatric practice became more independent from political influences, Konieczyńska severely criticized lobotomy for purely clinical reasons, without resorting to ideological arguments.
It is important to note that Korzeniowski reported effects achieved after lobotomy that are similar to those described by Freeman and Watts (Freeman, 1950; Freeman and Watts, 1939, 1950). Whether a negative or positive evaluation of the procedure was made depended on the approach adopted by different specialists. Those who evaluated lobotomy positively – including Korzeniowski – emphasized the disappearance of the symptoms that were troublesome for the environment. Referring to the same data, Bornsztajn found changes in personality unacceptable, so he assessed the method in a definitely negative manner.
It should also be noted that lobotomized patients who suffered from schizophrenia in the majority of cases analysed (Broszkiewicz, 1955; Konieczyńska, 1976; Korzeniowski, 1948), started to show morbid symptoms in the 1940s during World War II, which was an extremely difficult time for Polish people. The severe conditions must have contributed to a deterioration in their mental health, and they became more likely to fall seriously ill. The detailed examination of the influence of Polish war experiences on mental health would need research that could be difficult, because of the incomplete medical documentation from that period. Korzeniowski (1948: 64–5) also stated that he did not have access to detailed descriptions of the state of the lobotomized patients before surgery. In the light of insufficient and improper examination of the patients and the lack of a clear indication for the operation, it seems very likely that the cases that were lobotomized could and should have been provided with a different therapy, considering the relatively short time between the onset of disease and the surgery.
After the motion concerning lobotomy had been put forward during the 26th Convention of the Polish Psychiatric Association in 1951, no more patients underwent lobotomy in Poland. However, Broszkiewicz seemed to be justified in stating that the motion was simply an adaptation of the Soviet rules against lobotomy rather than a result of Polish psychiatrists’ criticism of the method. Although the regulation did not ban lobotomy in Poland and only restricted its use, in practice it put an end to the procedure in the country. The political atmosphere at that time and the negative clinical evaluation of lobotomized patients must also have played a role.
The most outstanding characteristic of lobotomy in Poland was low interest in the method on the part of psychiatrists. It resulted in very few publications on the topic in times when lobotomy was practised in Poland and very few further clinical evaluations of lobotomized patients. This lack of interest was criticised by Broszkiewicz in 1955, but not much has changed in following decades.
Footnotes
Funding
This work was supported by the Faculty of Medicine at the Jagiellonian University Medical College (the programme of supporting young scholars, grant number: K/DSC/003079).