Lobotomy

PROCEDURE OF THE DAY

Lobotomy

A lobotomy (Greek: lobos: Lobe of brain, tomos: "cut/slice") is a neurosurgical procedure, a form of psychosurgery, also known as a leukotomy or leucotomy (from Greek leukos: clear or white and tomos meaning "cut/slice"). It consists of cutting the connections to and from the prefrontal cortex. Lobotomies have now fallen out of use, as doctors use various drugs and psychological therapies to treat mental health issues. Lobotomies were used mainly from the 1930s to 1950s to treat a wide range of severe mental illnesses, including schizophrenia, clinical depression, and various anxiety disorders, as well as people who were considered a nuisance by demonstrating behavior characterized as, for example, "moodiness" or "youthful defiance". The patient's informed consent in the modern sense was often not obtained. After the introduction of the antipsychotic chlorpromazine (Thorazine), lobotomies fell out of common use[1] and the procedure has since been characterized "as one of the most barbaric mistakes ever perpetrated by mainstream medicine".[2]


History

In 1890, psychiatrist Gottlieb Burckhardt removed pieces of the frontal lobes of six patients in a psychiatric hospital in Switzerland. One died after the operation, and another was found dead in a river 10 days after release (whether by accident, suicide, or crime is unknown).[citation needed] The others exhibited altered behavior.

These experiments marked one of the first forays into the field of psychosurgery. Burckhardt claimed a 50% success rate but didn't properly assess or follow-up, and his reports "made everyone feel ill at ease and encountered harsh comments from colleagues". Emil Kraepelin said "he suggested that restless patients could be pacified by scratching away the cerebral cortex".

Burckhardt wrote in 1891 that "Doctors are different by nature. One kind adheres to the old principle: first, do no harm (primum non nocere); the other one says: it is better to do something than do nothing (melius anceps remedium quam nullum). I certainly belong to the second category", but he ended his research and practice of psychosurgery due to the heavy criticism.[3]

Psychosurgery was not publicly attempted again until 1910, when Estonian neurosurgeon Ludvig Puusepp operated on a few patients. Then, in 1935, Portuguese physician and neurologist António Egas Moniz pioneered a surgery he called prefrontal leucotomy. The procedure involved drilling holes in the patient's head and destroying tissue in the frontal lobes by injecting alcohol. He later changed technique, using a surgical instrument called a leucotome that cut brain tissue by rotating a retractable wire loop (a quite different cutting instrument also used for lobotomies shares the same name).[4] Moniz was given the Nobel Prize for medicine in 1949 for this work.[5]

The American neurologist and psychiatrist Walter Freeman was intrigued by Moniz's work, and with the help of his close friend, a neurosurgeon named James W. Watts, he performed the first prefrontal leucotomy in the U.S. in 1936. Freeman and Watts gradually refined the surgical technique, and created the Freeman-Watts procedure (the "precision method," the standard prefrontal lobotomy).

The Freeman-Watts prefrontal lobotomy still required drilling holes in the scalp, so surgery had to be performed in an operating room by trained neurosurgeons. Walter Freeman believed this surgery would be unavailable to those he saw as needing it most: patients in state mental hospitals having no operating rooms, surgeons, or anesthesia, and limited budgets. Freeman wanted to simplify the procedure so that it could be carried out by psychiatrists in mental asylums, which housed roughly 600,000 American inpatients at the time.

Inspired by the work of Italian psychiatrist Amarro Fiamberti, Freeman decided to access the frontal lobes through the eye sockets, instead of through drilled holes in the scalp. In 1945, he took an icepick from his own kitchen and began to test the new surgical technique on cadavers. The technique was called "transorbital lobotomy," and it involved lifting the upper eyelid and placing the point of a thin surgical instrument (often called an orbitoclast or leucotome, although quite different from the wire loop leucotome described above) under the eyelid and against the top of the eyesocket. A hammer or mallet was then used to drive the leucotome through the thin layer of bone and into the brain. The leucotome was then moved from side to side, to sever the nerve fibers connecting the frontal lobes to the thalamus.

In selected patients, the butt of the leucotome was pulled upward, sending the tip farther back into the brain, producing a "deep frontal cut," a more radical form of lobotomy. The leucotome was then withdrawn, and the procedure was repeated on the other side. Walter Freeman first performed a transorbital lobotomy on a live patient in 1946. This new form of psychosurgery was intended for use in state mental hospitals that often did not have the facilities for anesthesia, so Freeman suggested using electroconvulsive therapy to render the patient unconscious.[6]

As early as 1944, an author in the Journal of Nervous and Mental Disease could remark that: "The history of prefrontal lobotomy has been brief and stormy. Its course has been dotted with both violent opposition and with slavish, unquestioning acceptance."

In 1947, Swedish psychiatrist Snorre Wohlfahrt evaluated early trials and reported that "It is distinctly hazardous to leucotomize schizophrenics", "It is still too imperfect to enable us, with its aid, to venture on a general offensive against chronic cases of mental disorder", and in 1949 that "Psychosurgery has as yet failed to discover its precise indications and contraindications and the methods must unfortunately still be regarded as rather crude and hazardous in many respects".[7]

In 1948, Norbert Wiener, the author of Cybernetics, said: "...prefrontal lobotomy ...has recently been having a certain vogue, probably not unconnected with the fact that it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier."[8]

Concerns about lobotomy steadily grew. The USSR banned the procedure in 1950.[9] Doctors in the Soviet Union concluded that the procedure was "contrary to the principles of humanity", and, that it turned "an insane person into an idiot".[10] Numerous countries subsequently banned the procedure, including Yugoslavia, Germany and Japan, as did several U.S. states. Lobotomy was legally practiced in controlled and regulated U.S. centers and in Finland, Sweden, Norway (2,005 known cases[11]), the United Kingdom, Spain, India, Belgium and the Netherlands.

In 1977, the U.S. Congress created a National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery—including lobotomy techniques—was used to control minorities and restrain individual rights. It also investigated the after-effects of surgery. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects.

By the early 1970s the practice had generally ceased, but some countries continued small-scale operations through the late 1980s. According to a report by the International Graphoanalysis Society (IGAS), between 1980 and 1986 there were 70 lobotomies performed in Belgium, 32 in France, 15 per year in the United Kingdom and several cases performed for the Massachusetts General Hospital in Boston.

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