prefrontal lobotomy

Lobotomy

[luh-bot-uh-mee, loh-]

A lobotomy (Greek: lobos: Lobe of brain, tomos: "cut/slice") is 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. These procedures often result in major personality changes and possible mental disabilities. Lobotomies were used in the 20th century 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". After the introduction of the antipsychotic Chlorpromazine (Thorazine), lobotomies fell out of common use and the procedure has since been characterized "as one of the most barbaric mistakes ever perpetrated by mainstream medicine".

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). 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.

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 with a retractable wire loop. Moniz was given the Nobel Prize for medicine in 1949 for this work.

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 that this surgery would be unavailable to the patients who needed it most: those that lived in state mental hospitals with no operating rooms, no surgeons, no anesthesia, and very little money. 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 a leucotome or orbitoclast) 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.

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 in Sweden, psychiatrist Snorre Wohlfahrt evaluated early trials and "blew the whistle", reporting 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".

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.

Concerns about lobotomy steadily grew. The USSR banned the procedure in 1950. 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". 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), 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. In France, 32 lobotomies were performed between 1980 and 1986 according to an IGAS report; about 15 each year in the UK, 70 in Belgium, and about 15 for the Massachusetts General Hospital of Boston.

Scale

Quantitatively, most lobotomy procedures were done in the United States, where approximately 40,000 persons were so treated. Great Britain performed procedures on 17,000 people, and the three Scandinavian countries had a combined figure of approximately 9,300 people treated. Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the United States. Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women and also including young children.

Cases

  • Rosemary Kennedy, the sister of President John F. Kennedy, was given a lobotomy when her father complained to doctors about the 23-year-old's moodiness. Dr. Walter Freeman personally performed the procedure. Rather than any improvement, however, the lobotomy reduced Rosemary to an infantile mentality including incontinence. Her verbal skills were reduced to unintelligible babble. Her father hid the nature of Rosemary's affliction for years and described it as the result of mental retardation. Rosemary's sister Eunice Kennedy Shriver founded the Special Olympics in her honor in 1968.
  • Howard Dully had a lobotomy at 12, after his stepmother was simply tired of his "youthful defiance". At the age of 56 he said, "I've always felt different -- wondered if something's missing from my soul. I have no memory of the operation". Late in his life, Dully uncovered the story of his lobotomy. Crown Publishers published Dully's memoir (co-written by Charles Fleming), My Lobotomy, in September 2007.
  • New Zealand author and poet Janet Frame was due to have a lobotomy because of a diagnosis of mental illness. She was saved from this procedure by receiving a literary award the day before her operation was to take place.
  • French Canadian singer Alys Robi was renowned worldwide during the 1940s. In the 1950s, following many cases of violence and disturbance, she was admitted to a Quebec mental hospital where she underwent a lobotomy. She was later released and pursued her career.
  • Swedish modernist painter Sigrid Hjertén died following a botched lobotomy in 1948.
  • The older sister of playwright Tennessee Williams, Rose, received a lobotomy which left her incapacitated for life and provided inspiration for his plays, Suddenly, Last Summer and The Glass Menagerie.

Literary and cinematic portrayals

Lobotomies have been featured in several literary and cinematic presentations that both reflected society's attitude towards the procedure and, at times, changed it. The 1946 novel All the King's Men by Robert Penn Warren described a lobotomy in such nauseating detail "that [it] would have made a Comanche brave look like a tyro [novice] with a scalping knife". The surgeon is portrayed as a repressed person who couldn't change others with love but instead resorted to "high-grade carpentry work". In Tennessee Williams's 1958 play, Suddenly, Last Summer, the protagonist is threatened with a lobotomy to stop her from telling the truth about her cousin Sebastian. The surgeon said, "I can't guarantee that a lobotomy would stop her—babbling!!!" To which her aunt responded, "That may be, maybe not, but after the operation who would believe her, Doctor?

A most damning portrayal of the procedure is found in Ken Kesey's 1962 novel One Flew Over the Cuckoo's Nest and the subsequent 1975 movie adaptation. Randle McMurphy was lobotomized after he angrily attacked Nurse Ratched. The operation is described as brutal and abusive, a "frontal-lobe castration". Chief Bromden is shocked: "There's nothin' in the face. Just like one of those store dummies." Another patient's surgery changed him from an acute to a chronic condition. "You can see by his eyes how they burned him out over there; his eyes are all smoked up and gray and deserted inside."

Other sources include Sylvia Plath's depiction of a young woman, Valerie, who was lobotomized in her 1963 novel The Bell Jar. The character Esther reacts with horror to her "perpetual marble calm". Elliott Baker's 1964 novel and 1966 film version A Fine Madness portrayed the dehumanizing lobotomy of a womanizing, quarrelsome poet who, in the end, is just as aggressive as ever. The surgeon is portrayed as inhumane and a crackpot. The 1982 biopic Frances included a fictional, disturbing scene of the eponymous actress Frances Farmer undergoing transorbital lobotomy. Whether a lobotomy ever occurred or whether it was performed by Dr. Freeman himself is a matter of much debate.

See also

  • Frontal lobe injury
  • For an example of the personality changes associated with damage to the frontal lobe not related to a surgical leukotomy, see the famous case of Phineas Gage.
  • Elliot Valenstein, author of Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness

References

External links

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