Lobotomy
A lobotomy or leucotomy is a discredited form of neurosurgical treatment for psychiatric disorder or neurological disorder that involves severing connections in the brain's prefrontal cortex. The surgery severs most of the connections to and from the prefrontal cortex, and the anterior part of the frontal lobes of the brain.
In the past, this treatment was used for handling psychiatric disorders as a mainstream procedure in some countries. A preoccupation with the ability to work and personal responsibility over patient well-being were contributing factors to the prevalence of lobotomies in the US.
The originator of the procedure, Portuguese neurologist António Egas Moniz, shared the Nobel Prize for Physiology or Medicine of 1949 for the "discovery of the therapeutic value of leucotomy in certain psychoses", although the awarding of the prize has been subject to controversy.
The procedure was modified and championed by Walter Freeman, who performed the first lobotomy at a mental hospital in the United States in 1936. Its use increased dramatically from the early 1940s and into the 1950s; by 1951, almost 20,000 lobotomies had been performed in the US and proportionally more in the United Kingdom. More lobotomies were performed on women than on men: a 1951 study found that nearly 60% of American lobotomy patients were women, and limited data shows that 74% of lobotomies in Ontario from 1948 to 1952 were performed on female patients. From the 1950s onward, lobotomy began to be abandoned, first in the Soviet Union, where the procedure immediately garnered extensive criticism and was not widely employed, before being banned in December 1950, and then Europe. However, derivatives of it such as stereotactic tractotomy and bilateral cingulotomy are still used.
Outline
Historically, patients of frontal lobotomy were, immediately following surgery, often stuporous and incontinent. Some developed an enormous appetite and gained considerable weight. Seizures were another common complication of surgery. Emphasis was put on the training of patients in the weeks and months following surgery.The purpose of the operation was to reduce the symptoms of mental disorders, and it was recognized that this was accomplished at the expense of a person's personality and intellect. British psychiatrist Maurice Partridge, who conducted a follow-up study of 300 patients, said the treatment achieved its effects by "reducing the complexity of psychic life". Following the operation, spontaneity, responsiveness, self-awareness, and self-control were reduced. Activity was replaced by inertia, and people were mostly left emotionally blunted and restricted in their intellectual range.
The consequences of the operation have been described as "mixed". However, many lobotomy patients suffered devastating postoperative complications, including intracranial hemorrhage, epilepsy, alterations in affect and personality, brain abscess, dementia, and death. Ominous portrayals of lobotomized patients in novels, plays, and films further diminished public opinion, and the development of antipsychotic medications led to a rapid decline in lobotomy's popularity and Walter Freeman's reputation. Others could leave the hospital or become more manageable within the hospital.
A precarious number of people managed to return to responsible work, while at the other extreme, people were left with severe and disabling impairments. Most people fell into an intermediate group, left with some improvement of their symptoms but also with emotional and intellectual deficits to which they made a better or worse adjustment. On average, there was a mortality rate of approximately 5% during the 1940s. A survey of British lobotomy patients lobotomised between 1942 and 1954 found that 13% of patients were deemed to have made a full recovery and a further 28% were deemed to have made a significant recovery; for 25% lobotomy was deemed to have made no change and 4% died as a result of the surgery.
The frontal lobotomy procedure could have severe negative effects on a patient's personality and ability to function independently. Lobotomy patients often show a marked reduction in initiative and inhibition. They may also exhibit difficulty imagining themselves in the position of others because of decreased cognition and detachment from society.
Walter Freeman coined the term "surgically induced childhood" and used it constantly to refer to the results of lobotomy. The operation left people with an "infantile personality"; a period of maturation would then, according to Freeman, lead to recovery. In an unpublished memoir, he described how the "personality of the patient was changed in some way in the hope of rendering him more amenable to the social pressures under which he is supposed to exist." He described one 29-year-old woman as being, following lobotomy, a "smiling, lazy and satisfactory patient with the personality of an oyster" who could not remember Freeman's name and endlessly poured coffee from an empty pot. When her parents had difficulty dealing with her behavior, Freeman advised a system of rewards and punishment.
History
In the early 20th century, the number of patients residing in mental hospitals increased significantly while little in the way of effective medical treatment was available. Lobotomy was one of a series of radical and invasive physical therapies developed in Europe at this time that signaled a break with the psychiatric culture of therapeutic nihilism which had prevailed since the mid-nineteenth-century. The new "heroic" physical therapies devised during this experimental era, including malarial therapy for general paresis of the insane, deep sleep therapy, insulin shock therapy, cardiazol shock therapy, and electroconvulsive therapy, served to galvanize a profession which had been both therapeutically moribund and systemically demoralized. Unlike other medical disciplines which applied surgical and pharmacological treatments that were both apparent and measurable regarding their efficacy, psychiatry had often struggled with quantification. These novel remedial methodologies, however, meant that modern psychiatric treatments were no longer relegated to the metaphysical or abstract, and this increased the popularity of the field among clinicians and prospective patients alike. Suddenly, conditions like insanity, psychosis, and others felt less like incurable afflictions and more like surmountable diagnoses, emboldening psychiatrists to attempt new procedures. Additionally, the relative success of the shock therapies, despite the considerable risks they posed to patients, also helped to inspire doctors in the field to pioneer ever more drastic forms of medical interventions, including lobotomies.The clinician-historian Joel Braslow argues that from malarial therapy onward to lobotomy, physical psychiatric therapies "spiral closer and closer to the interior of the brain", with this organ increasingly taking "center stage as a source of disease and site of cure". For medical historian Roy Porter, the often violent and invasive psychiatric interventions developed during the 1930s and 1940s are indicative of both the well-intentioned desire of psychiatrists to find some medical means of alleviating the suffering of the vast number of patients then in psychiatric hospitals and also the relative lack of social power of those same patients to resist the increasingly radical and even reckless interventions of asylum doctors. Many doctors, patients, and family members of the period believed that despite potentially catastrophic consequences, the results of lobotomy were seemingly positive in many instances or were at least deemed as such when measured next to the apparent alternative of long-term institutionalisation. Lobotomy has always been controversial, but for a period of the medical mainstream, it was regarded as a legitimate last-resort remedy for categories of patients who were otherwise regarded as hopeless. Today, lobotomy has become a disparaged procedure, a byword for medical barbarism and an exemplary instance of the medical trampling of patients' rights.
Early psychosurgery
Before the 1930s, individual doctors had infrequently experimented with novel surgical operations on those deemed insane. Most notably in 1888, Swiss psychiatrist Gottlieb Burckhardt initiated what is commonly considered the first systematic attempt at modern human psychosurgery. He operated on six chronic patients under his care at the Swiss Préfargier Asylum, removing sections of their cerebral cortex. Burckhardt's decision to operate was informed by three pervasive views on the nature of mental illness and its relationship to the brain. First, the belief that mental illness was organic in nature, and reflected an underlying brain pathology; next, that the nervous system was organized according to an associationist model comprising an input or afferent system, a connecting system where information processing took place, and an output or efferent system ; and, finally, a modular conception of the brain whereby discrete mental faculties were connected to specific regions of the brain. Burckhardt's hypothesis was that by deliberately creating lesions in regions of the brain identified as association centers, a transformation in behaviour might ensue. According to his model, those mentally ill might experience "excitations abnormal in quality, quantity and intensity" in the sensory regions of the brain and this abnormal stimulation would then be transmitted to the motor regions giving rise to mental pathology. He reasoned, however, that removing material from either of the sensory or motor zones could give rise to "grave functional disturbance". Instead, by targeting the association centers and creating a "ditch" around the motor region of the temporal lobe, he hoped to break their lines of communication and thus alleviate both mental symptoms and the experience of mental distress.Intending to ameliorate symptoms in those with violent and intractable conditions rather than effect a cure, Burckhardt began operating on patients in December 1888, but both his surgical methods and instruments were crude and the results of the procedure were mixed at best. He operated on six patients in total and, according to his own assessment, two experienced no change, two patients became quieter, one patient experienced epileptic convulsions and died a few days after the operation, and one patient improved. Complications included motor weakness, epilepsy, sensory aphasia and "word deafness". Claiming a success rate of 50 percent, he presented the results at the Berlin Medical Congress and published a report, but the response from his medical peers was hostile and he did no further operations.
In 1912, two physicians based in Saint Petersburg, the leading Russian neurologist Vladimir Bekhterev and his younger Estonian colleague, the neurosurgeon Ludvig Puusepp, published a paper reviewing a range of surgical interventions that had been performed on the mentally ill. While generally treating these endeavours favorably, in their consideration of psychosurgery they reserved unremitting scorn for Burckhardt's surgical experiments of 1888 and opined that it was extraordinary that a trained medical doctor could undertake such an unsound procedure.
The authors neglected to mention, however, that in 1910 Puusepp himself had performed surgery on the brains of three mentally ill patients, sectioning the cortex between the frontal and parietal lobes. He had abandoned these attempts because of unsatisfactory results and this experience probably inspired the invective that was directed at Burckhardt in the 1912 article. By 1937, Puusepp, despite his earlier criticism of Burckhardt, was increasingly persuaded that psychosurgery could be a valid medical intervention for the mentally disturbed. In the late 1930s, he worked closely with the neurosurgical team of the Racconigi Hospital near Turin to establish it as an early and influential centre for the adoption of leucotomy in Italy.