Lobotomy

BIBLIOGRAPHY

Lobotomy describes a class of psychosurgical techniques that involve the cutting of nerve fibers in the prefrontal area of the brain with the intent to calm severely disturbed psychiatric patients. These procedures are designed to disrupt the limbic system, the area of the brain most closely associated with regulating emotion.

António Egas Moniz (1874–1955), a Portuguese neurologist, is credited as initiating the widespread use of psychosurgery. In 1935 Moniz attended a presentation by psychologist Carlyle Jacobsen at the Second International Neurological conference in London. Jacobsen noted that destruction of the prefrontal area in monkeys eliminated “experimental neurosis,” a pattern of frustrated behavior in response to errors when monkeys were given problem-solving tasks. Moniz questioned Jacobsen as to whether similar procedures could be used in humans to eliminate anxiety. Moniz and his colleague Almeida Lima initially treated psychiatric patients by using alcohol injections to destroy parts of the frontal lobes. By the end of 1935 Moniz and Lima were performing prefrontal leucotomy, a technique that involved cutting open the skull and severing nerve connections using a surgical instrument with a wire loop on the end called a leucotome.

In 1936 Moniz published encouraging results from twenty patients. Of these Moniz reported fourteen were either cured or showed improvement. Interest in lobotomy and for other dramatic procedures like insulininduced coma and electroconvulsive therapy grew rapidly in response to the social pressures of a growing number of psychiatric patients in state hospitals during the 1930s and 1940s. Available treatments prior to the rise of psychosurgical techniques consisted primarily of the use of heavy sedatives, such as opiates or barbiturates. Psychoanalysis was growing in popularity but was impractical for widespread use in hospital settings especially among patients with severe disorders, such as those with schizophrenia. In recognition of his contribution to medicine, Moniz was awarded the Nobel Prize in 1949.

Lobotomy’s greatest promoter was Walter Freeman, a U.S. neuropsychiatrist. Freeman corresponded with Moniz and closely followed the reports of his work. Freeman and neurologist James Watts established a practice and began performing their first lobotomies in 1936. Although Watts was trained as a surgeon while Freeman was not, the two often performed the operation together. After performing several surgeries using Moniz’s technique, Freeman and Watts developed a technique that involved drilling burr holes in both sides of the skull to be used as landmarks for making more precise cuts. Their procedure became known as the standard Freeman-Watts lobotomy. Freeman and Watts published Psychosurgery in 1942, which included reports about their patients, descriptions of the procedure, and theoretical explanations.

Freeman became discontent with inconsistent results of standard prefrontal lobotomy—particularly among schizophrenic patients who he felt were less benefited the longer their disorder progressed without psychosurgery. In 1946 Freeman performed the first transorbital lobotomy. Nonsurgical professionals could perform this procedure within a few minutes without anesthesia often during an office visit. The transorbital lobotomy involved inserting a sharp instrument resembling an ice pick through connective tissue between the eye and the orbital bones, and then thrusting the instrument upward to sever neural connections. After years together Watts split with Freeman over Freeman’s characterization of transorbital lobotomy as a minor operation and eager use of the procedure. Freeman went on to perform or supervise approximately 3,500 transorbital lobotomies and train many others to perform them in a tour of state hospitals to popularize the procedure.

The use of lobotomy declined rapidly with the advent of drug treatments in the mid-1950s such as chlorpromazine to treat schizophrenia. Introduction of viable alternatives strengthened support for lobotomy’s critics. Critics included Nolan Lewis, director of New York State Psychiatric Institute, who spoke at a psychiatric symposium in 1949 that included Freeman and Watts and challenged the validity of evidence in favor of lobotomy. Lewis claimed widespread underreporting of unsuccessful surgeries. He also questioned whether quieting the patient was really a cure or more a convenience to psychiatric caregivers. Patients were often described after surgery as emotionless zombies, impulsive, or lacking initiative. In a published critique in 1949, Jay Hoffman, chief of the Veteran’s Administration’s Neuropsychiatric Service, noted that results were typically deemed successful as long as patients showed improvement over their condition during hospitalization, but that family members were often unhappy with the results, as patients did not return to their prediagnosis, normal selves (Hoffman 1949).

Although technical improvements in psychosurgery allow more precise destruction of specific cells or neural circuits, ethical questions surrounding the irreversibility of these procedures have led to legal restrictions limiting psychosurgery to a treatment of last resort.

SEE ALSO Ethics in Experimentation; Medicine; Neuroscience

BIBLIOGRAPHY

Hoffman, Jay L. 1949. Clinical Observations Concerning Schizophrenic Patients Treated by Prefrontal Leukotomy. New England Journal of Medicine 241: 233–236.

Valenstein, Elliot S. 1973. Brain Control: A Critical Examination

of Brain Stimulation and Psychosurgery. New York: Wiley.

Valenstein, Elliot S. 1980. The Psychosurgery Debate: Scientific, Legal, and Ethical Perspectives. San Francisco: W. H. Freeman.

Valenstein, Elliot S. 1986. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books.

Craig C. Jackson

lobotomy, frontal ‘Lobotomy’ means cutting a lobe of the brain. It is synonymous with leucotomy (from the Greek ‘leukos’, ‘white’ and ‘tome’, ‘cut’) — that is, cutting tracts of nerve fibres (white matter) that connect different regions of the brain. Lobotomy of the frontal lobe is an operative procedure used to alleviate symptoms of mental illness. Currently, it is used more commonly in North America than elsewhere.

On 12 November 1935, a Portuguese neurosurgeon, Almeida Lima, performed the first human lobotomy, using alcohol injections to destroy the brain tissue. This procedure had been proposed by his Nobel Prize-winning colleague, Egas Moniz, as a result of hearing a lecture by the American neurologist John Fulton earlier that year. Fulton had described a chimpanzee that became much calmer after surgery destroying the connections between the frontal lobe and areas below the cerebral hemispheres, which are concerned with the emotions. Lima operated on a total of 20 patients, all of whom survived. Seven were considered to have made a complete recovery and an equal number were described as having markedly improved.

Encouraged by these findings, Walter Freeman and James Watts modified Moniz's technique and introduced ‘frontal lobotomy’ into the US. This operation, also called prefrontal leucotomy or standard lobotomy, was performed widely, and soon its beneficial as well as its detrimental effects became apparent.

Like other brain operations, frontal lobotomy was associated with risks of infection, bleeding, and an increased likelihood of developing seizures. In addition, it also became evident that it altered the behaviour and personality of patients, and this gradually limited its use, which further declined in the 1960s because of the development of pharmacological means of treating mental illness. Nevertheless, the use of neurosurgery for treating mental disorders has continued to the present day and is still available in several centres worldwide.

Earlier operations underwent many modifications, as neurosurgeons sought to reduce their damaging and irreversible side-effects. ‘Open’ procedures gave way to ‘closed’ ones, in which the neurosurgeons operated through small holes in the skull, and free-hand operations were replaced by stereotactic procedures, which allowed the neurosurgeon to site lesions with great precision. These changes and developments resulted in the neurosurgical procedures that are currently in use today. The four procedures available worldwide aim to interrupt key connections between specific parts of the frontal lobe and other areas of the brain. Lesion sites vary, and the surgeon's blade is no longer used; instead lesions are created using controlled radiation, or burning or freezing of tissue.

As more operations were performed it gradually became apparent that the patients that benefited most had primarily mood and anxiety disorders as opposed to schizophrenia. Hence, the aim of current procedures is to destroy those areas of the brain thought to be important in the regulation of emotion and anxiety.

Psychosurgery, the treatment of mental illness by neurosurgical procedures, has been criticized because it has developed empirically more than on rational grounds, and because of a lack of ‘scientific’ evidence supporting its purported therapeutic efficacy. However, the operations are offered only to those patients with severe intractable illnesses who have unsuccessfully tried all reasonable alternatives. In order to evaluate the effectiveness of these procedures accurately, a closely-matched, comparative group of patients would need to be studied, and this would be extremely difficult. Furthermore, it is not ethical to deny patients an operation altogether or to withold information concerning treatment options for the purposes of research, and this also limits the feasibility of conducting a ‘clinical trial’.

One novel neurosurgical technique, developed in New York, is of particular interest, since it allows surgeons to conduct a double-blind therapeutic trial of psychosurgery, comparing a mock procedure and the genuine operation. This technique is performed without a general anaesthetic and relies on the combined effect of more than 200 precisely-focused beams of cobalt-60 gamma radiation. As there are no significant adverse effects, it is possible for all patients to undergo both a mock procedure and the real operation but be unaware of the order in which these are administered. Hence currently a 5-year, randomly assigned, double-blind study is being carried out to evaluate this particular procedure in the treatment of intractable obsessive—compulsive disorder.

Open, uncontrolled studies, of which there are many, have repeatedly shown that these procedures are effective in alleviating the symptoms of obsessive–compulsive disorder, anxiety states, and major depressive disorder. In most series nearly half the patients have recovered and the majority have experienced some benefit, although there is often a need for continuing medication, and in some cases the operation has to be repeated in order to extend the size of the lesion. The results are impressive, especially when one considers that these patients are treatment-resistant and have not responded to all other available therapeutic measures.

For many people the term ‘lobotomy’ conjures up images of disturbed beings whose brains have been damaged or mutilated extensively, leaving them at best in a vegetative state without a personality or feelings. This was never true, even in the case of prefrontal leucotomy, and is certainly not the case for the modern stereotatic procedures. Indeed, even in the classical case of Phineas Gage, who in 1847 through an industrial accident suffered severe damage to his prefrontal brain, there was no evidence of impairment of intellect or memory.

The term psychosurgery has had years of bad press and is now wrongly associated with only the adverse effects and negative outcomes. It has been suggested that such terms should no longer be used to describe the sophisticated procedures in use today and that, in the new millennium, a simple descriptive term, ‘neurosurgery for mental disorders’ (NMD), be adopted, in the hope that the prejudices associated with this treatment can be forgotten. It is only then that NMD will be thoroughly evaluated and its place in the management of mental illness ascribed.

Gin Malhi

Bibliography

Malhi, G. S.,, Bridges, P. K.,, and and Malizia, A. L. (1997). Neurosurgery for mental disorders (NMD). A clinical worldwide perspective: past, present and furture. International Journal of Psychiatry in Clinical Practice, 1, 119–29.

lo·bot·o·my / ləˈbätəmē/ • n. (pl. -mies) a surgical operation involving incision into the prefrontal lobe of the brain, formerly used to treat mental illness.

lobotomy (prefrontal leucotomy) (loh-bot-ŏmi) n. see leucotomy.