[Paleopsych] SW: On Lobotomy

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History of Medicine: On Lobotomy

    The following points are made by Barron H. Lerner (New Engl. J. Med.
    2005 353:119):
    1) In the early 1900s, relatives frequently committed their loved ones
    to long stays in understaffed, overcrowded, and often filthy mental
    institutions. The therapeutic options for severe mental illness were
    quite limited. One option, the lobotomy, also known as leucotomy, was
    devised in 1935 by the Portuguese neurologist Antonio Egas Moniz
    (1847-1931). It involved drilling holes in the skull and using a blade
    to sever nerve fibers running from the frontal lobes to the rest of
    the brain. Moniz believed that psychiatric symptoms were caused by
    faulty nerve connections established over a period of years. If these
    nerves were severed and new connections were allowed to form, he
    postulated, patients' symptoms would improve. Lobotomies were
    originally used to treat patients with depression but were later often
    performed to treat schizophrenic patients suffering from agitation and
    paranoid delusions.
    2) The principal US proponent of lobotomy was the neurologist Walter
    J. Freeman, of George Washington University Medical School. In June
    1937, at the annual meeting of the American Medical Association,
    Freeman and his colleague James W. Watts, a neurosurgeon, presented
    data on 20 patients who had undergone lobotomy.{1,2] Their paper
    launched a fierce debate on the procedure. On the one hand, certain
    members of the medical profession consistently condemned it as brutal,
    unscientific, and harmful. This appears to have been the case with the
    1941 lobotomy performed on Rosemary Kennedy, the mildly retarded
    sister of John F. Kennedy, whose cognitive functions were severely
    worsened by the operation. The negative image of lobotomy entered the
    popular culture through Ken Kesey's 1962 novel ONE FLEW OVER THE
    CUCKOO'S NEST and the movie based on it, in which the rebellious hero
    becomes nearly catatonic after undergoing the operation.
    3) On the other hand, Freeman's data painted quite a different
    picture. The condition of 13 of the 20 patients, he and Watts claimed,
    had improved. In one case, a 63-year-old housewife who had had
    increasing anxiety and agitation for a year, they said, "now manages
    home and household accounts, enjoys people, attends theater, drives
    her own car."[2] Bolstered by such results, which were confirmed by
    later studies, Freeman's enthusiasm for lobotomy increased. In 1946,
    he devised the so-called transorbital lobotomy, in which he used a
    mallet to pound an ice pick through the patient's eye socket into the
    brain, then moved the pick around blindly to sever the nerve fibers.
    He traveled the world promoting his new procedure.
    4) Certain physicians, especially those who treated the roughly
    400,000 patients in state mental hospitals, embraced the lobotomy. So
    did the media, thanks in part to Freeman's showmanship. Tens of
    thousands of lobotomies were performed in the United States before the
    introduction of chlorpromazine and other neuroleptic medications made
    the operation all but obsolete by the 1960s. In 1949, Moniz was
    awarded the Nobel Prize in Physiology or Medicine for inventing the
    5) One of the virtues of historical scholarship is its dynamism: each
    scholar, building on new information and insights, can revise the
    conclusions of earlier works. The first book to evaluate lobotomy,
    Elliot S. Valenstein's GREAT AND DESPERATE CURES,[3] was highly
    critical of Freeman and his operation, which Valenstein saw as
    providing a cautionary tale about overzealous physicians. Joel
    Braslow's MENTAL ILLS AND BODILY CURES argued that a major motivation
    for lobotomies was to create "apathetic, indifferent, and docile"
    patients who would be more compliant than they had been.[4] But Jack
    D. Pressman, in LAST RESORT, emphasized the importance of evaluating
    historical events within the context of their own time.[5] Although
    the notion of cutting brain tissue in order to make people submissive
    is repugnant from our modern perspective, the ability to discharge
    psychiatric patients even to a limited existence at home was perceived
    as a therapeutic triumph in the 1940s and 1950s.
    1. El-Hai J. The lobotomist: a maverick medical genius and his tragic
    quest to rid the world of mental illness. New York: Wiley, 2005
    2. Laurence WL. Surgery used on the soul-sick: relief of obsessions is
    reported. New York Times. June 7, 1937:1, 10
    3. Valenstein ES. Great and desperate cures: the rise and decline of
    psychosurgery and other radical treatments for mental illness. New
    York: Basic Books, 1986
    4. Braslow J. Mental ills and bodily cures: psychiatric treatment in
    the first half of the twentieth century. Berkeley: University of
    California Press, 1997
    5. Pressman JD. Last resort: psychosurgery and the limits of medicine.
    Cambridge, England: Cambridge University Press, 1998
    New Engl. J. Med. http://www.nejm.org
    Related Material:
    Notes by ScienceWeek:
    The human cerebral hemispheres (collectively termed the "cerebrum")
    represent 85 percent of the brain by weight, and for nearly two
    centuries one sustained research effort, involving a large number of
    researchers, has been to identify which parts of the cerebral
    hemispheres are involved with which mental functions. Such
    identifications must be made carefully and in context, since
    essentially every part of the brain is directly or indirectly
    connected to every other part, with all parts in principle capable of
    Still, for certain higher functions, a high degree of localization is
    apparent. Apart from their large size in humans, what is most evident
    about the human cerebral hemispheres is the high degree of
    convolution, a tortuous array of foldings of tissue, one consequence
    of which is an enormous increase in surface area. This increase in
    surface area is of some significance, since the entire convoluted
    surface of the hemispheres comprises a laminated rind of neurons and
    supporting cells approximately 2 millimeters thick, the rind called
    the "cerebral cortex".
    The total surface area of the cerebral cortex comprises approximately
    1.6 square-meters, and it is within this relatively thin layer of
    neurons that most of the processing for the so-called "higher
    functions" is accomplished. The convolutions of the cerebrum thus make
    it possible to have an enormous number of neurons distributed in two
    dimensions in the cerebral cortex without the necessity for an
    excessively large head. Seen in toto, each cerebral hemisphere
    consists of 4 lobes: frontal, parietal, temporal, and occipital (named
    after the bones under which they lie), and it has been the frontal
    lobe, the large fore-part of the brain, which has been the most
    mysterious in terms of function.
    The most functionally well-defined region of the frontal lobe is the
    "primary motor area", which lies at the border between the frontal
    lobe and the parietal lobe, and which is involved in the voluntary
    control of movement. The back part of the frontal lobe anterior to the
    motor region is called the "prefrontal region", and prefrontal cortex
    is apparently involved in planning complex cognitive behaviors. In
    recent years, "*functional imaging" techniques, which are essentially
    non-invasive and which can be used with healthy and awake human
    subjects, have become important new approaches to an old problem.
    In general, the human frontal cortex apparently helps mediate "working
    memory", a system that is used by the brain for temporary storage and
    manipulation of information, and that is involved in many higher
    cognitive functions. Working memory apparently includes two
    components: short-term storage (on the order of seconds), and
    executive processes that operate on the contents of storage.
    The following points are made by E.E. Smith and J. Jonides (Science
    1999 283:1657):
    1) The authors present a review of current research concerning the
    functions of the human frontal lobes as revealed by experiments using
    *positron emission tomography or *functional magnetic resonance
    imaging to image subjects while the subjects engage in cognitive tasks
    designed to reveal processes of interest.
    2) The authors report that studies of storage indicate that different
    frontal regions are activated for different kinds of information:
    storage for verbal materials activates Broca's area (an area
    specialized for the production of language) and left-hemisphere
    prefrontal areas adjacent to primary motor cortex; storage of spatial
    information activates right-hemisphere prefrontal cortex adjacent to
    primary motor cortex; storage of object information activates other
    areas of prefrontal cortex. Selective attention and task management,
    two of the fundamental executive processes, both activate regions of
    prefrontal cortex. The authors conclude: "Neuroimaging analyses of
    executive processes are quite recent, and they have yet to lead to
    clear dissociations between processes. Perhaps the highest priority,
    then, is to turn further attention to executive processes and their
    implementation in frontal cortex."
    Science http://www.sciencemag.org
    Notes by ScienceWeek:
    functional imaging: In general, in this context, the term "functional
    imaging" refers to any technique which images neural activity produced
    by specific behaviors (functions).
    positron emission tomography: Positron emission tomography is a
    technique for producing cross-sectional images of the body after
    ingestion and systemic distribution of safely metabolized
    positron-emitting agents. The images are essentially functional or
    metabolic, since the ingested agents are metabolized in various
    tissues. Fluorodeoxyglucose and H(sub2)O(sup15) are common agents used
    for cerebral applications, and in cerebral applications of central
    importance to the technique is the fact that changes in the cellular
    activity of the brains of normal, awake humans and unanesthetized
    laboratory animals are invariably accompanied by changes in local
    blood flow and also changes in oxygen consumption.
    functional magnetic resonance: Magnetic resonance imaging is a
    technique involving images produced by mobile protons of a tissue
    excited by the application of a magnetic field, and when used in
    functional cerebral imaging, the basis of the technique is that it
    images very small metabolic, blood-flow, and perfusion-diffusion
    changes in vivo, in real time, and with no risk to the subject.

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