Editing Lobotomy (section)

==History==
[[File:Insulin shock therapy.jpg|thumb|[[Insulin shock therapy]] administered in [[Helsinki]] in the 1950s.]]
In the early 20th century, the number of patients residing in mental hospitals increased significantly{{refn|A 1937 report detailed that in the United States there were then 477 psychiatric institutions with a total population of approximately 451,672 patients, almost half of whom had been resident for five years or more.<ref name="Feldman650Mashour411">{{harvnb|Feldman|Goodrich|2001|p=650}}; {{harvnb|Mashour|Walker|Martuza|2005|p=411}}</ref> The report also observed that psychiatric patients occupied 55 percent of all hospital beds in America.<ref name="Feldman650Mashour411" /> Conditions within US mental hospitals became the subject of public debate as a series of exposes were published in the 1940s.<ref>{{harvnb|Maisel|1946}}; {{harvnb|Wright|1947}}; {{harvnb|Deutsch|1948}};{{harvnb|Feldman|Goodrich|2001|p=650}}; {{harvnb|Pressman|2002|pp=148–50}}</ref> A 1946 ''[[Life (magazine)|Life]]'' magazine article remarked that the nation's system of mental hospitals resembled "little more than concentration camps on the Belsen pattern";<ref>Albert Q. Maisel, "Bedlam 1946, Most U.S. Mental Hospitals are a Shame and a Disgrace", ''Life'' 20 (1946), pp. 102–03, quoted in {{harvnb|Pressman|2002|p=149}}</ref> a point the piece emphasized with documentary photography that depicted patient neglect and dilapidated material conditions within psychiatric institutions.{{sfn|Pressman|2002|pp=148–49}}|group=n}} while little in the way of effective medical treatment was available.{{refn|[[Ugo Cerletti]], the Italian psychiatrist and joint inventor with [[Lucio Bini]] of [[electroconvulsive therapy]], described psychiatry during the interwar period as a "funereal science".{{sfn|Shorter|1997|p=218}} Likewise Egas Moniz, the inventor of leucotomy, referred to the "impotência terapeutica" (therapeutic impotence) of existing therapeutic remedies during the 1930s.{{sfn|Gross|Schäfer|2011|p=5|ps=}}|group=n}}{{sfn|Gross|Schäfer|2011|p=5|ps=}} 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.<ref>{{harvnb|Swayze|1995|pp=505–15}};{{harvnb|Hoenig|1995|p=337}}; {{harvnb|Meduna|1985|p=53}}</ref> The new "[[heroic measure|heroic]]" physical therapies devised during this experimental era,{{sfn|Pressman|2002|p=200|ps=}} including [[malarial therapy]] for [[general paresis of the insane]] (1917),{{sfn|Brown|2000|pp=371–82}} [[deep sleep therapy]] (1920), [[insulin shock therapy]] (1933), [[cardiazol]] shock therapy (1934), and [[electroconvulsive therapy]] (1938),<ref>{{harvnb|Shorter|1997|pp=190–225}}; {{harvnb|Jansson|1998}}</ref> served to galvanize a profession which had been both therapeutically moribund and systemically demoralized. Unlike other medical disciplines (e.g., Cardiology, Dermatology, Orthopedics, etc.) 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 (at the time) 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.<ref>{{harvnb|Healy|2000|p=404}}; {{harvnb|Braslow|1995|pp=600–05}}; {{harvnb|Braslow|1997|pp=89, 93}}</ref> Additionally, the relative (and quantitative) 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 up to, and including, lobotomies.{{sfn|Pressman|2002|p=200|ps=}}

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".{{sfn|Braslow|1997|p=3}} For [[Roy Porter]], once the doyen of medical history,{{sfn|Cooter|2012|p=216|ps=}} 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.{{sfn|Porter|1999|p=520}} 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 even feted and regarded as a legitimate last-resort remedy for categories of patients who were otherwise regarded as hopeless.<ref>{{harvnb|Pressman|2002|p=428|ps=}}; {{harvnb|Raz|2009|pp=116, 129}}</ref> Today, lobotomy has become a disparaged procedure, a byword for medical barbarism and an exemplary instance of the medical trampling of [[patients' rights]].{{sfn|Raz|2009|p=116|ps=}}

===Early psychosurgery===
[[File:Gottlieb Burckhardt.jpg|thumb|left|The Swiss psychiatrist [[Gottlieb Burckhardt]] (1836–1907)]]

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]].<ref>{{harvnb|Gross|Schäfer|2011|p=1}}; {{harvnb|Heller|Amar|Liu|Apuzzo|2006|p=727}}; {{harvnb|Joanette|Stemmer|Assal|Whitaker|1993|pp=572, 575}}; {{harvnb|Kotowicz|2008|p=486}}; {{harvnb|Manjila|Rengachary|Xavier|Parker|2008|p=1}}; {{harvnb|Noll|2007|p=326}}; {{harvnb|Reevy|Ozer|Ito|2010|p=485}}; {{harvnb|Steck|2010|pp=85–89}}; {{harvnb|Stone|2001|pp=79–92}}; {{harvnb|Suchy|2011|p=37}}; {{harvnb|Mareke|Fangerau|2010|p=138}}; {{harvnb|Ford|Henderson|2006|p=219}}; {{harvnb|Green|Astradsson|Stacey|Aziz|2010|p=208}}; {{harvnb|Sakas|Panourias|Singounas|Simpson|2007|p=366}}; {{harvnb|Whitaker|Stemmer|Joanette|1996|p=276}}</ref> 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 [[associationism|associationist]] model comprising an input or [[Afferent nerve fiber|afferent system]] (a sensory center), a connecting system where information processing took place (an [[association center]]), and an output or [[Efferent nerve fiber|efferent]] system (a motor center); and, finally, a modular conception of the brain whereby discrete mental faculties were connected to specific regions of the brain.{{sfn|Berrios|1997|p=68|ps=}} Burckhardt's hypothesis was that by deliberately creating [[lesion]]s in regions of the brain identified as association centers, a transformation in behaviour might ensue.{{sfn|Berrios|1997|p=68|ps=}} 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 [[psychopathology|mental pathology]].{{sfn|Berrios|1997|p=69|ps=}} 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]].{{sfn|Berrios|1997|pp=69, 77|ps=}}
[[File:Ludvig Puusepp, 1920s.jpg|thumb|right|upright|The Estonian neurosurgeon [[Ludvig Puusepp]] c. 1920]]
Intending to ameliorate symptoms in those with violent and intractable conditions rather than effect a cure,{{sfn|Tierney|2000|p=26|ps=}} Burckhardt began operating on patients in December 1888,<ref>{{harvnb|Whitaker|Stemmer|Joanette|1996|p=276}}; {{harvnb|Berrios|1997|p=69}}</ref> but both his surgical methods and instruments were crude and the results of the procedure were mixed at best.{{sfn|Berrios|1997|p=69|ps=}} 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 seizure|epileptic convulsions]] and died a few days after the operation, and one patient improved.{{refn|The patient he thought improved subsequently committed suicide.{{sfn|Stone|2001|p=80}}|group=n}} Complications included motor weakness, [[epilepsy]], [[sensory aphasia]] and "[[word deafness]]".{{sfn|Berrios|1997|p=70|ps=}} Claiming a success rate of 50 percent,{{sfn|Manjila|Rengachary|Xavier|Parker|2008|p=1|ps=}} 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.{{sfn|Kotowicz|2005|pp=77–101|ps=}}

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.<ref>{{harvnb|Bechterev|Puusepp|1912}}; {{harvnb|Kotowicz|2008|p=486|ps=}}</ref> 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.<ref name="Kotowicz2005p802008p486">{{harvnb|Kotowicz|2005|p=80}}; {{harvnb|Kotowicz|2008|p=486|}}</ref>
{{Blockquote|We have quoted this data to show not only how groundless but also how dangerous these operations were. We are unable to explain how their author, holder of a degree in medicine, could bring himself to carry them out&nbsp;...<ref>Quoted in {{harvnb|Berrios|1997|p=71}}</ref>}}

The authors neglected to mention, however, that in 1910 Puusepp himself had performed surgery on the brains of three mentally ill patients,{{refn|According to Puusepp, the three patients had manic depression or considered "epileptic equivalents".{{sfn|Feldman|Goodrich|2001|p=149|ps=}}|group=n}}<ref>{{harvnb|Kotowicz|2005|p=80}}; {{harvnb|Kotowicz|2008|p=486|}}; {{harvnb|Berrios|1997|p=71}}</ref> sectioning the [[cerebral cortex|cortex]] between the [[frontal lobe|frontal]] and [[parietal lobe]]s.{{sfn|Feldman|Goodrich|2001|p=649|ps=}} 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.<ref name="Kotowicz2005p802008p486" /> By 1937, Puusepp, despite his earlier criticism of Burckhardt, was increasingly persuaded that psychosurgery could be a valid medical intervention for the mentally disturbed.{{refn|group=n|Puusepp admitted to his 1910 experimentation with psychosurgery in a 1937 publication.{{sfn|Puusepp|1937|ps=}} At that point he had completed a series of 14 leucotomies to relieve aggressive symptoms in patients. Convinced that the results had been positive in these cases, he felt that further research into psychosurgery was warranted.{{sfn|Feldman|Goodrich|2001|p=649|ps=}}}}{{sfn|Kotowicz|2008|p=486|ps=}} 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.{{sfn|Kotowicz|2008|p=477|ps=}}

===Development===
[[File:Moniz.jpg|thumb|left|upright|The pioneer of lobotomies, the Portuguese neurologist and Nobel Laureate [[António Egas Moniz]]]]
Leucotomy was first undertaken in 1935 under the direction of the [[Portuguese people|Portuguese]] [[neurologist]] (and inventor of the term ''psychosurgery'') [[António Egas Moniz]].{{refn|Professor of neurology at the University of Lisbon from 1911 to 1944, Moniz was also for several decades a prominent parliamentarian and diplomat. He was Portugal's ambassador to Spain during World War I and represented Portugal at the postwar [[Versailles Treaty]] negotiations,{{sfn|Tierney|2000|p=23|ps=}} but after the Portuguese [[28 May 1926 coup d'état|coup d'état of 1926]], which ushered in the [[Ditadura Nacional]] (National Dictatorship), the [[Republicanism|Republican]] Moniz, then 51 years old, devoted his considerable talents and energies to neurological research entirely. Throughout his career he published on topics as diverse as neurology, sexology, historical biography, and the history of card games.<ref>{{harvnb|Tierney|2000|p=25}}; {{harvnb|Tierney|2000|pp=22–23}}; {{harvnb|Kotowicz|2005|pp=78}}</ref> For his 1927 development of [[cerebral angiography]], which allowed routine visualisation of the brain's peripheral blood vessels for the first time, he was twice nominated, unsuccessfully, for a Nobel Prize. Some have attributed his development of leucotomy to a determination on his part to win the Nobel after these disappointments.<ref>{{harvnb|Shorter|1997|p=226}}; {{harvnb|Tierney|2000|pp=25}}</ref>|group=n}}<ref>{{harvnb|Doby|1992|p=2}}; {{harvnb|Tierney|2000|pp=25}}</ref> First developing an interest in psychiatric conditions and their somatic treatment in the early 1930s,{{sfn|El-Hai|2005|p=100|ps=}} Moniz conceived a new opportunity for recognition in the development of a surgical intervention on the brain as a treatment for mental illness.{{sfn|Tierney|2000|p=26|ps=}}

====Frontal lobes====
The source of inspiration for Moniz's decision to hazard psychosurgery has been clouded by contradictory statements made on the subject by Moniz and others both contemporaneously and retrospectively.{{sfn|Berrios|1997|p=72|ps=}} The traditional narrative addresses the question of why Moniz targeted the frontal lobes by way of reference to the work of the Yale neuroscientist [[John Farquhar Fulton|John Fulton]] and, most dramatically, to a presentation Fulton made with his junior colleague Carlyle Jacobsen at the Second International Congress of Neurology held in London in 1935.<ref>{{harvnb|Pressman|2002|pp=13–14, 48–51, 54–55}}; {{harvnb|Berrios|1997|pp=72–73}}; {{harvnb|Shorter|1997|p=226}}; {{harvnb|Heller|Amar|Liu|Apuzzo|2006|p=721}}</ref> Fulton's primary area of research was on the cortical function of primates and he had established America's first primate neurophysiology laboratory at Yale in the early 1930s.{{sfn|Heller|Amar|Liu|Apuzzo|2006|p=721|ps=}} At the 1935 Congress, with Moniz in attendance,{{refn|group=n|The American neuropsychiatrist Walter Freeman also attended the Congress where he presented his research findings on [[cerebral ventriculography]]. Freeman, who would later play a central role in the popularisation and practice of leucotomy in America, also had an interest in personality changes following frontal lobe surgery.{{sfn|Feldman|Goodrich|2001|p=649|ps=}}}} Fulton and Jacobsen presented two [[Common chimpanzee|chimpanzees]] named Becky and Lucy who had had frontal lobectomies and subsequent changes in behaviour and intellectual function.{{sfn|Pressman|2002|p=48}} According to Fulton's account of the congress, they explained that before surgery, both animals, and especially Becky, the more emotional of the two, exhibited "frustrational behaviour"{{snd}}that is, have tantrums that could include rolling on the floor and defecating{{snd}}if, because of their poor performance in a set of experimental tasks, they were not rewarded.<ref>{{harvnb|Pressman|2002|p=48}}; {{harvnb|Heller|Amar|Liu|Apuzzo|2006|p=721}}</ref> Following the surgical removal of their frontal lobes, the behaviour of both primates changed markedly and Becky was pacified to such a degree that Jacobsen apparently stated it was as if she had joined a "happiness cult".{{sfn|Pressman|2002|p=48}} During the question and answer section of the paper, Moniz, it is alleged, "startled" Fulton by inquiring if this procedure might be extended to human subjects suffering from mental illness. Fulton stated that he replied that while possible in theory it was surely "too formidable" an intervention for use on humans.<ref>{{harvnb|Pressman|2002|p=48}}; {{harvnb|Berrios|1997|p=73}}</ref>
[[File:Frontal lobe animation.gif|thumb|[[Human brain|Brain]] animation: left [[frontal lobe]] highlighted in red. Moniz targeted the frontal lobes in the leucotomy procedure he first conceived in 1933.]]

Moniz began his experiments with leucotomy just three months after the congress had reinforced the apparent cause-and-effect relationship between the Fulton and Jacobsen presentation and the Portuguese neurologist's resolve to operate on the frontal lobes.{{sfn|Berrios|1997|p=73|ps=}} As the author of this account Fulton, who has sometimes been claimed as the father of lobotomy, was later able to record that the technique had its true origination in his laboratory.{{sfn|Pressman|2002|pp=48–50|ps=}} Endorsing this version of events, in 1949, the Harvard neurologist [[Stanley Cobb]] remarked during his presidential address to the [[American Neurological Association]] that "seldom in the history of medicine has a laboratory observation been so quickly and dramatically translated into a therapeutic procedure". Fulton's report, penned ten years after the events described, is, however, without corroboration in the historical record and bears little resemblance to an earlier unpublished account he wrote of the congress. In this previous narrative, he mentioned an incidental, private exchange with Moniz, but it is likely that the official version of their public conversation he promulgated is without foundation.{{sfn|Pressman|2002|p=50|ps=}} In fact, Moniz stated that he had conceived of the operation sometime before his journey to London in 1935, having told in confidence his junior colleague, the young [[neurosurgeon]] Pedro Almeida Lima, as early as 1933 of his psychosurgical idea.{{sfn|Berrios|1997|pp=72–73|ps=}} The traditional account exaggerates the importance of Fulton and Jacobsen to Moniz's decision to initiate frontal lobe surgery, and omits the fact that a detailed body of neurological research that emerged at this time suggested to Moniz and other neurologists and neurosurgeons that surgery on this part of the brain might yield significant personality changes in the mentally ill.<ref>{{harvnb|Pressman|2002|pp=48–55}}; {{harvnb|Valenstein|1997|p=541}}</ref>

The frontal lobes have been the object of scientific inquiry and speculation since the late 19th century. Fulton's contribution, while it may have functioned as a source of intellectual support, is in itself unnecessary and inadequate as an explanation of Moniz's resolution to operate on this section of the brain.{{sfn|Pressman|2002|pp=51, 55|ps=}} Under an evolutionary and hierarchical model of brain development it had been hypothesized that those regions associated with the more recent development, such as the [[mammalian brain]] and, most especially, the frontal lobes, were responsible for more complex cognitive functions.{{sfn|Pressman|2002|p=51|ps=}} However, this theoretical formulation found little laboratory support, as 19th-century experimentation found no significant change in animal behaviour following surgical removal or electrical stimulation of the frontal lobes.{{sfn|Pressman|2002|p=51|ps=}} This picture of the so-called "silent lobe" changed in the period after World War I with the production of clinical reports of ex-servicemen with [[traumatic brain injury|brain trauma]]. The refinement of neurosurgical techniques also facilitated increasing attempts to remove brain tumours, and treat [[focal epilepsy]] in humans and led to more precise experimental neurosurgery in animal studies.{{sfn|Pressman|2002|p=51|ps=}} Cases were reported where mental symptoms were alleviated following the surgical removal of diseased or damaged brain tissue.{{sfn|Feldman|Goodrich|2001|p=649|ps=}} The accumulation of medical case studies on behavioural changes following damage to the frontal lobes led to the formulation of the concept of ''[[Witzelsucht#Frontal lobe|Witzelsucht]]'', which designated a neurological condition characterised by a certain hilarity and childishness in those with the condition.{{sfn|Pressman|2002|p=51|ps=}} The picture of frontal lobe function that emerged from these studies was complicated by the observation that neurological deficits attendant on damage to a single lobe might be compensated for if the opposite lobe remained intact.{{sfn|Pressman|2002|p=51|ps=}} In 1922, the Italian neurologist [[Leonardo Bianchi]] published a detailed report on the results of bilateral lobectomies in animals that supported the contention that the frontal lobes were both integral to intellectual function and that their removal led to the disintegration of the subject's personality.<ref>{{harvnb|Bianchi|1922}}; {{harvnb|Pressman|2002|p=51}}; {{harvnb|Levin|Eisenberg|1991|p=14}}</ref> This work, while influential, was not without its critics due to deficiencies in experimental design.{{sfn|Pressman|2002|p=51|ps=}}

The first bilateral lobectomy of a human subject was performed by the American neurosurgeon [[Walter Dandy]] in 1930.{{refn|The patient had [[meningioma]], a rare form of brain tumour arising in the [[meninges]].<ref name="Pressman02p52Kotowiczp85">{{harvnb|Pressman|2002|p=52}}; {{harvnb|Kotowicz|2005|p=84}}</ref>|group=n}}<ref name="Pressman02p52Kotowiczp85" /> The neurologist Richard Brickner reported on this case in 1932,{{sfn|Brickner|1932|ps=}} relating that the recipient, known as "Patient A", while experiencing a [[blunted affect|blunting of affect]], had no apparent decrease in intellectual function and seemed, at least to the casual observer, perfectly normal.{{sfn|Kotowicz|2005|p=84|ps=}} Brickner concluded from this evidence that "the frontal lobes are not 'centers' for the intellect".<ref name="QuotePressman02p52">Quoted in {{harvnb|Pressman|2002|p=52}}</ref> These clinical results were replicated in a similar operation undertaken in 1934 by the neurosurgeon [[Roy Glenwood Spurling]] and reported on by the neuropsychiatrist [[S. Spafford Ackerly|Spafford Ackerly]].{{sfn|Pressman|2002|p=52|ps=}} By the mid-1930s, interest in the function of the frontal lobes reached a high-water mark. This was reflected in the 1935 neurological congress in London, which hosted{{sfn|Pressman|2002|p=52|ps=}} as part of its deliberations,{{sfn|Pressman|2002|p=52|ps=}} "a remarkable symposium&nbsp;... on the functions of the frontal lobes".<ref>Quoted in {{harvnb|Freeman|Watts|1944|p=532}}</ref> The panel was chaired by [[Henri Claude]], a French neuropsychiatrist, who commenced the session by reviewing the state of research on the frontal lobes, and concluded that "altering the frontal lobes profoundly modifies the personality of subjects".<ref name="QuotePressman02p52" /> This parallel symposium contained numerous papers by neurologists, neurosurgeons and psychologists; amongst these was one by Brickner, which impressed Moniz greatly,{{sfn|Kotowicz|2005|p=84|ps=}} that again detailed the case of "Patient A".{{sfn|Pressman|2002|p=52|ps=}} Fulton and Jacobsen's paper, presented in another session of the conference on experimental physiology, was notable in linking animal and human studies on the function of the frontal lobes.{{sfn|Pressman|2002|p=52|ps=}} Thus, at the time of the 1935 Congress, Moniz had available to him an increasing body of research on the role of the frontal lobes that extended well beyond the observations of Fulton and Jacobsen.{{sfn|Pressman|2002|p=53|ps=}}

Nor was Moniz the only medical practitioner in the 1930s to have contemplated procedures directly targeting the frontal lobes.{{sfn|Valenstein|1990|p=541|ps=}} Although ultimately discounting brain surgery as carrying too much risk, physicians and neurologists such as [[William James Mayo|William Mayo]], Thierry de Martel, Richard Brickner, and [[Leo M. Davidoff|Leo Davidoff]] had, before 1935, entertained the proposition.{{refn|group=n|Brickner and Davidoff had planned, before Moniz's first leucotomies, to operate on the frontal lobes to relieve depression.{{sfn|Valenstein|1997|p=503|ps=}}}}{{sfn|Feldman|Goodrich|2001|p=650|ps=}} Inspired by [[Julius Wagner-Jauregg]]'s development of malarial therapy for the treatment of [[general paresis of the insane]], the French physician Maurice Ducosté reported in 1932 that he had injected 5&nbsp;ml of malarial blood directly into the frontal lobes of over 100 paretic patients through holes drilled into the skull.{{sfn|Valenstein|1990|p=541|ps=}} He claimed that the injected paretics showed signs of "uncontestable mental and physical amelioration" and that the results for psychotic patients undergoing the procedure were also "encouraging".<ref>Quoted in {{harvnb|Valenstein|1990|p=541}}</ref> The experimental injection of fever-inducing malarial blood into the frontal lobes was also replicated during the 1930s in the work of Ettore Mariotti and M. Sciutti in Italy and Ferdière Coulloudon in France.<ref>{{harvnb|Valenstein|1990|p=541}}; {{harvnb|Feldman|Goodrich|2001|p=650}}; {{harvnb|Kotowicz|2008|p=478}}</ref> In Switzerland, almost simultaneously with the commencement of Moniz's leucotomy programme, the neurosurgeon François Ody had removed the entire right frontal lobe of a [[Catatonic Schizophrenia|catatonic schizophrenic]] patient.<ref>{{harvnb|Berrios|1997|p=77}}; {{harvnb|Valenstein|1990|p=541}}; {{harvnb|Valenstein|1997|p=503}}</ref> In Romania, Ody's procedure was adopted by Dimitri Bagdasar and Constantinesco working out of the Central Hospital in Bucharest.{{sfn|Valenstein|1997|p=503|ps=}} Ody, who delayed publishing his own results for several years, later rebuked Moniz for claiming to have cured patients through leucotomy without waiting to determine if there had been a "lasting remission".<ref>Quoted in {{harvnb|Valenstein|1997|p=503}}</ref>

====Neurological model====

The theoretical underpinnings of Moniz's psychosurgery were largely commensurate with the nineteenth-century ones that had informed Burckhardt's decision to excise matter from the brains of his patients. Although in his later writings, Moniz referenced both the [[neuron theory]] of [[Ramón y Cajal]] and the [[conditioned reflex]] of [[Ivan Pavlov]],{{sfn|Gross|Schäfer|2011|p=1|ps=}} in essence he simply interpreted this new neurological research in terms of the old psychological theory of [[associationism]].{{sfn|Berrios|1997|p=72|ps=}} He differed significantly from Burckhardt, however in that he did not think there was any organic pathology in the brains of the mentally ill, but rather that their neural pathways were caught in fixed and destructive circuits leading to "predominant, obsessive ideas".{{refn|Moniz wrote in 1948: 'sufferers from melancholia, for instance, are distressed by fixed and obsessive ideas&nbsp;... and live in a permanent state of anxiety caused by a fixed idea which predominates over all their lives&nbsp;... in contrast to automatic actions, these morbid ideas are deeply rooted in the synaptic complex which regulates the functioning of consciousness, stimulating it and keeping it in constant activity&nbsp;... all these considerations led me to the following conclusion: it is necessary to alter these synaptic adjustments and change the paths chosen by the impulses in their constant passage so as to modify the corresponding ideas and force thoughts along different paths&nbsp;...'<ref>Quoted in {{harvnb|Berrios|1997|p=74}}</ref>|group=n}}<ref>{{harvnb|Kotowicz|2005|p=99}}; {{harvnb|Gross|Schäfer|2011|p=1}}</ref> As Moniz wrote in 1936:
<blockquote>[The] mental troubles must have&nbsp;... a relation with the formation of cellulo-connective groupings, which become more or less fixed. The cellular bodies may remain altogether normal, their cylinders will not have any anatomical alterations; but their multiple liaisons, very variable in normal people, may have arrangements more or less fixed, which will have a relation with persistent ideas and deliria in certain morbid psychic states.<ref>Quoted in {{harvnb|Kotowicz|2005|p=88}}</ref></blockquote>

For Moniz, "to cure these patients", it was necessary to "destroy the more or less fixed arrangements of cellular connections that exist in the brain, and particularly those which are related to the frontal lobes",<ref>Quoted in {{harvnb|Feldman|Goodrich|2001|p=651}}</ref> thus removing their fixed pathological brain circuits. Moniz believed the brain would functionally adapt to such injury.{{sfn|Berrios|1997|p=74|ps=}} Unlike the position adopted by Burckhardt, it was [[unfalsifiable]] according to the knowledge and technology of the time as the absence of a known correlation between physical brain pathology and mental illness could not disprove his thesis.{{sfn|Kotowicz|2005|p=89|ps=}}

====First leucotomies====

{{quote box|salign=right|align=right|quote=The hypotheses underlying the procedure might be called into question; the surgical intervention might be considered very audacious; but such arguments occupy a secondary position because it can be affirmed now that these operations are not prejudicial to either physical or psychic life of the patient, and also that recovery or improvement may be obtained frequently in this way.|width=35em|source=—Egas Moniz (1937){{sfn|Moniz|1994|p=237}}}}

On 12 November 1935 at the [[Hospital de Santa Marta]] in [[Lisbon]], Moniz initiated the first of a series of operations on the brains of people with mental illnesses.<ref>{{harvnb|Kotowicz|2005|pp=80–81}}; {{harvnb|Feldman|Goodrich|2001|p=650}}</ref> The initial patients selected for the operation were provided by the medical director of Lisbon's Miguel Bombarda Mental Hospital, José de Matos Sobral Cid.<ref>{{harvnb|Gross|Schäfer|2011|p=2}}; {{harvnb|Kotowicz|2008|p=482}}</ref> As Moniz lacked training in neurosurgery and his hands were impaired by gout, the procedure was performed under general anaesthetic by Pedro Almeida Lima, who had previously assisted Moniz with his research on [[cerebral angiography]].{{refn|Lima described his role as that of an "instrument handled by the Master".{{sfn||Gross|Schäfer|2011|p=2|ps=}}|group=n}}<ref>{{harvnb|Tierney|2000|p=29}}; {{harvnb|Kotowicz|2005|pp=80–81}}; {{harvnb|Gross|Schäfer|2011|p=2}}</ref> The intention was to remove some of the long fibres that connected the frontal lobes to other major brain centres.{{sfn|Pressman|2002|p=54|ps=}} To this end, it was decided that Lima would [[trephine]] into the side of the skull and then inject [[ethanol]] into the "[[Cerebral cortex#Connections|subcortical]] [[white matter]] of the prefrontal area"{{sfn|Moniz|1994|p=237}} so as to destroy the connecting fibres, or [[association tract]]s,{{sfn|Finger|2001|p=292}} and create what Moniz termed a "frontal barrier".{{refn|group=n|Before operating on live subjects, they practised the procedure on a cadaver head.{{sfn|Feldman|Goodrich|2001|p=650|ps=}}}}{{sfn|Kotowicz|2005|p=81|ps=}} After the first operation was complete, Moniz considered it a success and, observing that the patient's depression had been relieved, he declared her "cured" although she was never, in fact, discharged from the mental hospital.{{sfn|Feldman|Goodrich|2001|p=651|ps=}} Moniz and Lima persisted with this method of injecting alcohol into the frontal lobes for the next seven patients but, after having to inject some patients on numerous occasions to elicit what they considered a favourable result, they modified the means by which they would section the frontal lobes.{{sfn|Feldman|Goodrich|2001|p=651|ps=}} For the ninth patient they introduced a surgical instrument called a [[leucotome]]; this was a [[cannula]] that was {{convert|11|cm|in}} in length and {{convert|2|cm|in}} in diameter. It had a retractable wire loop at one end that, when rotated, produced a {{convert|1|cm|in}} diameter circular lesion in the white matter of the frontal lobe.<ref>{{harvnb|Jansson|1998}}; {{harvnb|Gross|Schäfer|2011|p=2}}; {{harvnb|Feldman|Goodrich|2001|p=651}}. For Moniz's account of the procedure see, {{harvnb|Moniz|1994|pp=237–39}}</ref> Typically, six lesions were cut into each lobe, but, if they were dissatisfied by the results, Lima might perform several procedures, each producing multiple lesions in the left and right frontal lobes.{{sfn|Feldman|Goodrich|2001|p=651|ps=}}

By the conclusion of this first run of leucotomies in February 1936, Moniz and Lima had operated on twenty patients with an average period of one week between each procedure; Moniz published his findings with great haste in March of the same year.<ref>{{harvnb|Kotowicz|2005|p=81|ps=}}; {{harvnb|Feldman|Goodrich|2001|p=651}}; {{harvnb|Valenstein|1997|p=504}}</ref> The patients were aged between 27 and 62 years of age; twelve were female and eight were male. Nine of the patients were diagnosed with [[major depressive disorder|depression]], six with [[schizophrenia]], two with [[panic disorder]], and one each with [[mania]], [[catatonia]] and [[manic-depression]]. Their most prominent symptoms were anxiety and agitation. The duration of their illness before the procedure varied from as little as four weeks to as much as 22 years, although all but four had been ill for at least one year.{{sfn|Berrios|1997|p=75|ps=}} Patients were normally operated on the day they arrived at Moniz's clinic and returned within ten days to the Miguel Bombarda Mental Hospital.{{sfn|Kotowicz|2005|p=92|ps=}} A perfunctory post-operative follow-up assessment took place anywhere from one to ten weeks following surgery.<ref>{{harvnb|Berrios|1997|p=75}}; {{harvnb|Kotowicz|2005|p=92}}</ref> Complications were observed in each of the leucotomy patients and included: "increased temperature, vomiting, [[urinary incontinence|bladder]] and [[fecal incontinence|bowel incontinence]], diarrhea, and ocular affections such as [[ptosis (eyelid)|ptosis]] and [[nystagmus]], as well as psychological effects such as apathy, [[akinesia]], lethargy, timing, and local disorientation, [[kleptomania]], and abnormal sensations of hunger".{{sfn|Gross|Schäfer|2011|p=3|ps=}} Moniz asserted that these effects were transitory and,{{sfn|Gross|Schäfer|2011|p=3|ps=}} according to his published assessment, the outcome for these first twenty patients was that 35%, or seven cases, improved significantly, another 35% were somewhat improved and the remaining 30% (six cases) were unchanged. There were no deaths and he did not consider that any patients had deteriorated following leucotomy.<ref>{{harvnb|Berrios|1997|p=74}}; {{harvnb|Gross|Schäfer|2011|p=3}}</ref>