Editing Lobotomy (section)

===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>