Lobotomy Research Articles

La moderna psicocirugía: un nuevo enfoque de la neurocirugía en la enfermedad psiquiátrica

To obtain an up to date review of the different possible surgical approaches in the management of certain psychiatric disorders that are refractory to conservative treatment (pharmacotherapy, psychotherapy, electroconvulsive therapy). In order to conduct this research we reviewed the work published by centres with the most experience in this type of surgery, mainly in North America and Europe, since its beginnings in the 1930s, with the controversy concerning prefrontal leucotomy, until the appearance of modern stereotactic techniques. We analyse the anatomophysiological bases, their main clinical indications, the surgical techniques used and their results, as well as perspectives for the future of this neurosurgical treatment. The most noteworthy progress in psychosurgery in recent years has been the combination of a more rigorous selection of patients and the higher degree of specificity with which treatment is performed on the brain structures involved in psychiatric disease. The most widely employed psychosurgical procedures at present are cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy and postero medial hypothalamotomy, with favourable responses in about 35 70% of cases. The psychiatric diagnoses where the best results are to be found are obsessive compulsive disorder, chronic anxiety states and major depression. Current progress in neuroimaging techniques, increased neurophysiological knowledge and the revolutionary neuromodulation techniques, especially deep brain stimulation, offer an even more promising future for psychiatric neurosurgery.

The Advanced Handbook of Methods in Evidence Based Healthcare • Evidence-Based Counselling and Psychological Therapies: Research and Applications

The Advanced Handbook of Methods in Evidence Based Healthcare • Evidence-Based Counselling and Psychological Therapies: Research and Applications

The death of electroconvulsive therapy.

In Italy, where it began more than 62 years ago, ECT has almost been abolished. In some countries, however, ECT is still used inappropriately, particularly in elderly patients. There is no medical, moral, or legal justification for ECT, and the new requirements of modern psychiatric practice can all be achieved without it. Like prefrontal lobotomy and all previous shock treatments, ECT is nonviable. The death of ECT will help promote mental health and put the treatment where it belongs--in the archaeology of science.

An autopsy case of the schizophrenic 32 years after lobotomy

An autopsy case is reported here of a 69‐year‐old patient with schizophrenia, who was known retrospectively to have had a prefrontal lobotomy 32 years previously. The patient was diagnosed as schizophrenic at the age of 24 and the lobotomy was undertaken 13 years later. The patient was recently found outside in a dehydrated condition and admitted to a general hospital, where he died of respiratory failure. Bilateral cystic lesions were found in the deep white matter of the frontal lobe. The cyst walls consisted of glial fibrous tissues, and severe demyelination with axonal destruction was diffusely observed in the white matter of the frontal lobe. In the thinner frontal cortex without arcuate fibers (U fibers) close to the cavities, cytoarchitectural abnormalities were observed. In the thalamic nuclei marked retrograde degeneration and astrocytic gliosis were observed. The detailed neuropathological findings of a lobotomized schizophrenic brain are reported here. It is proposed that one should be reminded of a lobotomized brain if bilateral cysts are found.

Leukotomy revisited: late cognitive and behavioral effects in chronic institutionalized schizophrenics

Background: In the 1940s and 1950s, prefrontal lobotomy was widely used to treat aggressive, disruptive and psychotic behavior in schizophrenics. Subsequent observations have confirmed its ineffectiveness in schizophrenia. Few studies have addressed its long-term consequences. Methods: We conducted tests of frontal function, behavior (Frontal Behavioral Inventory), psychopathology (PANSS), neurological examinations and CT scans in 19 chronically institutionalized schizophrenic patients (mean age 74) who had undergone orbitofrontal leukotomy between 1948 and 1972 and 11 controls (mean age 74) matched for age, length of hospitalization, education, and diagnosis. Results: There were no significant differences between leukotomized patients and controls on: Folstein Mini-Mental score (leuko 22.13±5.66; controls 23.55±5.93), utilization behavior, Luria alternating written and motor sequences, verbal fluency, imitation behavior, motor impersistence, primitive reflexes, or psychopathology. Significant differences were found on clock drawing and on the go/no-go test, which may reflect the presence of an orbitofrontal lesion in the leukotomized group. There was a tendency for the leukotomized group to have fewer indices of frontal behavioral dysfunction. Both groups showed comparable impairment on the Stroop test and cognitive rigidity on the Odd Man Out test of category shifting. Conclusions: With few exceptions, elderly leukotomized and nonleukotomized schizophrenic patients show varying degrees of distractibility, difficulty in set shifting, poor planning and organization, susceptibility to interference, primitive reflexes and signs of global cognitive impairment. Allowing for the small sample size, variability in the surgical frontal lesion, and the long interval from surgery to testing, these observations likely reflect the long-term consequences of severe schizophrenia in both groups.

Loss of Recent Memory After Bilateral Hippocampal Lesions

Loss of Recent Memory After Bilateral Hippocampal Lesions

A century and a half of modern neurology, a decade of the brain, and the millennium.

Roger Rosenberg, MD, asked us to outline the greatest triumphs of the century and important research that needs to be addressed. Can we tell? I started neurology training in 1950. Some of the thencurrent technologies disappeared unpredictably, such as pneumoencephalography, direct carotid injections for angiography, frontal lobotomy, fever therapy, and tank respirators. In addition, diseases, such as paralytic poliomyelitis, measles encephalitis, Reye syndrome, and neurosyphilis, disappeared. New technologies came unpredictably, such as computed tomography, magnetic resonance imaging, interventional neuroradiology, stereotaxic brain surgery, microsurgery, neurointensive care, positive pressure respirators, and antibiotics, arrived unpredictably. Effective drug therapy for previously untreatable diseases replaced the practice pattern Labe Scheinberg, MD, labeled ADiagnose and Adios@. Unpredicted wonders of basic science included the DNA code and molecular genetics, which contributed to clinical research. Reciprocally, investigation of human disease contributed to basic science, for example, prions and prion diseases, triplet repeats, positional cloning, allelic and locus heterogeneity, familial parkinsonism, dementias, motor neuron disease, and brain implants. All this research accelerated during the Decade of the Brain. Unpredicted adverse developments included AIDS (acquired immunodeficiency syndrome), developmental disorders, age-related neurodegenerative diseases, drug abuse, and diseases of poverty. Which is the most amenable target of research? What have we learned? With the Human Genome Project, we expect to find the gene product for every single-gene disease, but complex inheritance and gene therapy are challenges. In the past, we were not prescient about what was coming or going. We will certainly encounter new unforeseen developments, and the changes will come faster and faster. What a wonderful world it will be!

Three pioneers in the early history of neuroradiology: the Snyder lecture.

The early history of neuroradiology is linked to three pioneers who worked during the first half of the 20th century. Two were neuropsychiatrists and one was a neurosurgeon. Arthur Schüller, a Viennese neuropsychiatrist, was the first to study systematically the X-ray skull changes caused by intracranial disease. He is generally regarded as the 'father of neuroradiology'. Walter Dandy, the great neurosurgeon of Johns Hopkins, introduced ventriculography and penumoencephalography. Egas Moniz, a Portuguese neuropsychiatrist, developed cerebral angiography, and was awarded the Nobel Prize in Medicine for originating prefrontal lobotomy. The work of these three pioneers laid the basis through which modern neuroradiology became a separate discipline.

The mystery of angiography and the "unawarded" Nobel Prize: Egas Moniz and Hans Christian Jacobaeus.

To investigate the circumstances surrounding why Egas Moniz was not awarded the Nobel Prize for his contribution of angiography, provide a synopsis of Moniz's political and medical careers, and present a biographical sketch of Hans Christian Jacobaeus, the neurologist who evaluated Moniz's Nobel Prize nominations, as well as to dispel long-standing misconceptions concerning Moniz's recognition and to acknowledge the contributions of other researchers. In 1936, António Caetano de Abreu Freire Egas Moniz published the results of a radical treatment for mental illness, a surgical procedure he termed prefrontal leucotomy. Moniz achieved such remarkable results with mental patients who suffered from conditions previously deemed incurable that many physicians throughout the world immediately embraced the procedure. In 1949, the Nobel Prize Committee recognized Moniz's contribution with the Nobel Prize in Physiology and Medicine. Why Moniz's earlier major contribution to medicine, the discovery and development of angiography, was not acknowledged in like fashion has remained a mystery. Nobel Prize documents reveal that Moniz was nominated for the award on two separate occasions; both times, Jacobaeus, Chairman of the Department of Neurology at Karolinska Institute and a member of the Nobel Prize Committee, evaluated the nominations and recommended against awarding Moniz the prize. The development of imaging techniques was not isolated to any one individual's contribution. Several persons, including Walter Dandy and Jacobaeus, were leading figures.

A Neuropsychological Investigation of Theory of Mind in an Elderly Lady with Frontal Leucotomy

This single case study assessed an elderly lady with prefrontal leucotomy on Theory of Mind (ToM) and executive function tasks. The case subject demonstrated impairment on higher order ToM tasks and executive function tasks. She passed first order ToM tasks and her ability to recognise mental state terms was unimpaired. Results are discussed in terms of the role of the frontal lobes as a potential, common mediating structure for these functions.

DNA pioneers and their legacy

I returned from Brazil loving that land as much as the one I was born. I do not know how I could separate myself from that country, a continuation of my own.EGAS MONIZ (LETTER TO ALMEIDA LIMA)In 1935, Egas Moniz, a distinguished Portuguese neurologist and the discoverer of cerebral angiography, had his neurosurgeon, Almeida Lima, perform the first surgical intervention for the treatment of mental illness.6 The initial procedure involved injection of alcohol into the frontal lobes and was named “prefrontal leukotomy,” becoming the first valid attempt in the surgical treatment of mental diseases. The neurosurgical treatment of psychiatric illness had thus begun and the term psychosurgery was coined to describe this novel approach. In 1949, Egas Moniz was awarded the Nobel Prize for his contributions in the field of psychosurgery and for his study on the functions and physiology of the frontal lobes. It was undoubtedly, one of the more stimulating contributions in the field of psychiatric thinking in the last six decades.The technique of prefrontal leucotomy, used in many thousands of desperate psychiatric patients, during the first decades following its discovery, subsequently has been replaced by more modern approaches. Nonetheless, it aroused a monumental volume of investigations in neuroanatomy, neurophysiology and psychiatry. Egas Moniz's leukotomy procedure has provoked a revolution, not only in modern psychiatric thinking but in all philosophical and social sectors that are based in a better knowledge of cerebral mechanisms.Dozens of new psychosurgical techniques were introduced after the discovery of Egas Moniz, and many structures of the brain were targeted in an attempt to reduce the mortality and morbidity rates of the early procedures. Observations regarding the response to surgery in cases of mental disease considered refractory to treatment in the prepsychopharmacologic era of psychiatry were largely empirical, but supplied valuable insights into the functioning of these areas. Many of these empirical observations then were combined with laboratory research techniques by the psychiatrist and neurophysiologist MacLean, who introduced the concept of the “limbic system” in 1952.18 Subsequent investigations have stemmed from his original work, thus launching the basis for his novel concept of a “psychencephalon,” a denomination of the limbic brain and related structures introduced by MacLean in 1982.20 The psychophysiology of the limbic system and related structures, which have been better understood in recent years, constitutes the modern “triune brain” theory also proposed by MacLean. These new concepts may soon present to psychiatric thought and the new science of physiodynamics (in distinction to psychodynamics) the same significance and impact that the historical Freudian concepts had to the knowledge of the structure of human personality.The recognition of Papez's theory on the importance of the rhinencephalic structures28 and the experimental demonstration of their functions and connections by MacLean, Nauta, and many other authors, supported the concept previously unknown to medicine that the limbic system is the likely neuroanatomic substrate responsible for behavior, emotion, and psychiatric disease. After the 1950s, psychiatric thinking was guided by the investigative neurosciences, and the limbic system started to become the link between the brain, mind, and human conduct in a functional continuum.Present day psychiatry finally has absorbed all the contributions from the neurosciences that allowed for a better understanding of affect, humor, learning, memory, motivation, sexual behavior, and the control of many visceral and neurovegetative functions. We now can demonstrate that cortical, subcortical, and basal ganglia functions, without the participation of the limbic system, would have no relevance in the daily survival of an animal in a world that is biologically organized. Without this system, the intellectual functions never would experience the limits of reality, and human thinking would be ungoverned completely. This system will, thus, determine what will prevail in an individual—psychic normality, reason, or insanity.

Half-life of truth in surgical literature

The hypothetico-deductive model of Karl Popper contends that “An assertion is true if it corresponds to, or agrees with, the facts”. Because “the facts” change over time, truth is relative. In this view of events, science progresses via a series of theories (paradigms) that are held to be true until they are replaced by a better approximation of reality. It follows that some “truths” will last longer than others. We decided to estimate the half-life of dogma relating to the practice of surgery. The journal Surgery Gynecology and Obstetrics had a section entitled International Surgical Abstracts that concluded at the end of 1994. We obtained copies of all of the abstracts for the even numbered months for each fifth year after 1935. The first 20 abstracts about general surgery from each of the 13 review periods were selected for study. The one sentence from each abstract that best summarised the conclusion was copied to a database. Editing of these sentences was restricted to the rephrasing of outdated terminology and the elimination of redundant words. The form, which contained the 260 selected sentences in a random order, was assessed by seven general surgeons. They were asked to mark each question as being either true or false. We explored the relation between time and the number of positive responses from the questionnaire using scatter plots and regression analyses. The linear model detailed in the figure was found to be most appropriate (R=0·86, p<0·001). It suggests that the rate of loss of truth is 0·75% per year and that the estimated half-life of truth for clinical statements in the surgical literature is 45 years. This seems appropriate; 45 years ago it was suggested that: prefrontal lobotomy usefully altered patients’ reactions so that “no anxiety, fear, or concern over their impending death from cancer was manifest”; “in primary malignant hypertension the malignant phase may disappear” after lumbodorsal sympathectomy; and, the detection of a gastric ulcer was “a strong indication for immediate operation”. Extrapolation of the regression line can be used to hypothesise that the current era of surgery extends between 1904 and 2038. From an historical perspective, 1904 is a reasonable estimate of the commencement of the era of “open” surgery. Gauze masks and rubber gloves had just been introduced into operating theatres and abdominal surgery gained public respectability in the UK in 1902 when Edward VII’s coronation was delayed by the need to drain his appendiceal abscess. More contentious is extrapolation of the regression line to predict the future. However, a nexus point for the present era of surgery in the second quartile of the next century is consistent with the current trend towards the ascendancy of minimally invasive procedures and medical treatments over open surgery.

The role of psychosurgery in the treatment of selected cases of refractory schizophrenia: a reappraisal

Prefrontal lobotomy (i.e. leukotomy) was widely performed for the treatment of schizophrenia during the late 1930s and 1940s but met with growing disrepute after the introduction of effective antipsychotic agents in the early 1950s. While non-invasive methods of treatment are undeniably preferable to somatic interventions for the management of psychiatric illnesses, there nevertheless continues to be a valid role for leukotomy in the treatment of patients with severe, chronic, refractory schizophrenia, particularly when the patient poses a risk to himself and/or to society. The present article traces the history of leukotomy in the treatment of schizophrenia, and reviews the author's experience with this surgical procedure in 16 patients who fulfilled the above criteria and underwent leukotomy during the years spanning 1985–1996. This operation reduced aggression and/or produced marked to slight improvement in all patients, and in no case led to adverse consequences. Thus, leukotomy is recommended as a legitimate treatment modality in selected patients with schizophrenia.

Transorbital lobotomy at Eastern State Hospital (1951-1954).

1. Lobotomy was one of several somatic treatments for psychiatric illness developed in Europe during the 1930s, and was first performed in the United States in 1936. 2. Patients who underwent transorbital lobotomy at Eastern State Hospital were carefully chosen candidates who had exhausted psychiatric treatment options and for whom little else could be offered. 3. Transorbital lobotomy was displaced in 1955 by rauwolfia and chlorpromazine; no lobotomies were performed thereafter at Eastern State Hospital.

S-75-4 - Contemporary indications and interventions for psychiatric neurosurgery: Anoverview

Psychosurgery, the neurosurgical treatment of psychiatric disease, has a history dating back to antiquity, and involves all of the clinical neurosciences. This review discusses the history of psychosurgery, its development in the 19th century, and the conditions of its use and abuse in the 20th century, with a particular focus on the frontal lobotomy. The transition to the modern era of psychosurgery is discussed, as well as the neurobiology underlying current psychosurgical procedures. The techniques of stereotactic cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leukotomy are described, as well their indications and side effects. Due to the past abuse of psychosurgery, procedures are currently under strict control, and the example of the Cingulotomy Committee at the Massachusetts General Hospital is discussed. Finally, future directions of psychosurgery and somatic therapies are explored, including transcranial magnetic stimulation, vagal nerve stimulation, deep brain stimulation, gene therapy, and stem cell therapy. In summary, this review provides a concise yet comprehensive introduction to the history, current practice, and future trends of neurosurgery for psychiatric disorders.

Misconceptions about the role of medical device regulations and their resultant impact on the effectiveness on medical devices

This publication will attempt to describe one of the most vibrant manufacturing sectors in the entire US economy and evaluate the present and future potential impact of government oversight and excessive domestic litigation on this industry. The first section of the report includes an overview of the medical device industry which has grown from its infancy in the latter half of the twentieth century. This is an industry characterized by an innovative and entrepreneurial personality that has brought many marvelous new devices to patients around the world which contribute not only to extending life, but more importantly, to improving the quality of life. I remember as a child reading a science fiction story about a futuristic doctor's bag which contained a series of instruments which, when applied against the skin, provide an accurate diagnosis and then, by simply pushing a button, administers a bloodless, non-invasive surgical treatment of the disease or injury. If we step back and look at today's treatments for heart disease, where an EMG can detect irregular heartbeats through patches placed on one's chest and where high blood pressure is treated through a patch placed on one's arm, we are obviously at the threshold of this fictitious miracle treatment only imagined in science fiction in the mid-half of this century. The use of balloon catheters for treatment of occluded coronary arteries, laproscopes for gall bladder removal and arthroscopes for meniscus tears in the knee are further examples of bloodless surgeries that resemble science fiction of the fifties. Who would have imagined in 1950 that before the end of the century, we would be able to replace successfully almost any mechanical structure or function of the human body? Who would have imagined that we could operate on microscopic regions of the brain to correct tumors or other maladies of this complex organ? During the first half of the century, most surgery of the brain was limited to converting a raving lunatic to a benign vegetable through a frontal lobotomy. Much of this miraculous new medical care is a result of a dynamic research and development philosophy within the medical device industry. There are many people today, including this author, who fear that the achievements of the last fifty years would be impossible in today's regulatory and litigious environments. Later sections of this paper will present statistics and deal with concerns about the constraints to innovation if the current legal and regulatory trends, aimed at seemingly zero-risk decision making, continue into the next century.

Frontal leukotomy and related psychosurgical procedures in the era before antipsychotics (1935-1954): a historical overview.

This article provides an overview of the history of psychosurgery as a treatment for psychiatric illnesses. The author reviewed articles describing psychosurgery between 1935 and 1954 in order to summarize surgical techniques, clinical indications for surgery, patient selection, complications, and outcome. Patients were operated on for a wide variety of psychiatric illnesses. Initially, a large number of uncontrolled studies reported considerable therapeutic benefit in at least one-third of the patients operated on. Complications with the early surgical techniques included hemorrhage, seizures, infection, and personality changes. Surgical techniques proliferated in hopes of achieving greater therapeutic benefit while minimizing detrimental side effects. As psychosurgery became more widely accepted, its principal supporters began to use it as a routine therapy. A number of uncontrolled and controlled short-term studies supported the efficacy of psychosurgery, but long-term controlled studies showed mixed results. Psychosurgery was promoted as a treatment for patients who had shown little or no response to less drastic therapies. In the context of an era when no efficacious treatments were available for psychosis, its use was understandable. However, its history illustrates the importance of critical evaluation of new treatments in the context of long-term controlled outcome studies, the natural course of specific illnesses, and an understanding of brain physiology.

Naming is the key to the future

Whether you believe it or not and whether you like it or not, all networking protocols are getting a lobotomy these days. All of them. IP is being modified to IPng or IP6 as it will eventually be called. DECnet Phase IV going to DECnet/OSI. The list goes on and on.

Prefrontal leucotomy in the treatment of mental disorders. 1937 [classical article

Following this exposition I do not wish to make any comment since the facts speak for themselves. These were hospital patients who were well studied and well followed. The recoveries have been maintained. I cannot believe that the recoveries can be explained upon simple coincidence. Prefrontal leucotomy is a simple operation, always safe, which may prove to be an effective surgical treatment in certain cases of mental disorder.

Effects of schizophrenia and prefrontal leukotomy on movement preparation and generation.

The purpose of this study was to investigate the ability of leukotomized and unleukotomized schizophrenic patients to use advance information in the process of movement preparation. Subjects participated in an aiming task in which movements could be defined on the basis of hand used to perform the task, and distance travelled to the target. Subjects were provided with full, partial, or no prior information about the upcoming movement by either precueing hand, distance, both hand and distance, or by providing no precue. The leukotomized and unleukotomized schizophrenic patients were able to use this advance information to facilitate the speed of their responses in much the same way as did subjects in a normal control group. These results are discussed in terms of models of movement preparation, and the role of the frontal lobes in schizophrenia and movement planning.