A cautionary tale of how medicine can become far too accepting of a procedure of limited value and great potential for harm…
First, some background on the lobotomy:
The lobotomy may well be the most notorious and misunderstood medical procedure ever to have been developed. It’s the butt of many jokes and is portrayed widely in the media as a savage operation preformed on those who were unruly as a means of turning them into dribbling vegetables, incapable of resisting and placid in all respects. This is partially true, but is an overly simplistic portrayal of what the lobotomy really was and how it was used.
To understand the use of the lobotomy one must first realize the environment it was developed in. Prior to the mid 20th century, there was very little that could be done for the severely mentally ill. Psychotherapy existed and was useful in helping those with problems like anxiety, phobias and depression better manage their symptoms, but this could do little for the truly insane. For those who suffered from severe delusions, violent episodes, severe depression with suicidal tendencies, extreme bipolarism, there was no effective therapy.
Such individuals were placed in mental institutions, where they were often forced to live the entirety of their lives. Often miserable places, institutions provided little more than warehousing for many individuals. Mental institutions were enormous, becoming huge communities onto themselves. Attempts were made to make life more pleasant by providing classes and recreation, but the enormous expense of caring for the populations made that difficult to do on a large scale. The worst cases were often left restrained or locked in padded cells. With so many completely crippled by mental disease, conditions could easily degrade to the point where wards became filthy and filled with the screams of insane patients.
The origins of psycosurgury can be traced back to the 1880’s, when Gottlieb Burckhardt, a Swiss neurosurgeon began to experiment with operations on the brains of the most severely insane. Small sections of brain were removed in the hope that it might calm the continual mania of the patients operated on. The results were not encouraging, but research continued into the 20th century. It was known that traumatic brain injury, brain tumors or their removal could alter a person’s personality, but only the most basic understanding of the regions of the brain associated with various aspects of thought and emotion existed.
The lobotomy was developed in 1935 by Portuguese doctor António Egas Moniz, who intitially called the procedure the leukotomy. Moniz had become aware of experiments carried out on apes in which portions of the brain were intentionally removed or disconnected. Operations that removed the frontal lobes had a major effect on the learning capacity of the animals, but also made them more placid and less prone to expressions of frustration and emotional outbursts. He believed that doing so on humans might allow those with the most violent psychiatric episodes to lead more normal lives, or at least be more manageable. Early experiments involved injecting alcohol into the nerves that connected the frontal lobes to the rest of the brain. This was later replaced by simply cutting the connections.
The belief at the time was that mental illness was caused by areas of the brain becoming too active or the brain being overstimulated and going haywire with out of control signals. It was thought that there was simply too much emotional activity that that cutting away the overly active portions of the brain would relieve this. While this belief is not always entirely false, it’s overly simplistic and does not apply to most cases of mental illness. While there are portions of the brain that are associated with certain functions or aspects of personality, it is far too complex for a single region to be defined as the source of something like delusions, violent episodes or depression.
Still, the procedure did appear to have some validity. Many of those who received the operation did indeed become calmer and more easy to manage. Contrary to popular belief, it did not necessarily render the individual incapable of speech or basic function, although this did sometimes happen. It seems that overall, the results were highly variable. This is likely attributable to the simplicity and crudeness of the surgery. It involved drilling holes in the head of patients and cutting the pathways by inserting instruments. Exactly what kind of effects this had on the brain could vary quite a bit, especially since the individuals it was preformed on had all manner of conditions to begin with.
Early observations considered the outcome of the procedure to be result in a 33% to 33% to 33% success rate. In other words, roughly one third of patients could be considered to have improved from the operation. One third could be considered to be worse than before the operation and one third were roughly the same. This is hardly a stellar success rate, but given the lack of options for the worst cases of mental disease, it may have seemed worth the risk. There certainly were a few cases of individuals who seemed to gain extensive relief with few complications, but these were relatively rare.
A few individuals died during the procedure. Others were left completely incapacitated and severely disabled. Many, however, did retain their basic abilities to communicate and do simple tasks. Some lost the ability to walk or talk but subsequently relearned it. A number of reports indicated that the patients became very child-like and lost the ability to comprehend complex concepts. Lack of emotional responses or social capacity was also reported. Another effect was the loss of inhibitions. Many seemed to have no fear or anxiety, even in circumstances where it would be appropriate. Apathy and social disconnection were common. Many patients began to overeat and put on large amounts of weight. Some developed complications ranging from incontinence to lack of balance to sleep disorders.
The psychiatric community accepted the procedure with varying levels of enthusiasm. It gained rapid acceptance across the world, but many remained uneasy about the implications and ethical considerations. It was used primarily on the worst of the worst cases, at least initially. Directors of mental hospitals welcomed anything that could make it easier to manage their overcrowded wards, resulting in an expansion of use that raised questions about whether it was really being used as a last resort. Overall, the procedure was never without controversy, but given the lack of alternatives, it often was considered about the only thing that could be done to at least try to relieve severe mental illness.
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