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From Wikipedia the free encyclopedia
Lobotomy | |
Other names | Leucotomy, leukotomy |
Specialty | psychosurgery |
MeSH | D011612 |
A lobotomy (from Greek λοβός (lobos) 'lobe', and τομή (tomē) 'cut, slice') or leucotomy is a discredited form of neurosurgical treatment for psychiatric disorder or neurological disorder (e.g. epilepsy, depression) that involves severing connections in the brain's prefrontal cortex.[1] The surgery causes most of the connections to and from the prefrontal cortex, the anterior part of the frontal lobes of the brain, to be severed.
In the past, this treatment was used for treating psychiatric disorders as a mainstream procedure in some countries. The procedure was controversial from its initial use, in part due to a lack of recognition of the severity and chronicity of severe and enduring psychiatric illnesses, so it was said to be an inappropriate treatment.[2]
The originator of the procedure, Portuguese neurologist António Egas Moniz, shared the Nobel Prize for Physiology or Medicine of 1949 for the "discovery of the therapeutic value of leucotomy in certain psychoses",[n 1] although the awarding of the prize has been subject to controversy.[4]
The use of the procedure increased dramatically from the early 1940s and into the 1950s; by 1951, almost 20,000 lobotomies had been performed in the United States and proportionally more in the United Kingdom.[5] A large number of patients were gay men.[6] More lobotomies were performed on women than on men: a 1951 study found that nearly 60% of American lobotomy patients were women, and limited data shows that 74% of lobotomies in Ontario from 1948 to 1952 were performed on female patients.[7][8][9] From the 1950s onward, lobotomy began to be abandoned,[10] first in the Soviet Union[11] and Europe.[12]
Historically, patients of lobotomy were, immediately following surgery, often stuporous and incontinent. Some developed an enormous appetite and gained considerable weight. Seizures were another common complication of surgery. Emphasis was put on the training of patients in the weeks and months following surgery.[13]
The purpose of the operation was to reduce the symptoms of mental disorders, and it was recognized that this was accomplished at the expense of a person's personality and intellect. British psychiatrist Maurice Partridge, who conducted a follow-up study of 300 patients, said that the treatment achieved its effects by "reducing the complexity of psychic life". Following the operation, spontaneity, responsiveness, self-awareness, and self-control were reduced. The activity was replaced by inertia, and people were mostly left emotionally blunted and restricted in their intellectual range.[14]
The consequences of the operation have been described as "mixed".[15] Some patients died as a result of the operation and others later committed suicide. Some were left severely brain damaged. Others were able to leave the hospital, or became more manageable within the hospital.[15] A few people managed to return to responsible work, while at the other extreme, people were left with severe and disabling impairments.[16] Most people fell into an intermediate group, left with some improvement of their symptoms but also with emotional and intellectual deficits to which they made a better or worse adjustment.[16] On average, there was a mortality rate of approximately 5% during the 1940s.[16]
The lobotomy procedure could have severe negative effects on a patient's personality and ability to function independently.[17] Lobotomy patients often show a marked reduction in initiative and inhibition.[18] They may also exhibit difficulty imagining themselves in the position of others because of decreased cognition and detachment from society.[19]
Walter Freeman coined the term "surgically induced childhood" and used it constantly to refer to the results of lobotomy. The operation left people with an "infantile personality"; a period of maturation would then, according to Freeman, lead to recovery. In an unpublished memoir, he described how the "personality of the patient was changed in some way in the hope of rendering him more amenable to the social pressures under which he is supposed to exist." He described one 29-year-old woman as being, following lobotomy, a "smiling, lazy and satisfactory patient with the personality of an oyster" who could not remember Freeman's name and endlessly poured coffee from an empty pot. When her parents had difficulty dealing with her behaviour, Freeman advised a system of rewards (ice cream) and punishment (smacks).[20]
In the early 20th century, the number of patients residing in mental hospitals increased significantly[n 2] while little in the way of effective medical treatment was available.[n 3][26] Lobotomy was one of a series of radical and invasive physical therapies developed in Europe at this time that signaled a break with a psychiatric culture of therapeutic nihilism that had prevailed since the late nineteenth-century.[27] The new "heroic" physical therapies devised during this experimental era,[28] including malarial therapy for general paresis of the insane (1917),[29] deep sleep therapy (1920), insulin shock therapy (1933), cardiazol shock therapy (1934), and electroconvulsive therapy (1938),[30] helped to imbue the therapeutically moribund and demoralised psychiatric profession with a renewed sense of optimism in the curability of insanity and the potency of their craft.[31] The success of the shock therapies, despite the considerable risk they posed to patients, also helped to accommodate psychiatrists to ever more drastic forms of medical intervention, including lobotomy.[28]
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".[32] For Roy Porter, once the doyen of medical history,[33] 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.[34] 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.[35] Today, lobotomy has become a disparaged procedure, a byword for medical barbarism and an exemplary instance of the medical trampling of patients' rights.[2]
Early psychosurgery[edit]
Before the 1930s, individual doctors had infrequently experimented with novel surgical operations on the brains of those deemed insane. Most notably in 1888, the Swiss psychiatrist Gottlieb Burckhardt initiated what is commonly considered the first systematic attempt at modern human psychosurgery.[36] 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 associationist model comprising an input or afferent system (a sensory center), a connecting system where information processing took place (an association center), and an output or 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.[37] Burckhardt's hypothesis was that by deliberately creating lesions in regions of the brain identified as association centers, a transformation in behaviour might ensue.[37] 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 mental pathology.[38] He reasoned, however, that removing material from either of the sensory or motor zones could give rise to "grave functional disturbance".[38] 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.[39]
Intending to ameliorate symptoms in those with violent and intractable conditions rather than effect a cure,[40] Burckhardt began operating on patients in December 1888,[41] but both his surgical methods and instruments were crude and the results of the procedure were mixed at best.[38] 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 convulsions and died a few days after the operation, and one patient improved.[n 4] Complications included motor weakness, epilepsy, sensory aphasia and "word deafness".[43] Claiming a success rate of 50 percent,[44] 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.[45]
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.[46] 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.[47]
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 ...[48]
The authors neglected to mention, however, that in 1910 Puusepp himself had performed surgery on the brains of three mentally ill patients,[n 5][50] sectioning the cortex between the frontal and parietal lobes.[51] 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.[47] By 1937, Puusepp, despite his earlier criticism of Burckhardt, was increasingly persuaded that psychosurgery could be a valid medical intervention for the mentally disturbed.[n 6][53] 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.[54]
Leucotomy was first undertaken in 1935 under the direction of the Portuguese neurologist (and inventor of the term psychosurgery) António Egas Moniz.[n 7][58] First developing an interest in psychiatric conditions and their somatic treatment in the early 1930s,[59] Moniz apparently conceived a new opportunity for recognition in the development of a surgical intervention on the brain as a treatment for mental illness.[40]
Frontal lobes[edit]
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.[60] 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 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.[61] 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.[62] At the 1935 Congress, with Moniz in attendance,[n 8] Fulton and Jacobsen presented two chimpanzees, named Becky and Lucy who had had frontal lobectomies and subsequent changes in behaviour and intellectual function.[63] 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" – that is, have tantrums that could include rolling on the floor and defecating – if, because of their poor performance in a set of experimental tasks, they were not rewarded.[64] 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".[63] 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.[65]
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.[66] 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.[67] 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.[68] In fact, Moniz stated that he had conceived of the operation some time 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.[69] 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.[70]
The frontal lobes had been the object of scientific inquiry and speculation since the late 19th century. Fulton's contribution, while it may have functioned as source of intellectual support, is of itself unnecessary and inadequate as an explanation of Moniz's resolution to operate on this section of the brain.[71] Under an evolutionary and hierarchical model of brain development it had been hypothesized that those regions associated with more recent development, such as the mammalian brain and, most especially, the frontal lobes, were responsible for more complex cognitive functions.[72] 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.[72] 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 brain trauma. The refinement of neurosurgical techniques also facilitated increasing attempts to remove brain tumours, treat focal epilepsy in humans and led to more precise experimental neurosurgery in animal studies.[72] Cases were reported where mental symptoms were alleviated following the surgical removal of diseased or damaged brain tissue.[51] The accumulation of medical case studies on behavioural changes following damage to the frontal lobes led to the formulation of the concept of Witzelsucht, which designated a neurological condition characterised by a certain hilarity and childishness in those with the condition.[72] 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.[72] 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.[73] This work, while influential, was not without its critics due to deficiencies in experimental design.[72]
The first bilateral lobectomy of a human subject was performed by the American neurosurgeon Walter Dandy in 1930.[n 9][74] The neurologist Richard Brickner reported on this case in 1932,[75] relating that the recipient, known as "Patient A", while experiencing a blunting of affect, had no apparent decrease in intellectual function and seemed, at least to the casual observer, perfectly normal.[76] Brickner concluded from this evidence that "the frontal lobes are not 'centers' for the intellect".[77] These clinical results were replicated in a similar operation undertaken in 1934 by the neurosurgeon Roy Glenwood Spurling and reported on by the neuropsychiatrist Spafford Ackerly.[78] 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[78] as part of its deliberations,[78] "a remarkable symposium ... on the functions of the frontal lobes".[79] 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".[77] This parallel symposium contained numerous papers by neurologists, neurosurgeons and psychologists; amongst these was one by Brickner, which impressed Moniz greatly,[76] that again detailed the case of "Patient A".[78] 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.[78] 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.[80]
Nor was Moniz the only medical practitioner in the 1930s to have contemplated procedures directly targeting the frontal lobes.[81] Although ultimately discounting brain surgery as carrying too much risk, physicians and neurologists such as William Mayo, Thierry de Martel, Richard Brickner, and Leo Davidoff had, before 1935, entertained the proposition.[n 10][83] 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 ml of malarial blood directly into the frontal lobes of over 100 paretic patients through holes drilled into the skull.[81] He claimed that the injected paretics showed signs of "uncontestable mental and physical amelioration" and that the results for psychotic patients undergoing the procedure was also "encouraging".[84] 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.[85] 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 schizophrenic patient.[86] In Romania, Ody's procedure was adopted by Dimitri Bagdasar and Constantinesco working out of the Central Hospital in Bucharest.[82] 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".[87]
Neurological model[edit]
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,[88] in essence he simply interpreted this new neurological research in terms of the old psychological theory of associationism.[60] 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".[n 11][90] As Moniz wrote in 1936:
[The] mental troubles must have ... 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.[91]
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",[92] thus removing their fixed pathological brain circuits. Moniz believed the brain would functionally adapt to such injury.[93] 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.[94]
First leucotomies[edit]
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.
—Egas Moniz (1937)[95]
On 12 November 1935 at the Hospital Santa Marta in Lisbon, Moniz initiated the first of a series of operations on the brains of people with mental illnesses.[96] 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.[97] 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.[n 12][99] The intention was to remove some of the long fibres that connected the frontal lobes to other major brain centres.[100] To this end, it was decided that Lima would trephine into the side of the skull and then inject ethanol into the "subcortical white matter of the prefrontal area"[95] so as to destroy the connecting fibres, or association tracts,[101] and create what Moniz termed a "frontal barrier".[n 13][102] 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.[103] 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.[103] For the ninth patient they introduced a surgical instrument called a leucotome; this was a cannula that was 11 centimetres (4.3 in) in length and 2 centimetres (0.79 in) in diameter. It had a retractable wire loop at one end that, when rotated, produced a 1 centimetre (0.39 in) diameter circular lesion in the white matter of the frontal lobe.[104] 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.[103]
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.[105] 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 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.[106] Patients were normally operated on the day they arrived at Moniz's clinic and returned within ten days to the Miguel Bombarda Mental Hospital.[107] A perfunctory post-operative follow-up assessment took place anywhere from one to ten weeks following surgery.[108] Complications were observed in each of the leucotomy patients and included: "increased temperature, vomiting, bladder and bowel incontinence, diarrhea, and ocular affections such as ptosis and nystagmus, as well as psychological effects such as apathy, akinesia, lethargy, timing and local disorientation, kleptomania, and abnormal sensations of hunger".[109] Moniz asserted that these effects were transitory and,[109] 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.[110]
Moniz rapidly disseminated his results through articles in the medical press and a monograph in 1936.[102] Initially, however, the medical community appeared hostile to the new procedure.[111] On 26 July 1936, one of his assistants, Diogo Furtado, gave a presentation at the Parisian meeting of the Société Médico-Psychologique on the results of the second cohort of patients leucotomised by Lima.[102] Sobral Cid, who had supplied Moniz with the first set of patients for leucotomy from his own hospital in Lisbon, attended the meeting and denounced the technique,[111] declaring that the patients who had been returned to his care post-operatively were "diminished" and had experienced a "degradation of personality".[112] He also claimed that the changes Moniz observed in patients were more properly attributed to shock and brain trauma, and he derided the theoretical architecture that Moniz had constructed to support the new procedure as "cerebral mythology."[112] At the same meeting the Parisian psychiatrist, Paul Courbon, stated he could not endorse a surgical technique that was solely supported by theoretical considerations rather than clinical observations.[113] He also opined that the mutilation of an organ could not improve its function and that such cerebral wounds as were occasioned by leucotomy risked the later development of meningitis, epilepsy and brain abscesses.[114] Nonetheless, Moniz's reported successful surgical treatment of 14 out of 20 patients led to the rapid adoption of the procedure on an experimental basis by individual clinicians in countries such as Brazil, Cuba, Italy, Romania and the United States during the 1930s.[115]
Italian leucotomy[edit]
In the present state of affairs if some are critical about lack of caution in therapy, it is, on the other hand, deplorable and inexcusable to remain apathetic, with folded hands, content with learned lucubrations upon symptomatologic minutiae or upon psychopathic curiosities, or even worse, not even doing that.
—Amarro Fiamberti[116]
Throughout the remainder of the 1930s the number of leucotomies performed in most countries where the technique was adopted remained quite low. In Britain, which was later a major centre for leucotomy,[n 14] only six operations had been undertaken before 1942.[118] Generally, medical practitioners who attempted the procedure adopted a cautious approach and few patients were leucotomised before the 1940s. Italian neuropsychiatrists, who were typically early and enthusiastic adopters of leucotomy, were exceptional in eschewing such a gradualist course.[54]
Leucotomy was first reported in the Italian medical press in 1936 and Moniz published an article in Italian on the technique in the following year.[54] In 1937, he was invited to Italy to demonstrate the procedure and for a two-week period in June of that year he visited medical centres in Trieste, Ferrara, and one close to Turin – the Racconigi Hospital – where he instructed his Italian neuropsychiatric colleagues on leucotomy and also oversaw several operations.[54] Leucotomy was featured at two Italian psychiatric conferences in 1937 and over the next two years a score of medical articles on Moniz's psychosurgery was published by Italian clinicians based in medical institutions located in Racconigi, Trieste, Naples, Genoa, Milan, Pisa, Catania and Rovigo.[54] The major centre for leucotomy in Italy was the Racconigi Hospital, where the experienced neurosurgeon Ludvig Puusepp provided a guiding hand.[n 15][54] Under the medical directorship of Emilio Rizzatti, the medical personnel at this hospital had completed at least 200 leucotomies by 1939.[120] Reports from clinicians based at other Italian institutions detailed significantly fewer leucotomy operations.[54]
Experimental modifications of Moniz's operation were introduced with little delay by Italian medical practitioners.[121] Most notably, in 1937 Amarro Fiamberti, the medical director of a psychiatric institution in Varese,[122] first devised the transorbital procedure whereby the frontal lobes were accessed through the eye sockets.[121] Fiamberti's method was to puncture the thin layer of orbital bone at the top of the socket and then inject alcohol or formalin into the white matter of the frontal lobes through this aperture.[123] Using this method, while sometimes substituting a leucotome for a hypodermic needle, it is estimated that he leucotomised about 100 patients in the period up to the outbreak of World War II.[122] Fiamberti's innovation of Moniz's method would later prove inspirational for Walter Freeman's development of transorbital lobotomy.[123]
American leucotomy[edit]
The first prefrontal leucotomy in the United States was performed at the George Washington University Hospital, on 14 September 1936, by the neurologist Walter Freeman, and his friend and colleague, the neurosurgeon James W. Watts.[124] Freeman had first encountered Moniz at the London-hosted Second International Congress of Neurology in 1935, where he had presented a poster exhibit of the Portuguese neurologist's work on cerebral angiography.[125] Fortuitously occupying a booth next to Moniz, Freeman, delighted by their chance meeting, formed a highly favourable impression of Moniz, later remarking upon his "sheer genius".[125] According to Freeman, if they had not met in person, it is highly unlikely that he would have ventured into the domain of frontal lobe psychosurgery.[126] Freeman's interest in psychiatry was the natural outgrowth of his appointment in 1924 as the medical director of the Research Laboratories of the Government Hospital for the Insane in Washington, known colloquially as St Elizabeth's.[127] Freeman, who favoured an organic model of mental illness causation, spent the next several years exhaustively, yet ultimately fruitlessly, investigating a neuropathological basis for insanity.[128] Chancing upon a preliminary communication by Moniz on leucotomy in the spring of 1936, Freeman initiated a correspondence in May of that year. Writing that he had been considering psychiatric brain surgery previously, he informed Moniz that, "having your authority I expect to go ahead".[129] Moniz, in return, promised to send him a copy of his forthcoming monograph on leucotomy and urged him to purchase a leucotome from a French supplier.[130]
Upon receipt of Moniz's monograph, Freeman reviewed it anonymously for the Archives of Neurology and Psychiatry.[130] Praising the text as one whose "importance can scarcely be overestimated",[130] he summarised Moniz's rationale for the procedure as based on the fact that while no physical abnormality of cerebral cell bodies was observable in the mentally ill, their cellular interconnections may harbour a "fixation of certain patterns of relationship among various groups of cells" and that this resulted in obsessions, delusions and mental morbidity.[131] While recognising that Moniz's thesis was inadequate, for Freeman it had the advantage of circumventing the search for diseased brain tissue in the mentally ill by instead suggesting that the problem was a functional one of the brain's internal wiring where relief might be obtained by severing problematic mental circuits.[131]
In 1937 Freeman and Watts adapted Lima and Moniz's surgical procedure, and created the Freeman-Watts technique, also known as the Freeman-Watts standard prefrontal lobotomy, which they styled the "precision method".[132]
Transorbital lobotomy[edit]
The Freeman–Watts prefrontal lobotomy still required drilling holes in the skull, so surgery had to be performed in an operating room by trained neurosurgeons. Walter Freeman believed this surgery would be unavailable to those he saw as needing it most: patients in state mental hospitals that had no operating rooms, surgeons, or anesthesia and limited budgets. Freeman wanted to simplify the procedure so that it could be carried out by psychiatrists in psychiatric hospitals.[133]
Inspired by the work of Italian psychiatrist Amarro Fiamberti, Freeman at some point conceived of approaching the frontal lobes through the eye sockets instead of through drilled holes in the skull. In 1945 he took an icepick[n 16] from his own kitchen and began testing the idea on grapefruit[n 17] and cadavers. This new "transorbital" lobotomy involved lifting the upper eyelid and placing the point of a thin surgical instrument (often called an orbitoclast or leucotome, although quite different from the wire loop leucotome described above) under the eyelid and against the top of the eyesocket. A mallet was used to drive the orbitoclast through the thin layer of bone and into the brain along the plane of the bridge of the nose, around 15 degrees toward the interhemispherical fissure. The orbitoclast was malleted 5 centimetres (2 in) into the frontal lobe, and then pivoted 40 degrees at the orbit perforation so the tip cut toward the opposite side of the head (toward the nose). The instrument was returned to the neutral position and sent a further 2 centimetres (4⁄5 in) into the brain, before being pivoted around 28 degrees each side, to cut outward and again inward. (In a more radical variation at the end of the last cut described, the butt of the orbitoclast was forced upward so the tool cut vertically down the side of the cortex of the interhemispheric fissure; the "Deep Frontal Cut".) All cuts were designed to transect the white fibrous matter connecting the cortical tissue of the prefrontal cortex to the thalamus. The leucotome was then withdrawn and the procedure repeated on the other side.[citation needed]
Freeman performed the first transorbital lobotomy on a live patient in 1946. Its simplicity suggested the possibility of carrying it out in mental hospitals lacking the surgical facilities required for the earlier, more complex procedure. (Freeman suggested that, where conventional anesthesia was unavailable, electroconvulsive therapy be used to render the patient unconscious.)[135] In 1947, the Freeman and Watts partnership ended, as the latter was disgusted by Freeman's modification of the lobotomy from a surgical operation into a simple "office" procedure.[136] Between 1940 and 1944, 684 lobotomies were performed in the United States. However, because of the fervent promotion of the technique by Freeman and Watts, those numbers increased sharply toward the end of the decade. In 1949, the peak year for lobotomies in the US, 5,074 procedures were undertaken, and by 1951 over 18,608 individuals had been lobotomized in the US.[137] An estimated 40% of Freeman's patients were gay men, lobotomized to change their sexual orientation.[6]
In the United States, approximately 40,000 people were lobotomized and in England, 17,000 lobotomies were performed. According to one estimate, in the three Nordic countries of Denmark, Norway, and Sweden, a combined figure of approximately 9,300 lobotomies were performed.[138] Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the US.[139] According to another estimate, Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women. This figure includes young children.[140] And in Norway, there were 2,005 known lobotomies.[141] In Denmark, there were 4,500 known lobotomies.[142] In Japan, the majority of lobotomies were performed on children with behaviour problems. The Soviet Union banned the practice in 1950 on moral grounds.[143][144][145] In Germany, it was performed only a few times.[146] By the late 1970s, the practice of lobotomy had generally ceased, although it continued as late as the 1980s in France.[147]
As early as 1944, an author in the Journal of Nervous and Mental Disease remarked: "The history of prefrontal lobotomy has been brief and stormy. Its course has been dotted with both violent opposition and with slavish, unquestioning acceptance." Beginning in 1947 Swedish psychiatrist Snorre Wohlfahrt evaluated early trials, reporting that it is "distinctly hazardous to leucotomize schizophrenics" and that lobotomy was "still too imperfect to enable us, with its aid, to venture on a general offensive against chronic cases of mental disorder", stating further that "Psychosurgery has as yet failed to discover its precise indications and contraindications and the methods must unfortunately still be regarded as rather crude and hazardous in many respects."[148] In 1948 Norbert Wiener, the author of Cybernetics: Or the Control and Communication in the Animal and the Machine, said: "[P]refrontal lobotomy ... has recently been having a certain vogue, probably not unconnected with the fact that it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier."[149]
Concerns about lobotomy steadily grew. Soviet psychiatrist Vasily Gilyarovsky criticized lobotomy and the mechanistic brain localization assumption used to carry out lobotomy:
It is assumed that the transection of white substance of the frontal lobes impairs their connection with the thalamus and eliminates the possibility to receive from it stimuli which lead to irritation and on the whole derange mental functions. This explanation is mechanistic and goes back to the narrow localizationism characteristic of psychiatrists of America, from where leucotomy was imported to us.[150]
The Soviet Union officially banned the procedure in 1950[151] on the initiative of Gilyarovsky.[152] Doctors in the Soviet Union concluded that the procedure was "contrary to the principles of humanity" and "'through lobotomy' an insane person is changed into an idiot".[145] By the 1970s, numerous countries had banned the procedure, as had several US states.[153]
In 1977, the US Congress, during the presidency of Jimmy Carter, created the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery – including lobotomy techniques – was used to control minorities and restrain individual rights. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects.[154]
Torsten Wiesel has called the award of the Nobel Prize to Moniz an "astounding [error] of judgment ... a terrible mistake",[155] and there have been calls for the Nobel Foundation to rescind the award; the Foundation has not done so, and its website still hosts an article defending lobotomy.[156][4]
Notable cases[edit]
- Rosemary Kennedy, sister of US president John F. Kennedy, underwent a lobotomy in 1941 that left her incapacitated and institutionalized for the rest of her life.[157]
- Howard Dully wrote a memoir of his late-life discovery that he had been lobotomized in 1960 at age 12.[158]
- Josef Hassid, a Polish violinist and composer, was diagnosed with schizophrenia and died at the age of 26 following a lobotomy performed on him in England.[159]
- Swedish modernist painter Sigrid Hjertén died following a lobotomy in 1948.[160]
- American playwright Tennessee Williams' older sister Rose received a lobotomy that left her incapacitated for life; the episode is said to have inspired characters and motifs in some of his works.[161]
- It is often said that when an iron rod was accidentally driven through the head of Phineas Gage in 1848, this constituted an "accidental lobotomy", or that this event somehow inspired the development of surgical lobotomy a century later. According to the only book-length study of Gage, careful inquiry turns up no such link.[162]
- In 2011, Daniel Nijensohn, an Argentine-born neurosurgeon at Yale, examined X-rays of Eva Perón and concluded that she underwent a lobotomy for the treatment of pain and anxiety in the last months of her life.[163]
Literary and cinematic portrayals[edit]
Lobotomies have been featured in several literary and cinematic presentations that both reflected society's attitude toward the procedure and, at times, changed it. Writers and film-makers have played a pivotal role in turning public sentiment against the procedure.[4]
- Robert Penn Warren's 1946 novel All the King's Men describes a lobotomy as making "a Comanche brave look like a tyro with a scalping knife", and portrays the surgeon as a repressed man who cannot change others with love, so he instead resorts to "high-grade carpentry work".[164]
- Tennessee Williams criticized lobotomy in his play Suddenly, Last Summer (1958) because it was sometimes inflicted on homosexuals – to render them "morally sane".[4] In the play, a wealthy matriarch offers the local mental hospital a substantial donation if the hospital will give her niece a lobotomy, which she hopes will stop the niece's shocking revelations about her son.[165] Warned that a lobotomy might not stop her niece's "babbling", she responds, "That may be, maybe not, but after the operation, who would believe her, Doctor?".[166]
- In Ken Kesey's 1962 novel One Flew Over the Cuckoo's Nest and its 1975 film adaptation, lobotomy is described as "frontal-lobe castration", a form of punishment and control after which "There's nothin' in the face. Just like one of those store dummies." In one patient, "You can see by his eyes how they burned him out over there; his eyes are all smoked up and gray and deserted inside."[164]
- In Sylvia Plath's 1963 novel The Bell Jar, the protagonist reacts with horror to the "perpetual marble calm" of a lobotomized young woman.[164]
- Elliott Baker's 1964 novel and 1966 film version, A Fine Madness, portrays the dehumanizing lobotomy of a womanizing, quarrelsome poet who, afterward, is just as aggressive as ever. The surgeon is depicted as an inhumane crackpot.[167]
- The 1982 biopic film Frances depicts actress Frances Farmer (the subject of the film) undergoing transorbital lobotomy (though the idea[168] that a lobotomy was performed on Farmer, and that Freeman performed it, has been criticized as having little or no factual foundation).[169]
- The 2018 film The Mountain centers on lobotomy, attitudes about mental health in general, in 1950s America. The protagonist, a young man whose mother had been lobotomized, takes a job as a medical photographer for a doctor whose character is loosely based on Freeman.[170][171]
See also[edit]
- Bilateral cingulotomy – destruction of a part of the brain
- Bioethics and medical ethics
- Frontal lobe disorder
- Frontal lobe injury
- Psychosurgery
- History of psychosurgery in the United Kingdom
- ^ Walter Rudolf Hess, who was the joint winner with Moniz of the Nobel Prize in 1949 for his work on the function of the midbrain, had no involvement with leucotomy.[3]
- ^ 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 a period of five years or more.[21] The report also observed that psychiatric patients occupied 55 per cent of all hospital beds in America.[21] Conditions within US mental hospitals became the subject of public debate as a series of exposes were published in the 1940s.[22] A 1946 Life magazine article remarked that the nation's system of mental hospitals resembled "little more than concentration camps on the Belsen pattern";[23] a point the piece emphasized with documentary photography that depicted patient neglect and dilapidated material conditions within psychiatric institutions.[24]
- ^ Ugo Cerletti, the Italian psychiatrist and joint inventor with Lucio Bini of electroconvulsive therapy, described psychiatry during the interwar period as a "funereal science".[25] Likewise Egas Moniz, the inventor of leucotomy, referred to the "impotência terapeutica" (therapeutic impotence) of existing therapeutic remedies during the 1930s.[26]
- ^ The patient he thought improved subsequently committed suicide.[42]
- ^ According to Puusepp, the three patients had manic depression or considered "epileptic equivalents".[49]
- ^ Puusepp admitted to his 1910 experimentation with psychosurgery in a 1937 publication.[52] 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.[51]
- ^ 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,[55] but after the Portuguese coup d'état of 1926, which ushered in the Ditadura Nacional (National Dictatorship), the 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.[56] 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.[57]
- ^ 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.[51]
- ^ The patient had meningioma, a rare form of brain tumour arising in the meninges.[74]
- ^ Brickner and Davidoff had planned, before Moniz's first leucotomies, to operate on the frontal lobes to relieve depression.[82]
- ^ Moniz wrote in 1948: 'sufferers from melancholia, for instance, are distressed by fixed and obsessive ideas ... and live in a permanent state of anxiety caused by a fixed idea which predominates over all their lives ... 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 ... 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 ...'[89]
- ^ Lima described his role as that of an "instrument handled by the Master".[98]
- ^ Before operating on live subjects, they practised the procedure on a cadaver head.[83]
- ^ It was estimated by William Sargant and Eliot Slater that 15,000 leucotomies had been performed in the UK by 1962.[117]
- ^ The 14 leucotomies reported by Puusepp in his 1937 paper were performed at the Racconigi Hospital.[119]
- ^ Frank Freeman, Walter Freeman's son, stated in an interview with Howard Dully that: "He had several ice-picks that just cluttered the back of the kitchen drawer. The first ice-pick came right out of our drawer. A humble ice-pick to go right into the frontal lobes. It was, from a cosmetic standpoint, diabolical. Just observing this thing was horrible, gruesome." When Dully asked Frank Freeman, then a 79-year-old security guard, whether he was proud of his father, he replied: "Oh yes, yes, yeah. He was terrific. He was really quite a remarkable pioneer lobotomist. I wish he could have gotten further."[134]
- ^ Rodney Dully, whose son Howard Dully had had a transorbital lobotomy performed on him by Walter Freeman when he was twelve years old, stated in an interview with his son that: "I only met him [Freeman] I think the one time. He described how accurate it [transorbital lobotomy] was and that he had practised the cutting on, literally, a carload of grapefruit, getting the right move and the right turn. That's what he told me."[134]
- ^ "Lobotomy: Definition, Procedure & History". Live Science. Retrieved 28 June 2018.
- ^ a b Raz 2009, p. 116
- ^ Nobelprize.org 2013.
- ^ a b c d Sutherland 2004
- ^ Levinson, Hugh (8 November 2011). "The strange and curious history of lobotomy". BBC News. BBC.
- ^ a b Kaye, Hugh (25 April 2023). "The dark history of gay men, lobotomies and Walter Jackson Freeman II". attitude. Retrieved 28 June 2023.
- ^ Johnson, Jenell (2014). American Lobotomy: A Rhetorical History. University of Michigan Press. pp. 50–60. ISBN 978-0472119448. Retrieved 12 August 2017.
- ^ El-Hai, Jack (21 December 2016). "Race and Gender in the Selection of Patients for Lobotomy". Wonders & Marvels. Retrieved 12 August 2017.
- ^ "Lobotomies". Western University. Archived from the original on 14 March 2016. Retrieved 12 August 2017.
- ^ Kalat, James W. (2007). Biological psychology (9th ed.). Belmont, California: Wadsworth/Thomson Learning. p. 101. ISBN 9780495090793.
- ^ Zajicek, Benjamin (2017). "Banning the Soviet Lobotomy: Psychiatry, Ethics, and Professional Politics during Late Stalinism". Bulletin of the History of Medicine. 91 (1): 33–61. doi:10.1353/bhm.2017.0002. ISSN 1086-3176. PMID 28366896. S2CID 46563971.
- ^ Gallea, Michael (Summer 2017). "A brief reflection on the not-so-brief history of the lobotomy". BCMedical Journal. 59: 302–04. Archived from the original on 7 February 2019. Retrieved 4 February 2019.
- ^ Noyes & Kolb 1962, pp. 550–55
- ^ Partridge 1950, pp. 470–71
- ^ a b Cooper 2014, pp. 143–54.
- ^ a b c Valenstein 1997, pp. 499–516
- ^ Szasz 2007, pp. 151–72
- ^ Freberg 2010, pp. 416–17
- ^ Shutts 1982
- ^ Raz 2013, pp. 101–13
- ^ a b Feldman & Goodrich 2001, p. 650; Mashour, Walker & Martuza 2005, p. 411
- ^ Maisel 1946; Wright 1947; Deutsch 1948;Feldman & Goodrich 2001, p. 650; Pressman 2002, pp. 148–50
- ^ Albert Q. Maisel, "Bedlam 1946, Most U.S. Mental Hospitals are a Shame and a Disgrace", Life 20 (1946), pp. 102–03, quoted in Pressman 2002, p. 149
- ^ Pressman 2002, pp. 148–49.
- ^ Shorter 1997, p. 218.
- ^ a b Gross & Schäfer 2011, p. 5
- ^ Swayze 1995, pp. 505–15;Hoenig 1995, p. 337; Meduna 1985, p. 53
- ^ a b Pressman 2002, p. 200
- ^ Brown 2000, pp. 371–82.
- ^ Shorter 1997, pp. 190–225; Jansson 1998
- ^ Healy 2000, p. 404; Braslow 1995, pp. 600–05; Braslow 1997, pp. 89, 93
- ^ Braslow 1997, p. 3.
- ^ Cooter 2012, p. 216
- ^ Porter 1999, p. 520.
- ^ Pressman 2002, p. 428; Raz 2009, pp. 116, 129
- ^ Gross & Schäfer 2011, p. 1; Heller et al. 2006, p. 727; Joanette et al. 1993, pp. 572, 575; Kotowicz 2008, p. 486; Manjila et al. 2008, p. 1; Noll 2007, p. 326; Reevy, Ozer & Ito 2010, p. 485; Steck 2010, pp. 85–89; Stone 2001, pp. 79–92; Suchy 2011, p. 37; Mareke & Fangerau 2010, p. 138; Ford & Henderson 2006, p. 219; Green et al. 2010, p. 208; Sakas et al. 2007, p. 366; Whitaker, Stemmer & Joanette 1996, p. 276
- ^ a b Berrios 1997, p. 68
- ^ a b c Berrios 1997, p. 69
- ^ Berrios 1997, pp. 69, 77
- ^ a b Tierney 2000, p. 26
- ^ Whitaker, Stemmer & Joanette 1996, p. 276; Berrios 1997, p. 69
- ^ Stone 2001, p. 80.
- ^ Berrios 1997, p. 70
- ^ Manjila et al. 2008, p. 1
- ^ Kotowicz 2005, pp. 77–101
- ^ Bechterev & Puusepp 1912; Kotowicz 2008, p. 486
- ^ a b Kotowicz 2005, p. 80; Kotowicz 2008, p. 486
- ^ Quoted in Berrios 1997, p. 71
- ^ Feldman & Goodrich 2001, p. 149
- ^ Kotowicz 2005, p. 80; Kotowicz 2008, p. 486; Berrios 1997, p. 71
- ^ a b c d Feldman & Goodrich 2001, p. 649
- ^ Puusepp 1937
- ^ Kotowicz 2008, p. 486
- ^ a b c d e f g Kotowicz 2008, p. 477
- ^ Tierney 2000, p. 23
- ^ Tierney 2000, p. 25; Tierney 2000, pp. 22–23; Kotowicz 2005, pp. 78
- ^ Shorter 1997, p. 226; Tierney 2000, pp. 25
- ^ Doby 1992, p. 2; Tierney 2000, pp. 25
- ^ El-Hai 2005, p. 100
- ^ a b Berrios 1997, p. 72
- ^ Pressman 2002, pp. 13–14, 48–51, 54–55; Berrios 1997, pp. 72–73; Shorter 1997, p. 226; Heller et al. 2006, p. 721
- ^ Heller et al. 2006, p. 721
- ^ a b Pressman 2002, p. 48.
- ^ Pressman 2002, p. 48; Heller et al. 2006, p. 721
- ^ Pressman 2002, p. 48; Berrios 1997, p. 73
- ^ Berrios 1997, p. 73
- ^ Pressman 2002, pp. 48–50
- ^ Pressman 2002, p. 50
- ^ Berrios 1997, pp. 72–73
- ^ Pressman 2002, pp. 48–55; Valenstein 1997, p. 541
- ^ Pressman 2002, pp. 51, 55
- ^ a b c d e f Pressman 2002, p. 51
- ^ Bianchi 1922; Pressman 2002, p. 51; Levin & Eisenberg 1991, p. 14
- ^ a b Pressman 2002, p. 52; Kotowicz 2005, p. 84
- ^ Brickner 1932
- ^ a b Kotowicz 2005, p. 84
- ^ a b Quoted in Pressman 2002, p. 52
- ^ a b c d e Pressman 2002, p. 52
- ^ Quoted in Freeman & Watts 1944, p. 532
- ^ Pressman 2002, p. 53
- ^ a b Valenstein 1990, p. 541
- ^ a b Valenstein 1997, p. 503
- ^ a b Feldman & Goodrich 2001, p. 650
- ^ Quoted in Valenstein 1990, p. 541
- ^ Valenstein 1990, p. 541; Feldman & Goodrich 2001, p. 650; Kotowicz 2008, p. 478
- ^ Berrios 1997, p. 77; Valenstein 1990, p. 541; Valenstein 1997, p. 503
- ^ Quoted in Valenstein 1997, p. 503
- ^ Gross & Schäfer 2011, p. 1
- ^ Quoted in Berrios 1997, p. 74
- ^ Kotowicz 2005, p. 99; Gross & Schäfer 2011, p. 1
- ^ Quoted in Kotowicz 2005, p. 88
- ^ Quoted in Feldman & Goodrich 2001, p. 651
- ^ Berrios 1997, p. 74
- ^ Kotowicz 2005, p. 89
- ^ a b Moniz 1994, p. 237.
- ^ Kotowicz 2005, pp. 80–81; Feldman & Goodrich 2001, p. 650
- ^ Gross & Schäfer 2011, p. 2; Kotowicz 2008, p. 482
- ^ , Gross & Schäfer 2011, p. 2
- ^ Tierney 2000, p. 29; Kotowicz 2005, pp. 80–81; Gross & Schäfer 2011, p. 2
- ^ Pressman 2002, p. 54
- ^ Finger 2001, p. 292.
- ^ a b c Kotowicz 2005, p. 81
- ^ a b c Feldman & Goodrich 2001, p. 651
- ^ Jansson 1998; Gross & Schäfer 2011, p. 2; Feldman & Goodrich 2001, p. 651. For Moniz's account of the procedure see, Moniz 1994, pp. 237–39
- ^ Kotowicz 2005, p. 81; Feldman & Goodrich 2001, p. 651; Valenstein 1997, p. 504
- ^ Berrios 1997, p. 75
- ^ Kotowicz 2005, p. 92
- ^ Berrios 1997, p. 75; Kotowicz 2005, p. 92
- ^ a b Gross & Schäfer 2011, p. 3
- ^ Berrios 1997, p. 74; Gross & Schäfer 2011, p. 3
- ^ a b Kotowicz 2008, p. 482
- ^ a b Quoted in Kotowicz 2008, p. 482
- ^ Kotowicz 2008, pp. 482–83
- ^ Kotowicz 2008, p. 483
- ^ Feldman & Goodrich 2001, p. 652; Kotowicz 2005, p. 81
- ^ Quoted in El-Hai 2005, p. 182
- ^ Kotowicz 2008, pp. 486 n.1; Sargant & Slater 1963, p. 98
- ^ Kotowicz 2008, pp. 476–77
- ^ Puusepp 1937; Kotowicz 2008, pp. 477, 486
- ^ Kotowicz 2008, pp. 477, 487
- ^ a b Kotowicz 2008, p. 478
- ^ a b El-Hai 2005, p. 182
- ^ a b El-Hai 2005, p. 182; Finger 2001, p. 293; Weiss, Rauch & Price 2007, p. 506
- ^ Shorter 1997, p. 227; Pressman 2002, p. 78
- ^ a b Pressman 2002, p. 76; Feldman & Goodrich 2001, p. 649
- ^ Pressman 2002, p. 76; Kotowicz 2005, p. 94
- ^ Pressman 2002, p. 73
- ^ Pressman 2002, pp. 73–75
- ^ Quoted in Pressman 2002, p. 76
- ^ a b c Pressman 2002, p. 76
- ^ a b Pressman 2002, p. 77
- ^ Finger 2001, p. 293
- ^ El-Hai 2005, p. 184.
- ^ a b Dully 2005.
- ^ El-Hai 2005
- ^ Caruso, James P.; Sheehan, Jason P. (2017). "Psychosurgery, ethics, and media: a history of Walter Freeman and the lobotomy". Neurosurgical Focus. 43 (3): E6. doi:10.3171/2017.6.FOCUS17257. PMID 28859561.
- ^ Shorter 1997, pp. 227–28
- ^ Tranøy & Blomberg 2005, p. 107
- ^ Tranøy 1996, pp. 1–20
- ^ Ogren & Sandlund 2005, pp. 353–67
- ^ Goldbeck-Wood 1996, pp. 708–09
- ^ "Jesper Vaczy Kragh: "Sidste udvej? Træk af psykokirurgiens historie i Danmark" (Dansk Medicinhistorisk Årbog 2007)" (PDF). Archived from the original (PDF) on 5 March 2016. Retrieved 20 January 2018.
- ^ Lichterman 1993, pp. 1–4
- ^ USSR Ministry of Health 1951, pp. 17–18
- ^ a b Diefenbach et al. 1999, pp. 60–69
- ^ Bangen, Hans: Geschichte der medikamentösen Therapie der Schizophrenie. Berlin 1992, ISBN 3-927408-82-4
- ^ "La neurochirurgie fonctionnelle d'affections psychiatriques sévères" (PDF) (in French). Comité Consultatif National d'Ethique. 25 April 2002. Archived from the original (PDF) on 20 July 2011. (French national consultative committee on ethics, opinion #71: Functional neurosurgery of severe psychiatric conditions)
- ^ Ogren & Sandlund 2005.
- ^ Wiener 1948, p. 148.
- ^ Gilyarovsky 1950
- ^ Lichterman 1993, pp. 1–4; USSR Ministry of Health 1951, pp. 17–18
- ^ Gilyarovsky 1973, p. 4
- ^ Wood & Wood 2008, p. 153.
- ^ Szasz, Thomas (2011). Coercion as Cure: A Critical History of Psychiatry. Transaction. p. 165. ISBN 978-1-4128-0895-8.
- ^ Jansson 1998.
- ^ Feldman 2001, p. 271
- ^ Day 2008
- ^ Prior 2008
- ^ Snyder & Steffen-Fluhr 2012, p. 52
- ^ Kolin 1998, pp. 50–51
- ^ Macmillan (2000, p. 250, 1999–2012)
- ^ Nijensohn 2012, p. 582
- ^ a b c Grenander 1978, pp. 42–44
- ^ Bigsby 1985, p. 100
- ^ Williams 1998, p. 15
- ^ Gabbard & Gabbard 1999, pp. 119–20
- ^ Arnold 1982.
- ^ Bragg 2005, pp. 72–75; El-Hai 2005, pp. 241–42
- ^ Lapin, Andrew (25 July 2019). "A Lobotomist Struggles To Hang on in the Brilliant, Blistering 'The Mountain'". NPR. Retrieved 8 November 2020.
- ^ Kohn, Eric (30 August 2018). "'The Mountain' Review: Jeff Goldblum and Tye Sheridan Are Lost Souls in Rick Alverson's Beautiful, Fractured America". IndieWire. Retrieved 8 November 2020.
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Online sources
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- Sutherland, John. Should they de-Nobel Moniz?; 5 August 2004 [Retrieved 22 December 2011].
External links[edit]
- My Lobotomy Radio story: Interview with Sallie Ellen Ionesco, lobotomised in 1946
- Mental Cruelty: Sunday Times article on lobotomy and contemporary psychosurgery
- Lobotomy's back: Discover article on cingulotomy
- 'My Lobotomy': Howard Dully's Journey. NPR Radio Documentary
- A Qualified Defence of 'Then': QJM
- Ten Notable Lobotomies
- Nobel Panel Urged to Rescind Prize for Lobotomies
- The Lobotomists: BBC Radio 4 documentary on the history of lobotomy


text:
Using additive manufacturing as a pathway to change the qualification paradigm
Solid Freeform Fabrication 2018: Proceedings of the 29th Annual International Solid Freeform Fabrication Symposium - An Additive Manufacturing Conference, SFF 2018
Additive Manufacturing (AM) offers the opportunity to transform design, manufacturing, and qualification with its unique capabilities. AM is a disruptive technology, allowing the capability to simultaneously create part and material while tightly controlling and monitoring the manufacturing process at the voxel level, with the inherent flexibility and agility in printing layer-by-layer. AM enables the possibility of measuring critical material and part parameters during manufacturing, thus changing the way we collect data, assess performance, and accept or qualify parts. It provides an opportunity to shift from the current iterative design-build-test qualification paradigm using traditional manufacturing processes to design-by-predictivity where requirements are addressed concurrently and rapidly. The new qualification paradigm driven by AM provides the opportunity to predict performance probabilistically, to optimally control the manufacturing process, and to implement accelerated cycles of learning. Exploiting these capabilities to realize a new uncertainty quantification-driven qualification that is rapid, flexible, and practical is the focus of this paper.

subset: commoncrawl


text:
One of history's most controversial characters is Al Hakim Bi Amr Allah. Seen as God incarnate by some, as an eccentric "mad" ruler by others, and vilianised by yet others.
Al Hakim was a Caliph of the Fatimid dynasty of Egypt, North Africa, Palestine and Syria. Contrary to the majority of their subjects, who were Sunni, the Fatimids were Shia of the Ismaili branch. They engaged in missionary work to spread their sect's belief as wide as possible.
Al Hakim reigned from 996 C.E. to 1021 C.E, having acceded to the throne at the young age of 11, he lived to be only 36 and ruled for 25.
Some pro-Fatimid sources are too lenient on him, and do not elaborate on his character and eccentricities, such as Wikipedia's entry, or the Institute of Ismaili Studies in the UK, or the quasi official Ismaili.Net web site.
On the contrary, most Sunni sources take a very hostile attitude to him, saying that he claimed divinity for himself.
The truth is somewhere in between. Balanced and objective historians have wrote extensive accounts on him. One such source is the Egyptian Historian, al-Maqrizi المقريزي, himself being a descendent of the Fatimids. Al-Maqrizi dedicated one of his work to the Fatimid dynasty, it is called إتعاظ الحنفاء Iti'az al-Hunufa in it, he chronicles the origin of this dynasty, detailed biographies of its rulers, and events during their reign. The section on al-Hakim is quite comprehensive.
He sums up the bias of sources on Fatimids at the end of his book as: "you will find that the worst histories of them are found only in the Mashreqi books, the Iraqis and Levantines", and then lists examples of those, then continues: "But you will not find any of that in books authored by Egyptians on the Fatimid dynasty".
ومما يدلك على كثرة الحمل عليهم أن الأخبار الشنيعة لا سيما التي فيها إخراجهم من ملة الإسلام لا تكاد تجدها إلا في كتب المشارقة من البغداديين والشاميين
كالمنتظم لابن الجوزي والكامل لابن الأثير وتاريخ حلب لابن أبي طي وتاريخ العماد لابن كثير وكتاب ابن واصل الحموي وكتاب ابن شداد وكتاب العماد الأصفهاني ونحو هؤلاء.
أما كتب المصريين الذين اعتنوا بتدوين أخبارها فلا تكاد تجد في شيء منها ذلك ألبتة.
What is certain is that al-Hakim was very generous, giving away money to people who asked. He was also pious, and fought consumption of alcoholic drinks. But he was also erratic, unpredictable, and very cruel.
Al Maqrizi sums him up as: "he did not stick to one thing. If he inclines to something, he would show it and then force people on it. Then he would abandon it, and then force people to abandon it to whatever he is now inclined to".
وكان قليل الثبات سريع الاستمالة إذا مال إلى اعتقاد شيء أظهره وحمل الناس عليه
ثم لا يلبث أن يرجع عنه إلى غيره فيريد من الناس ترك ما كان قد أهم به والمصير إلى ما استحدثه ومال إليه.
I will include here excerpts about al-Hakim's deeds, trying to draw conclusions from there acts as appropriate. They are in Arabic, with a summary in English.
See the links below for details:
Mohamed Jiwa (not verified)
Mon, 2008/11/17 - 12:02I like much of your blog and will probably return to it, especially for the recipes and the connection between the Arab and Maltese cultures and language.
But I found your information on Hakim bi amri'llah a bit far fetched because the children of Imams are generally quite aware of their heritage and are well versed in their religion which does not allow antinomial activity by people who have been given power.
I am however not well-informed in this area and would like to do more research.
Do you have any strong evidence of the activities you mention (like killing without the evidence taken to court and forbidding eating of certain things and so on), many of which seem to me to be either quite mad or reprehensible or both?
I have also heard (though have not verified) that Hakim disappeared in the end, and never returned, and his sister Sitt ul Mulk took over the caliphate for a few years before she invested Zahir to the imamate. I am researching slowly but surely. I would love to get more sources on Hakim and the more reliable the better.
The Fatimid period was generally very intellectually and culturally driven with respect for differences in religion.
Mohamed Jiwa
All quotes are provided
Tue, 2008/11/18 - 11:08I have provided quotes for everything I mentioned. They are from reputed scholars, like Al Maqrizi of Cairo. He is well known for a full history of Fatimids that is well researched and neutral, unlike many other non-Ismaili historical sources, which are biased against them.
Al Hakim was eccentric. I am sure that doctors nowadays can look at his actions and conclude that he was probably suffering from an undiagnosed condition. This would have caused mood swings and arbitrary decisions. A similar example is King George III of the United Kingdom, and his suffering from porphyria.
The set of articles I have written on Al Hakim are not complete yet. I plan to work on them more as time permits.
Anonymous (not verified)
"Do you have any strong
Mon, 2009/04/13 - 21:16"Do you have any strong evidence of the activities you mention (like killing without the evidence taken to court and forbidding eating of certain things and so on), many of which seem to me to be either quite mad or reprehensible or both?"
Very good question! No one has any evidence. This is all Sunni propaganda.
What our friend here has is a collection from the internet or some hostile literatures.
Dismiss it as you like
Tue, 2009/04/14 - 10:15You can dismiss this since it goes against your ingrained belief, but fact of the matter is that his acts are well documented in many sources, and no, these are not from the internet nor hostile literature. These are from Al Maqrizi who is very impartial and objective. He is among the few Sunni historians who acknowledged the Fatimid Dynasty's descent from the Prophet.
Al-Hakim's acts continue to be known historically until today: examples: the excuse for the First Crusades was because Al-Hakim destroyed the Church of the Holy Sepulchre earlier in the 1th century, then rebuilt it again paying the expenses! The Egyptian slang expression "Blue bone" which is used as derogatory term for Egyptian Copts, was because of him ordering the Copts to wear heavy crosses that used to bruise their collar bones!
There is a lot more, but it is all as factual as history can be. You can dimiss, ignore it, or accept it as it is: there has been lot of eccentric rulers in all ages and of all religion. Al-Hakim is just one of those.
Anonymous (not verified)
You say, "the quasi official
Thu, 2012/01/05 - 15:46You say, "the quasi official Ismaili.Net web site" as if your site is very authentic in itself.
Sunnis like present day jihadis were a murderous bunch of thugs out to get Shias and Ahlul Bayt. There's not doubt that they tried to denigrate Imam Hakim just like they did to Ali-Ibn Abi Talib and his father. Umar, Usman, Abu Bakr, may they be cursed. It was them that propagated the lies that Ali's father was a mushriq.
Its because of enemies of Ahlul Bayt that the whole of Islam is being humiliated now.
Anonymous (not verified)
Imam al-Hakim Bi AmrAllah(SWS)
Thu, 2010/10/14 - 14:59Al-Maqrizi was a chronicler under the Mamluk rulers, who were not only very zealous Sunnis,but also anti-Fatimid.
al-Maqrizi lived hundreds of years after Al-Hakim Bi amrAllah(SWS).
Scholars fro Dollarsd are not authoritative for balanced researchers.
Also he did order the Jews and Christians to wear these things because they were causing economic hardship and after these regulations the economy went up again and he withdrew these Rules.
The Church of the Sepulcher was a spy base for the Byzantines so he ordered it to be destroyed. The prophet Muhammad also ordered the Masjid al-Daraar to be Destroyed.
Al-Hakim Bi AmrAllah faced a lot of Abbassid propaganda,and he gave the women the right to choose hijab or not, and he was maligned by Sunni scholars later on.
It is to be noted al-Hakim was very pious.
He only gave women this freedom as the Prophet Muhammad did not force anyone.
References needed
Tue, 2010/11/02 - 21:06If you were talking about other Sunni historians, e.g. Ibn Kathir, then I would agree with you they have a tone of bias against the Ismaili Shia Fatimid dynasty.
However, Al-Maqrizi is the most objective scholar when it comes to Fatimids.
He has a book dedicated to the history of the Fatimid Caliphs اتعاظ الحنفا. Moreover, he is one of only a few Sunni scholars to assert that they indeed were from the progeny of the Prophet, rather than just say they were false claimants to such descent.
It is said that he himself descended from them, and that is one reason why he was partial towards them.
The Mamlukes did not bother with anti-Fatimid propaganda, since the Fatimids were long gone. Saladin ended their dynasty in 1160s or 1170s, and the Mamluks did not come into power until around 1250s. There were no Fatimids then to contend with.
Moreover, there is a difference between regular Fatimid Caliphs, and Al-Hakim in particular. Like most dynasties, the Fatimids had some rulers who were reasonable, some who were weak, some who were unjust, ...etc.
Al-Hakim stands out from all the others because of his erratic and eccentric behavior.
This can only be properly explained by a physical or mental condition, like King George III of England and his "madness", most often diagnosed as porphyria.
Please cite credible sources for your assertions rather than say they are just propaganda.
Anonymous (not verified)
Sat, 2012/01/21 - 22:49Documented in many sources!!!!!!!!!!!! You make me laugh when you to about Al-Hakim behavior.... How do you know all this?
Random (not verified)
It's been mentioned by
Mon, 2019/08/19 - 08:43It's been mentioned by notable historians including Professor Farhad daftary and Paul Walker in their works, who are probably two of the leading Academics on Ismaili History.
halby (not verified)
Al Hakim's return
Fri, 2019/11/15 - 00:46Daftary and Walker are they still around, if not who has replaced them in the field? You could say, I'm a big fan of Al Hakim's work, 1000 years ago.


text:
In January 1969 Canterbury AC and Thanet AC merged to form Invicta Athletic Club - the kit of the new club was red vest. Invicta (meaning 'undefeated') is the motto of the county of Kent and dates back to the 1066 invasion of England by William I, known as William the Conqueror who did not "conquer" Kent on his way to London. The new club had no formal headquarters and admin meetings were held either at Dennis Townsend's home or in the Royal Dragoon pub in Military Road : the total membership, fewer than 50 (mostly male), comprised mainly middle and long-distance runners.
However, in the 1970s, what the club lacked in numbers was more than made up in quality with many outstanding track, road and cross-country performances by the Senior Men both as individuals as well as in team events at county, national and international level.
British Athletics saw a boom period in the late 70s and early 80s, feeding off success of Coe, Ovett, Cram, Foster, Wells, Sanderson, Whitbread and the irrepressible Daly Thompson at the Olympics in Montreal, Moscow and Los Angeles. This led to increased participation in all forms of athletics at club level with Invicta AC's membership rose to over 200, bringing a demand for a wider range of competition, accentuated by the appearance of big city marathons. Local interest was particularly stimulated by Archbishop schoolmaster Mike Gratton's splendid bronze medal in the Commonwealth Games marathon in Brisbane (1982) followed by his superb marathon victory in London in 1983.
The club found itself unable to satisfy the new demand within the existing setup of mainly distance runners : the decision was therefore taken in 1984 to amalgamate with East Kent AC (a predominantly track & field club) which was based at a cinder track on the campus of the University of Kent, overlooking the City. The colours of East Kent AC's were blue vest with gold sash and gold shorts : the newly-amalgamated club went for red vest (Invicta) and East Kent AC's contribution was the gold lettering of the club's new name on the vest. A decade of outstanding success followed in all aspects of athletics, during which time we had to move HQ in the University grounds - twice.
First, it was clear that the rather run-down set of changing rooms of the days of East Kent AC were increasingly inadequate for the growing membership and it was decided to raise £25,000 to build our own wood-hut HQ, which was completed in 1987 in the area now developed as housing on Parkwood Road. However, within 3 years, the rapidly growing university meant that land on which the track and Clubhouse were located, was reclaimed by the University for student accommodation.
In compensation, in 1992 the Club HQ was moved with a "peppercorn rent agreement" to a new sports pavilion across the road, adjacent to Parkwood and overlooking a newly laid cinder track. Although the adjoining sports fields and woods provided superb training facilities (and good cross-country terrain) the new red shale track was unsuitable for legal competition because it was oversized, it sloped and had strangely positioned facilities... The curb was exactly 400m meaning the minimum running distance for a human was actually 402 metres - great for training, but totally useless for official competition.
More....... it sloped.
An under-sized long jump sand pit was located 3-4 metres behind the 100m start line, requiring long jumnpers to run form halfway down the straight BACK toward the start line, taking off where sprinters normally plant their starting blocks and then land almost at the clubhouse door. Somewhere between the move from wooden hut to the brick clubhouse, East Kent AC's gold lettering on the vest was replaced by white lettering, and most people now called the club "Invicta", unaware of the major contribution made by East Kent AC to our impressive track and field heritage.
For much of the 80s and 90s there was talk of Canterbury building a modern synthetic athletic track. Various proposals and locations were considered, but it was the government's PFI initiative which finally brought together the required £3 million lottery funding and a location, The Canterbury High School.
In 2000 a new facility comprising a 6-lane all-weather track, an indoor sports hall and a gym was completed : as the principal athletics club in the area, IEK AC was involved from the outset, raising £45,000 to relocate to a new Clubroom within the new complex.
Since moving to the new complex, we've had regular access to good indoor facilities and also to a regulation size track as a home for official competitions as well as for training : membership (across all age groups, from juniors age 7 up to veterans over-65) has grown to just over 380, covering all track & field areas involving running, jumping, throwing and hurdling.
There are about 20 coaches across all athletic disciplines, each contributing to the club's ethos of developing potential at all levels. The pursuit of excellence enables both those capable of achieving county and national honours to flourish, as well as providing a professional base for those wishing to get the best out of themselves, even though their limit might be just short of getting into one of our league teams.
Membership, and access to good coaches, is not restricted just to those with known pedigree, or even to those with long-term potential - ALL Invicta members and ALL newcomers have equal access to good athletic training and practice.
We are proud to live up to the motto of "Sport fitness and fun".


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Fight Breast Cancer With These 7 Foods
Breast Cancer Awareness Month is a good reminder that we should all pay more attention to our health. That means thinking about what we choose to eat and how the right foods can help us stay healthy. There are so many items we can add to our diets that can actually aid our bodies in the fight against cancer that it would be insane not to start eating more of them right away.
Whether you've already fought cancer, are currently fighting it or are concerned about a family history, experts believe that diet is an important factor. The seven foods listed below are just a few examples that can help fight the fight for you. Take a look at the options and choose the diet that's right for you.
Broccoli and other cruciferous vegetables (like cabbage, kale and cauliflower) are great cancer fighters because they are filled with antioxidants that search your body for cancer-causing free radicals. The antioxidants in broccoli have been proven to fight breast, cervical, prostate and gastric cancers. Broccoli also contains phytochemicals that have been linked to cancer prevention. Load up your plate with these nutrient dense, low calorie veggies.
Spinach and other leafy vegetables are also key additions to a healthful, cancer-fighting diet. You've heard it before. Vegetables like spinach, arugula, kale and collard greens are loaded with vitamin C, beta-carotene and antioxidants -- all known cancer combatants. Plus, leafy green vegetables are low in calories and don't contain fats and toxins, so they help keep your whole body healthy, making it stronger and more capable of fighting cancer. Fill your plate and enjoy.
Vegetables don't get all the credit in the fight against cancer. Adding berries to your diet can also help you stay cancer-free. In particular, black raspberries get high marks for fighting cancer. They contain anthocyanins, which are powerful antioxidants. This phytochemical has been shown to attack premalignant cells and keep new, tumor-feeding blood vessels from forming. Any berries are going to be packed with nutrients, but black raspberries are going to pack the most punch.
Beans are one of the more frequently mocked dietary staples, but if you want to focus your diet on fighting cancer, add some legumes to the grocery list. A diet rich in black and navy beans can increase your levels of the fatty acid butyrate. In high concentrations, it has been proven that this fatty acid can protect against cancer growth. Studies have shown that beans reduced incidences of breast and colon cancer in rats.
Opinions on whether or not soy in your diet will prevent or promote cancer have swayed back and forth. Soy contains isoflavones, which have been shown to be effective in preventing tumor growth as well as blocking the stimulation of cancer cells by estrogen and testosterone. It's also important to note that isoflavone supplements have been linked to aggravation of certain breast cancers, so those should be avoided. However, whole soy is a healthy addition to your diet.
Garlic doesn't merely keep vampires at bay, it can also keep cancer away. In fact the entire allium family -- including onions, leeks, chives, shallots and scallions -- is filled with those cancer-fighting antioxidants that should be in your diet. Studies have shown that certain nutrients in garlic have the ability to slow or stop the growth of certain tumors. Garlic can also boost your immune system to help your body fight off anything that doesn't belong. And to top it off, garlic is a natural detoxifier and adds wonderful flavor to any dish.
Green Tea
Green tea has so many health benefits that it's really no surprise that it can also be a good cancer fighter. This power drink contains catechins that are thought to be even better than vitamin C at tracking down and eliminating free radicals in your body. Studies have also shown that the nutrients in green tea can shrink existing tumors and inhibit the growth of cancer cells. If you are building a cancer-fighting diet, you should be drinking green tea every day.