Monday, March 26, 2007

A Brief History of the Frontal Lobotomy

Update: I am pretty flattered right now, the subject of my term paper, Howard Dully himself, commented on my paper. He has a website over here, and has a book due out in September called My Lobotomy. Glance at my paper for a synopsis, it's a great story.

I have a history of publishing my term papers on my blogs. I know its not education related, but just in case you are interested. It should be noted as I did my research, that I noticed a simularity between the history of lobotomies and education. Bonus points if you accurately predict my grade (out of 100).

Rory D. Hester
Psy 201
March 26, 2007

Frontal lobotomies have achieved a unique place in the culture of the United States. The procedure is lampooned in cartoons, mentioned in popular music (Hanzlick), and the term used frequently in common conversation, often as part of a derogatory remark… i.e. “Did you have a lobotomy or what?” My stereotype image of a neurosurgeon is still that of a mad scientist hacking away parts of people’s brains, even though it has been over 40 years since Walter Freeman performed his last lobotomy. This paper will attempt to give a brief history of frontal lobotomies, including its effects on several patients, and take a look at its influence on future neurological surgeries.

The history of the frontal lobotomy can be traced back to a German scientist, Friederich Golz, who performed experiments that involved the removal of the neocortex of dogs in 1890 to calm them down (Sabattini). This inspired at least one physician to experiment with a similar procedure on six schizophrenic patients, but the procedure was criticized by medical authorities.

In 1935, Carlyle Jacobsen and Dr. John Fulton performed similar experiments on chimpanzees, which got the attention of a Portuguese neuropsychiatrist, Dr. Antônio Egas Moniz, at the University of Lisbon Medical School. Moniz, started experimenting with a procedure called a leucotomy, which involved cutting the nerves that connected the prefrontal and the frontal cortex to the thalamus. His results were mixed however and he strongly advocated that the procedure should only be used on completely hopeless patients.

Moniz’s work inspired a young ambitious neurologist, Walter Freeman, to take up where he had left off. Eventually he developed and perfected a procedure called the "ice-pick lobotomy". This procedure was so quick and easy, that it was able to be done on an outpatient basis. Frontal lobotomies could now be performed on a wide scale basis, and public opinion supported it. Over 18,000 frontal lobotomies were performed in this country, with tens of thousands performed overseas between 1939 and 1951.

Unlike other physicians in the past, Freeman was able to convince both the press and his colleges that the new procedure would revolutionize the treatment of mentally ill patients. A study of popular press articles on frontal lobotomies showed the positive effects of lobotomies were mentioned more than possible negative consequences until the mid 1950’s (Diefenbach). They also noted that Freeman’s enthusiasm for the procedure predated studies on the long term effects of the operation. This surely contributed to the sheer volume of procedures performed.

While today, we look back at this period with a sense of embarrassment, it should be remembered that at the time the procedure was accepted by much of the medical establishment. According to a review of the scientific journals of the day, “The neurosurgeons who performed the operations, and the scientists who justified it, all came from the highest ranks” (Pressman 4). The culmination of neurosurgeons seeking legitimization, the simplicity of the procedure, and a large number of state psychiatric hospitals all created the perfect conditions for a culture of “lobotomy” to take over the psychiatric field. Not only did lobotomies have the potential to cure people they were also “aesthetically pleasing and financially rewarding” (Pressman, 194).

In the 1950’s though, the climate began to change. A large scale study, called the Columbia-Greystone project, failed to provide evidence of positive benefits of the procedure. Then in the 1950’s a new class of drugs began to be developed that enabled psychiatrists to manage many of the symptoms that lobotomies had been used to cure (Vertosick). A national debate began to take place about the morality of damaging healthy tissue of vulnerable patients. Lobotomy started to loose its luster, and gradually faded out from the mainstream of neurosurgery, but not before it was performed on a young boy named Howard Dully.

In 1960, Rodney and Lou Dully, Howard’s stepmother, went to see Walter Freedman about their 12 year old son. According to Dr. Freedman’s notes, Lou Dully was at her wits end with Howard, even though other doctors had told her that he was a normal 12 year old boy. With Freedman’s encouragement, Howard’s parents agreed to have him lobotomized in December of 1960. Howard had no memory of the operation, and after he was told of the operation “he took it without a quiver. He sits quietly, grinning most of the time and offering nothing” (My Lobotomy). Apparently though, the operation was not successful enough for his parents and shortly thereafter he was shipped off into mental institution.

Even though you would never notice anything peculiar about Howard Dully, except of course for his size, he always felt that something was missing inside of him. After an exhaustive two year investigation of his procedure, he was finally able to confront his father about the operation. He was also able to meet some other victims of lobotomies, and come to terms with the procedure. As he notes in the All Things Considered story, "I know my lobotomy didn't touch my soul. For the first time I feel no shame. I am, at last, at peace." He was one of the lucky ones though, the procedure did much more damage to many people, including Rose Marie Kennedy, a relative of President John F. Kennedy, who after having the operation at the age of 23 for mood swings and mile mental retardation, was reduced to an infantile state according to her biography at the John F. Kennedy Presidential Library and Museum.

In February 1967, Walter Freeman performed his last lobotomy on Helen Mortenson. She died of a brain hemorrhage, and ended the chapter of Freeman’s lobotomies on demand, though the procedures still has effects on medical ethics and modern neuroscience. A new generation of neurosurgeons is wrestling with the same issues. Today, Harvard Medical School and the Massachusetts General Hospital, perform a procedure called a cingulotomy, which consists of burning dime size holes in the frontal cortex of patients (Eskandar). Even the perception of neurosurgery is that of extreme precision, but the reality is that the brain is an extremely complex organ, and operating on it is similar to repairing a watch with a monkey wrench.

While I support the need for scientists to conduct research and experiments with brain surgery, history tells us that we must be careful. The history of brain research and psychiatry has been riddled with fads, including Freud’s psychotherapy, electroshock therapy, and lobotomies. We have to be careful, that our curiosity about the way the mind works does not blind us into leaping on a large scale onto the next medical fad. The popularity of the Freeman’s lobotomy would be harder to duplicate into days world. The general public is more skeptical of scientists, and the media is much quicker to investigate potential problems with procedures. Though we shake our heads today at what Freeman did in the past, in fifty years, I can’t help but get the feeling that doctors will consider some of our methods almost as crazy. Medicine is best served by the scientific method, but we must remember that unlike other scientific fields, fellow human beings are the guinea pigs.

References

Biography of Rosemary Kennedy. Retrieved March 22, 2007 from John F. Kennedy Presidential Library website:
http://www.jfklibrary.org/Historical+Resources/Biographies+and+Profiles/Biographies/Biography+of+Rosemary+Kennedy.htm

Boeree, C. (2001). A Brief History of the Lobotomy. Retrieved March 22, 2007 from Shippenburg University, George Boeree’s web site: http://webspace.ship.edu/cgboer/lobotomy.html

Diefenbach, G., Diefenbach D., Baumeister, A., West, M. (1999). Portrayal of Lobotomy in the Popular Press: 1935-1960*. Retrieved March 25, 2007 from University of North Carolina at Asheville. Department of Psychology website: http://facstaff.unca.edu/ddiefenb/lobotomy.html

Eskandar, E., Cosgrove, G. (2001). Psychiatric Neurosurgery Overview. Retrieved March 22, 2007 from Harvard University, Massachusetts General Hospital, Department of Neurosurgery website: http://neurosurgery.mgh.harvard.edu/Functional/Psychosurgery2001.htm

Hanzlick, R. (1983). I’d rather have a bottle in front of me (Than a frontal lobotomy). Lyrics retrieved March 22, 2007 from http://everything2.com/index.pl?node=frontal%20lobotomy

Pressman, J. (1998). Last Resort, Psychosurgery and the Limits of Medicine [Electronic version]. Cambridge University Press. New York.

My Lobotomy: Howard Dully’s Journey. (2005). Retrieved March 19, 2007 from National Public Radio website: http://www.npr.org/templates/story/story.php?storyId=5014080

Sabbatini, R. (1997). The History of Psychosurgery [Electronic version]. Brain and Mind. Retrieved March 22, 2007 from http://www.cerebromente.org.br/n02/historia/lobotomy.htm

Whitaker, R. (2002). Mad In America, Bad Science, Bad Medicine, and the Mistreatment of the Mentally Ill [Electronic Version]. Perseus Publishing. Cambridge, Ma.

Vertosick, F. (1997). Lobotomy's back - controversial procedure is making a comeback [electronic version]. Discover Magazine. Retrieved March, 23 2007 from http://discovermagazine.com/1997/oct/lobotomysback1240

5 comments:

Howard D said...

Great story !!!!
BTW my book will be out Sept 4 of this year....

Parentalcation said...

Thanks Howard... hopefully my instructor thinks so too.

I also hope that I didn't mess up on your story.

Good luck with your book... stories like yours can help publicize important ethical questions, and perhaps help prevent other people having to go through similar experiences.

Anonymous said...

Nice summary; I have a comment. The below description is true. It's the latest, cutting-edge research. I hope it can be stopped.

Jay Chawla, JD, PhD
***********************

Ultrasound technology is currently in secret, nonpublic human trials to selectively ablate healthy frontal lobe tissue, including broad areas of both left and right lobes, as well as specifically targeting blood vesssels and functional tissue in the left medial lobe. When blood vessels die, all the cells they feed die. When large blood vessels are damaged, large amounts of brain tissue become permanently compromised, undernourished, and underperforming. That is the intent of this procedure – to make the patient more tractable and easily controlled – more manageable. The procedure, or at least current thinking on it, involves:
1. Doing a standard MRI of the patient to determine such things as skull shape, where the tissue to be ablated is, etc.
2. Putting the patient in the same machine, telling the patient that a ‘follow up study’ is needed for some fictive reason (with a guardian’s permission or some other justification)
3. Using a phased array of acoustic transducers to target in varying levels various parts of the frontal brain. Focused ultrasound superheats tissue, causing cell death.
This phased array is not visible — it’s just swapped into the MRI machine, so the patient has no way of seeing it.
There are problems with this procedure, including
1. difficulty focusing the beam due to irregularities in conduction characterisitics and shape of the skull, etc.
2. the possibility of a secondary hematoma
3. difficulty in controlling the rampant damage, including to major arteries, resulting possibly in a permanent need for vasodilative medication
4. Limited follow up on prior studies investigating damage to rabbit brains — necrosis (cell death), scarring, etc., just after psychosurgery, and at various later stages was not studied sufficiently to fully determine how dire the long-term impact of this procedure will be on humans.
I believe that the procedure is able to avoid skull heating without the use of cooling elements by using a large array that covers most of the skull, and the beam is able to focus in an (approximately) 1-2cm^3 region, and the beam moves around continuously at a rate of 1-3 cm/s. Bursts are not used as in the FDA approved uterine fibroid focused ultrasound procedure for 2 reasons:
1. In the FDA approved uterine procedure, precise ultrasound beam focus is possible since you don’t have to send the ultrasound through highly distorting, poorly modeled skull bone, and tissue ablation can be better controlled by superheating a focused spot. Multiple such bursts can destroy a substantial uterine tumor.
2. This is a lower-power procedure, so it needs to use continuous power focused ultrasound output. Also, the focus is very poor, oddly shaped, and in an unpredictable and only poorly measurable location. Primitive ray-tracing techniques using incomplete skull and other data are used to ‘guess’ at a focal point. (The location of beam focus is used by approximately and not-very-accurately measuring tissue heating with MRI and looking for ‘landmarks’ in brain geography from the preliminary MRI, and the focused ultrasound beam is offset based on such measurements.)
The unsuspecting patients were injected with a clear fluid prior to the procedure, contains microbubbles/ultrasound contrast agent for enhanced tissue destruction. By aiming a weak, poorly focused beam at tissue that has microbubbles in it, the microbubbles cause very extensive, diverse, uncontrollable and uncontainable damage in tissue even at the low power and focus available in this hack, primitive procedure.
The procedure takes some time, including preliminary passes over the left frontal lobe all the way from the temple to the middle of the brain, and the right frontal lobe, out to the medial area. This opens the blood-brain barrier for ultrasound contrast/microbubbles of large particle size to pass through the blood-brain barrier and aggregate in the left medial frontal lobe, which is the true target for destruction.
Unfortunately, in sonicating the blood-brain barrier, extensive collateral damage is caused to the barrier as well as underlying neural, prefrontal tissue. Furthermore, the integrity of the blood-brain barrier is compromised, resulting in possibly permanent hematoma.
The main target is areas in the left medial lobe. A few preliminary passes are done over the area, and the MRI is used to primitively guestimate the approximate temperature and area of heating of tissue in the generalized target area, focusing in particular on arteries (identified from the preliminary MRI) that are to be taken down or damaged. Some spatial offsets are used to guestimated focal points to translate the ultrasound focal point.
In the final pass, after enough time for the microbubbles to pass through the blood brain barrier and circulate to the left medial frontal lobe so they can be ‘detonated’ and haphazardly destroy brain and associated vascular tissue like mini-shrapnel, the final pass is done at a high power level (and even poorer geographic focus on the target area), and the most severe, intended damage from the procedure is done to the unwitting subject.
This procedure is painful, very excruciatingly painful. Terrifyingly painful. However, the patient is medicated with neither their knowledge nor consent, and staff and other confederates trick the patient into thinking the resulting pain is just ‘normal for an MRI’ and that they must be imagining things.
However, the damage is done. And it is terrible damage. The brain burns more calories per gram than any other tissue in the body, and as FMRIs show, it has a very sophisticated method of opening and closing various blood vessels to put the blood where you are ‘thinking’. A major object of this procedure is to make it much harder to ‘think’ in one’s left medial frontal lobe.
I cannot certify to all the details in the above description. But more details will come in time.

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