lobotomy, frontal ‘Lobotomy’ means cutting a lobe of the
brain. It is synonymous with
leucotomy (from the Greek ‘leukos’, ‘white’ and ‘tome’, ‘cut’) — that is, cutting tracts of nerve fibres (
white matter) that connect different regions of the
brain. Lobotomy of the frontal lobe is an operative procedure used to alleviate symptoms of mental illness. Currently, it is used more commonly in North America than elsewhere.
On 12 November 1935, a Portuguese neurosurgeon, Almeida Lima, performed the first human lobotomy, using alcohol injections to destroy the brain tissue. This procedure had been proposed by his Nobel Prize-winning colleague, Egas Moniz, as a result of hearing a lecture by the American neurologist John Fulton earlier that year. Fulton had described a chimpanzee that became much calmer after surgery destroying the connections between the frontal lobe and areas below the cerebral hemispheres, which are concerned with the
emotions. Lima operated on a total of 20 patients, all of whom survived. Seven were considered to have made a complete recovery and an equal number were described as having markedly improved.
Encouraged by these findings, Walter Freeman and James Watts modified Moniz's technique and introduced ‘frontal lobotomy’ into the US. This operation, also called
prefrontal leucotomy or
standard lobotomy, was performed widely, and soon its beneficial as well as its detrimental effects became apparent.
Like other brain operations, frontal lobotomy was associated with risks of
infection, bleeding, and an increased likelihood of developing seizures. In addition, it also became evident that it altered the behaviour and personality of patients, and this gradually limited its use, which further declined in the 1960s because of the development of pharmacological means of treating mental illness. Nevertheless, the use of neurosurgery for treating mental disorders has continued to the present day and is still available in several centres worldwide.
Earlier operations underwent many modifications, as neurosurgeons sought to reduce their damaging and irreversible side-effects. ‘Open’ procedures gave way to ‘closed’ ones, in which the neurosurgeons operated through small holes in the skull, and free-hand operations were replaced by stereotactic procedures, which allowed the neurosurgeon to site lesions with great precision. These changes and developments resulted in the neurosurgical procedures that are currently in use today. The four procedures available worldwide aim to interrupt key connections between specific parts of the frontal lobe and other areas of the brain. Lesion sites vary, and the surgeon's blade is no longer used; instead lesions are created using controlled radiation, or burning or freezing of tissue.
As more operations were performed it gradually became apparent that the patients that benefited most had primarily mood and
anxiety disorders as opposed to schizophrenia. Hence, the aim of current procedures is to destroy those areas of the brain thought to be important in the regulation of emotion and anxiety.
Psychosurgery, the treatment of mental illness by neurosurgical procedures, has been criticized because it has developed empirically more than on rational grounds, and because of a lack of ‘scientific’ evidence supporting its purported therapeutic efficacy. However, the operations are offered only to those patients with severe intractable illnesses who have unsuccessfully tried all reasonable alternatives. In order to evaluate the effectiveness of these procedures accurately, a closely-matched, comparative group of patients would need to be studied, and this would be extremely difficult. Furthermore, it is not ethical to deny patients an operation altogether or to withold information concerning treatment options for the purposes of research, and this also limits the feasibility of conducting a ‘clinical trial’.
One novel neurosurgical technique, developed in New York, is of particular interest, since it allows surgeons to conduct a double-blind therapeutic trial of psychosurgery, comparing a mock procedure and the genuine operation. This technique is performed without a general anaesthetic and relies on the combined effect of more than 200 precisely-focused beams of cobalt-60 gamma radiation. As there are no significant adverse effects, it is possible for all patients to undergo both a mock procedure and the real operation but be unaware of the order in which these are administered. Hence currently a 5-year, randomly assigned, double-blind study is being carried out to evaluate this particular procedure in the treatment of intractable obsessive—compulsive disorder.
Open, uncontrolled studies, of which there are many, have repeatedly shown that these procedures are effective in alleviating the symptoms of obsessive–compulsive disorder, anxiety states, and major depressive disorder. In most series nearly half the patients have recovered and the majority have experienced some benefit, although there is often a need for continuing medication, and in some cases the operation has to be repeated in order to extend the size of the lesion. The results are impressive, especially when one considers that these patients are treatment-resistant and have not responded to all other available therapeutic measures.
For many people the term ‘lobotomy’ conjures up images of disturbed beings whose brains have been damaged or mutilated extensively, leaving them at best in a
vegetative state without a personality or feelings. This was never true, even in the case of prefrontal leucotomy, and is certainly not the case for the modern stereotatic procedures. Indeed, even in the classical case of Phineas Gage, who in 1847 through an industrial accident suffered severe damage to his prefrontal brain, there was no evidence of impairment of intellect or memory.
The term
psychosurgery has had years of bad press and is now wrongly associated with only the adverse effects and negative outcomes. It has been suggested that such terms should no longer be used to describe the sophisticated procedures in use today and that, in the new millennium, a simple descriptive term, ‘neurosurgery for mental disorders’ (NMD), be adopted, in the hope that the prejudices associated with this treatment can be forgotten. It is only then that NMD will be thoroughly evaluated and its place in the management of mental illness ascribed.
Gin Malhi
Bibliography
Malhi, G. S.,, Bridges, P. K.,, and and Malizia, A. L. (1997). Neurosurgery for mental disorders (NMD). A clinical worldwide perspective: past, present and furture. International Journal of Psychiatry in Clinical Practice, 1, 119–29.
See also
psychological disorders;
psychosis.
