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Lobotomies

Humans intentionally produced one of the best-known forms of brain injury: the prefrontal lobotomy. This is an operation that cuts off communication between the frontal lobes and the rest of the brain.

The frontal lobe is not actually removed in a lobotomy; that would be a lobectomy. In a lobotomy, fibers below the frontal cortex are cut, isolating nerve cells in the frontal lobe from the remainder of the brain.

The communication between the frontal lobe and the rest of the brain is interrupted, but the blood supply to the frontal lobe is preserved and the tissue does not die, so there is little scarring. This is also called a leukotomy.

Lobotomies were first performed on humans as a form of therapy by the Portuguese psychiatrist Egas Moniz in 1937. Previous experiments had shown that the surgery had a calming effect on chimpanzees, so Moniz thought it would be useful to calm mental patients who were otherwise difficult to control, in the era before psychiatric drugs.

What does a lobotomy involve? Where did the idea come from?

Moniz shared the 1949 Nobel Prize for his work. Later this was regarded as tragically wrong, because lobotomies turned out to cause serious problems for the people who received them.

One research team surveyed all the people who had received prefrontal lobotomies on both sides of the brain (bilateral lobotomies). Not one of them ever returned to productive work.

What was true of all the people who received bilateral prefrontal lobotomies?

Moniz evidently got the idea for doing lobotomies from a presentation by two American brain researchers, John Fulton and Carlyle Jacobsen. They described dramatic changes of behavior in a chimpanzee, Becky, who was "tamed" by destruction of the prefrontal cortex. Previously the chimp had been wild and uncontrollable.

After Fulton's presentation, Moniz rose from the audience and asked if the same procedure might be applied to humans in mental institutions who were equally wild and uncontrollable. Fulton said later he was shocked by the suggestion.

Moniz went ahead with exploratory surgery on some mental patients. Moniz found that alcohol injections behind the frontal lobes, which destroyed fibers connecting the frontal lobes with other areas, did have a calming effect on otherwise uncontrollable mental patients.

Reports of a "miracle cure" crossed the Atlantic. American doctors began performing lobotomies by the thousands in the late 1940s.

One American doctor, Walter Freeman, developed a quick and easy technique. He inserted a blade through the eye socket, above the eyeball, and cut the fibers connecting the prefrontal cortex to the rest of the brain.

Freeman's technique was so fast that it could be performed on an outpatient basis (without admitting the patient to the hospital). The only obvious aftereffect was a black eye.

What did Dr. Freeman do, and what advice did he give to families?

Sometimes Freeman did not even tell patients they were getting lobotomies. He advised families to "provide the patient with sun glasses rather than explanations" to avoid upsetting them. "Most patients deny having been operated on," he wrote. (Freeman, 1949, reported in Valenstein, 1973, p.285.)

Effects of Lobotomies

Results of the earliest lobotomies were difficult to interpret, because people receiving lobotomies were already psychotic, seriously disturbed and out of touch with reality. In the late 1940s lobotomies were used on a new group: people suffering severe intractable pain : pain unresponsive to treatment.

Doctors had noticed that psychotic patients receiving lobotomies no longer complained of pain afterward. It seemed lobotomies might be useful for people who suffered from pain alone, without any sort of psychological disorder.

At first this seemed to be a success. Dynes and Poppen (1950) wrote, "The patient [after lobotomy] was unconcerned about pain and in practically all instances he was no longer anxious and fearful as he had been prior to the lobotomy." However, as time went on, some disas­trous consequences were discovered.

Dynes found that some patients were "slowed up in thinking and acting, they were dull, at times completely lacking in emotional expression or display and showed a striking reduction in interest and driving energy." Others receiving the same operation were "uninhibited and euphoric...restless with a purposeless type of activity."

When pain patients were given lobotomies, what was discovered?

Lobotomy patients were said to act stimulus-bound. They reacted to whatever was in front of them and did not respond to imaginary situations, rules, or plans for the future.

Many of the patients became fat. If food was set in front of them, they ate whether hungry or not. Some of the patients grew sexually promiscuous; they pursued immediate gratification without regard for consequences.

Few of the lobotomy patients could plan effectively for the future or sustain goal-oriented activities. A goal requires that complicated plans be held in mind, and this was evidently beyond the capacity of lobotomy patients, They tended to be distracted by immediate stimuli.

Dr. Gosta Rylander of Stockholm described a patient whom he employed as a cook after the patient recovered from a prefrontal lobotomy. Originally the patient was very innovative in the kitchen, but after the operation she had difficulty in using new recipes and made ridiculous mistakes.

She had no problem with old recipes. But when going out to buy food, she frequently disappeared for long periods, distracted by shop windows and forgetting to buy food.

What does it mean to be "stimulus-bound"?

Cobb (1944) described the problem of lobotomy patients as a reduction in long-circuiting. This metaphor suggests lots of brain space is required to represent something and grasp it over a long period of time. Frontal patients are worst at tasks that require holding something in mind: long-term plans, goals, intentions to diet, or even intentions to buy food.

Lobotomy-like symptoms are sometimes produced by loss of large amounts of brain tissue in other parts of the brain, not just the frontal lobe. That supports Cobb's suggestion that lobotomy symptoms can be produced by overall reduction in available circuitry.

C. Scott Moss was a psychology professor at the University of Illinois when he suffered a stroke in 1967. His gives an inside look at the experience of a stroke victim in Recovery with Aphasia, a book written with the aid of his wife. He describes problems in what Cobb called "long-circuiting":

It took a great deal of effort to keep an abstraction in mind. For example, in talking with the speech therapist I would begin to give a definition of an abstract concern, but as I held it in mind it would sort of fade, and chances were that I'd end up giving a simplified version rather than one at the original level of conception.

It was as though giving an abstrac­tion required so much of my addled intelligence that halfway through the definition I would run out of the energy available to me and regress to a more concrete answer. Something like this happened again and again. (Moss, 1973, p.10)

How did Moss's experience fit with Cobb's speculation about "long-circuiting"?

Lobotomies provided evidence there was something special about the prefrontal cortex, the part of the brain located behind the eyes. Brain scanning techniques confirmed this.

Prefrontal areas are activated when people exercise will power, make plans, or do creative thinking (Posner, 1993). The frontal lobes provide us with a capacity for comprehensive forward planning which is a hallmark of our species.

The Location of the "Executive"

A brain area called the anterior cingulate gyrus in the prefrontal area, slightly above the level of the eyes, lights up with activity when subjects perform active, intentional information processing of any type (Posner, 1993). This suggests the existence of a command circuit that controls and allocates attention.

Perhaps this is the location of the exec­utive processes cognitive psychologists like to talk about. This is what most people identify as willpower. It is also an area with impaired connectivity after a lobotomy.

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References:

Dynes, J. B., & Poppen, J. L. (1950). Lobotomy for Intractable Pain. JAMA, 140, 12.

Cobb, S. (1944). Personality as affected by lesions of the brain. In Hunt, J. M. (Ed.) Personality and the behavior disorders, Vol. 1. New York: Ronald, pp. 550-581.

Moss, C. (1972). Recovery with aphasia: The aftermath of my stroke. Oxford, England: U. Illinois Press.

Posner, M. I. (1993). Seeing the mind. Science, 262, 673-676

Valenstein, E. S. (1973) Brain Control. A Critical Examination of Brain Stimulation and Psychosurgery. New York: Wiley-Interscience.


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