Adapted from Brain and Mind

R.M.E. Sabbatini
http://www.cerebromente.org.br/index_i.html
Brain Srger!: "he Earl! #ioneer$
Before the invention of anesthetics and the practice of
asepsis, brain surgery was an awful mess. Historical records show
that surgery of the brain was practiced in Greece, by Hippocrates
and his followers, in the Roman times (Galen was thought to be a
great brain surgeon), in the Arab world, by edieval surgeons,
well until the !"th century. ost of the operations were
performed for treating super#cial tumors, fractures and brain
trauma, especially those caused by weapons (military surgery).
However, most of the patients died. $he delicate nature of the
brain was not made for the general principles of the general
surgical s%ills of the time.
&n addition, using bogus brain surgery to 'treat' madness,
epilepsy and other brain diseases, was very common among
medical (uac%s for many centuries. )or e*ample, in the edieval
times, barbers+surgeons roamed the countryside o,ering a
surgery for removing the 'stone of madness' or 'pierre de follie',
which supposedly e*isted inside the s%ulls of mentally deranged
people.
$hus, the brain remained for many centuries an almost forbidden
territory for serious open surgery.
$he road to scienti#c psychosurgery started with the discovery
that certain parts of the brain controlled temperament, mood and
intellect. &n the second half of the !-th century, medical science
was posed to amass a reasonable body of evidence that this was
true. &n opposition to the pseudoscienti#c ramblings of
phrenology, proposed by the )ran. /oseph Gall, biological
e*periments with lesions and stimulations of the brain of animals,
were beginning to show the way on how to study scienti#cally the
relations between brain and mind, for the #rst time.
$wo bi.arre and well+publici.ed clinical cases, however, were
fundamental in calling the attention of neurosurgeons to the
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e,ects of e*tensive lesion of a part of the brain, the prefrontal
corte*. Both became classical cases in the neurology te*tboo%s.
$he #rst was that of 0hineas Gage, a young America railroad
construction supervisor, who underwent profound changes in
mood and behavior following an accidental e*tensive lesion of
the frontal part of his brain when a steel rod traversed his s%ull.
$he #ndings about the 0hineas Gage1s case were later used to
corroborate the locali.ation of frontal lobe tumors2 and, by the
turn of century, several operations had been performed on the
frontal lobes. thus indirectly leading to the development of
lobotomy by 3gas oni., in !-45.
$he second was that of an institutionali.ed patient in 0aris,
)rance, who was %nown by the name of '$an', which was the only
word he could spea%, following a syphillitic lesion of the frontal
part of his left brain. He was studied by the brilliant physician
0aul 0ierre Broca, who was the #rst to determine the location of
the speech center of the brain, in the third gyrus of the prefrontal
corte*2 what is now called Broca1s area. $his and other Broca1s
patient consolidated in neuroscience the view that the lesion of
circumscribed areas of the brain could cause the loss of very
speci#c mental or nervous functions in the human being.
"he Ama%ing &a$e of #hinea$ 'age
0hineas Gage was a young railroad construction supervisor in the
Rutland and Burland Railroad site, in 6ermont. &n 7eptember
!"8", while preparing a powder charge for blasting a roc%, he
inadvertently tamped a steel rod into the hole. $he ensuing
e*plosion pro9ected the tamping rod, with :.; cm of diameter and
more than one meter of length against his s%ull, at a high speed.
$he rod entered his head through his left chee%, destroyed his
eye, traversed the frontal part of the brain, and left the top of the
s%ull at the other side. Gage lost consciousness immediately and
started to have convulsions. However, he recovered conscience
moments later, and was ta%en to a local doctor, /ohn Harlow, who
too% care of him. Ama.ingly, he was tal%ing and could wal%. He
lost a lot of blood, but after a bout with infection, he not only
survived to the ghastly lesion, but recovered well, too.
onths later, however, Gage began to have startling changes in
personality in mood. He became e*travagant and anti+social, a
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full mouth and a liar with bad manners, and could no longer hold
a 9ob or plan his future. 'Gage was no longer Gage', said his
friends of him. He died in !"5!, thirteen years after the accident,
penniless and epileptic, and no autopsy was performed on his
brain. His former physician, /ohn Harlow, interviewed his friends
and relatives, and wrote two, reporting Gage1s reconstructed
medical history, one in !-8", entitled '0assage of an &ron Rod
$hrough the Head', and another in !"5", titled 'Recovery from
the 0assage of an &ron Rod $hrough the Head'.
0hineas Gage became a classical case in the te*tboo%s of
neurology. $he part of the brain which he had lost, was forever
associated to the mental and emotional functions which he had
lost. Harlow believed that, as he wrote that '$he e(uilibrium
between his intellectual faculties and animal propensities seems
to have been destroyed.
His s%ull was recovered however, and preserved in the <arren
edical useum of Harvard =niversity. uch later, two
0ortuguese neurobiologists, Hanna and Antonio >amasio of the
=niversity of &owa, used computer graphics and neural imaging
techni(ues to plot the tra9ectory of the steel rod as it coursed
through Gage1s brain, and published the results in 7cience, in
!--8. $hey discovered that most of the damage was done to the
ventromedial region of the frontal lobes on both sides. $he part of
the frontal lobes responsible for speech and motor functions was
apparently spared, so they concluded that the changes in social
behavior observed in 0hineas Gage were probably due to this
lesion, because the >amasios have observed the same sort of
change in other patients with similar lesions, causing a defect in
rational decision ma%ing and the processing of emotion.
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"he (i$tor! of )obotom!
$he origins of modern psychosurgery are to be found in the last
decades of the !-th century, when science was beginning to
understand how the human mind and behavior could be mapped
out into the anatomical features of the brain. A German scientist
named )riederich Gol., doing e*periments with the surgical
ablation of neocorte* in dogs, reported in !"-? that when the
temporal lobe were removed, animals were more tame and
calmer than the unoperated ones.
$his inspired Gottlieb Bur%hardt, a physician and supervisor of an
insane asylum in 7wit.erland, to perform in !"-: an operation to
remove parts of the corte* of si* schi.ophrenic patients which
had hallucinations and became very agitated because of this.
7ome of his patients actually became calmer after the surgery,
but we don1t %now whether this was a direct e,ect of the surgery
(two of them died). Bur%hardt was opposed and criticised by the
medical authorities of his time, so that very few psychosurgeries
of this %ind were carried out in the ne*t 8? years or so.
$he situation changed again when several e*perimental
laboratories in the =7A started to ma%e ama.ing discoveries
about the role of the temporal and frontal corte* in the control of
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emotional behavior and aggressiveness. &n @ale =niversity, in
!-4;, a scientist named Aarlyle /acobsen made observations on
the behavior of chimpan.ees after damaging their frontal and
prefrontal corte* by means of a lobotomy ( 'lobe cutting'). Bne of
the animals, who was aggressive in certain situations before the
surgery, became very calm and manageable. $his happened
without apparent loss of other mental functions such as memory
and intelligence. Bne of @ale1s e*perimental neurologists, >r. /ohn
)ulton, had also removed completely the frontal lobes of two
chimpan.ees, hereafter he was unable to provo%e a form of
e*perimental neurosis in these animals.
Because of this )ulton was to become one of the scienti#c pillars
of the proponents of lobotomy in the =nited 7tates.
*ohn +lton
=pon hearing this from )ulton in a neurological conference in
Condon, a 0ortuguese neuropsychiatrist, >r. AntDnio 3gas oni.,
a professor at the =niversity of Cisbon edical 7chool, had the
idea to perform a similar operation to alleviate some severe
mental symptoms of intractable psychoses. 3gas oni. %new that
certain psychoses, such as paranoia and obsessive+compulsive
disorders, involve recurrent thought patterns that dominate all
normal psychological processes. Based on )ulton1s ideas, he
proposed to cut surgically the nerve #bers which connect the
frontal and prefrontal corte* to the thalamus, a structure located
deep in the brain, which is responsible for relaying sensory
information to the corte*. &n this way, oni. reasoned, there
might happen an interruption of the repetitive thoughts, allowing
a more normal life for the psychotic.
Ant,nio Ega$ Moni%
oni., wor%ing with a neurosurgeon and colleague, >r. Almeida
Cima, developed a surgical approach to the problem, which he
called leu%otomy ('white matter cutting'). He would open several
small holes by trepanning the two sides of the brain, and insert a
special wire %nife, called a leu%otome into the brain substance.
<ith a few sideways movements, the #bers were severed and the
patient could recover. oni. reported that the results were good
in several patients. 7everely agitated, an*ious or depressive
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patients had a general improvement in their symptoms, in some
cases in a sri%ing way. &n other patients, however, the operation
had no success, and oni. was cautious to propose that
leu%otomy should be used only when the case was so hopeless as
to warrant it.
After oni. and his colleagues reported his results to the world
(in si* countries, simultanously) in !-45, several centers around
the world started to try out the new surgery. &n Bra.il, the noted
neurosurgeon attos 0imenta, from the 0aulista 7chool of
edicine, in 7Eo 0aulo. was one of the #rst to perform oni.
leucotomies, with doubtful success.
$he Heyday of Cobotomy
7o, probably prefrontal leucotomy would #..le out (oni. would
retire early, after being shot in the spine by one of his e*+
patients, becoming paraplegic) and be abandoned a few years
after being invented. any psychiatrists, particularly the
psychoanalists were adamantly against it.
However, an ambitious American physician and clinical
neurologist, <alter )reeman, attended the same Condon
conference as oni.. Cater he read oni.1s reports in the library.
He became very e*cited with the idea and his results, and
teamed up with a neurosurgeon /ames <atts, to apply the newly
invented techni(ue in American patients. $hey #rst operated in
7eptember !-45. After a few cases, he was convinced that
leucotomy wor%ed, and started to propagandi.e it heavily. He was
met with suspicousness and resistance by the bul% of American
neurosurgeons, but he insisted, eventually winning the reluctant
approval of his colleagues. He and <atts perfectioned the
techni(ue, arriving to what he called the ')reeman+<atts
7tandard 0rocedure', which had a precise set of guidelines for the
insertion of the leu%otome.
-alter +reeman
)reeman was very good in convincing the general press about the
promises of the prefrontal lobotomy (as he called it now), and
almost singlehandedly pushed it as a valid therapeutic procedure
across the nation1s insane asylums, hospitals and psychiatric
clinics. He also performed with <atts many operations around the
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country, but he was dissatis#ed with the messiness and length of
the operation, Having heard about an &talian who had developed
a trans+orbital approach to the frontal lobe (i.e., by inserting a
leucotome after ma%ing an opening in the roof of the eye orbits),
he invented in !-8; a much (uic%er and simpler wayF the so+
called 'ice+pic% lobotomy'. &nstead of a leucotome, which
re(uired a surgical trepanning, he used a common tool to brea%
ice, which could be inserted under local anesthesia by tapping it
with a hammer. $he ice pic% would perforate s%in, subcutaneous
tissue, bone and meninges in a single plunge2 and then )reeman
would swing it to severe the prefrontal lobe. $his would ta%e no
more than a few minutes, with no need to intern the patient in
the hospital. $he procedure was so ghastly, however, that even
seasoned and veteran neurosurgeons and psychiatrists would not
stand the sight of it, and sometimes faint at the 'production line'
of lobotomies assembled by )reeman. /ames <atts became
distressed with this %ind of operation and bro%e his ties with
)reeman,
Cobotomy too% America and some other countries by storm. $hey
were performed in a wide scale in the 8?s, because the mental
asylums were brimming over with cases after the 7econd <orld
<ar. Between !-4- and !-;!, more than !",??? lobotomies were
performed in the =nited 7tates, and tens of thousands more in
other countries. &t was widely abused as a method to control
undesirable behavior, instead of being a last+resort therapeutic
procedure for desperate cases. &n /apan, the ma9ority of the
operated cases were children, many of whom had only
problematic behavior or a bad performance at the school.
&nmates in prisons for the insane were widely operated. )amilies
trying to get rid of diGcult relatives would submit them to
lobotomy. Rebels and political opponents were treated as
mentally deranged by authorities and operated. Amateur
surgeons would often perform hundreds of lobotomies without
even doing a systematic psychiatric evaluation.
&n !-8-, >r. AntDnio 3gas oni. was awarded the Hobel 0ri.e for
edicine and 0hysiology, in recognition of his creation of the
prefrontal leucotomy, $his had the e,ect of ma%ing lobotomy a
respectable procedure, and as a result, in the ensuing three
years, more lobotomies were performed than in all previous
years.
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$he >emise of Cobotomy
)inally, around !-;?, the #rst discordant voices against the
lobotomy folly started to be heard. 7cienti#c evidence for the
bene#ts of lobotomy was not coming. 3ven lobotomy1s
preponents admitted that only one third of the operated patients
would improve, while one+third remained the same, and one+third
got worst (:; to 4? I is the proportion of spontaneous
improvement in many %inds of mental diseases J $hus, a large
proportion of the operated patients could have recovered without
the lobotomy). &n the =nited 7tates, a ma9or evaluation study
called the Aolumbia+Greystone pro9ect was conducted in !-8K
and failed to provide evidence of the positive e,ects of
lobotomies. any times, the evaluation was performed by the
surgeons who did the wor%, without any %ind of scienti#c controls.
3thical ob9ections began to pile up, because of the irreversible
damage to the brain, and also because of the reports of severe
collateral e,ects of the surgery on the personality and emotional
life of the patients. &n addition, the appearance of new
antipsychotic and antidepressive drugs, such as $hora.ine in the
;?s, gave new means to combat most of the symptoms
e*perienced by agitated and uncontrollable patients.
Heurosurgeons everywhere started to abandon lobotomy in
favour of more humane methods of treatment.
Aoncern over the protection of patients against lobotomy and
similar radical therapies, particularly in inmates, where release
was widely e*changed with agreement to a lobotomy (a highly
unfair, biased and controversial o,er)2 translated into laws in the
=nited 7tates in the K?s and in many other countries as well.
0sychosurgery was classi#ed as an e*perimental therapy, with
many safeguards to the patient1s rights.
$he original lobotomy operation is now rarely performed, if ever,
although many countries still accept psychosurgery as a form of
radical control of violent behavior (/apan, Australia, 7weden and
&ndia are among them), &n the 7oviet =nion, land of psychiatric
abuse, lobotomy was outlawed in the 8?s, not because it was not
useful to suppress oponents of the Aommunist rLgime (they used
other methods, such as forced hospitali.ation), but because there
was a ideological stance against it.
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