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Day 1:
January 21, 2008
What is it about lobotomy that so fascinates us?
Question:
When Doctor Walter Freeman performed the lobotomy with his method, was the entire frontal lobe severed from the brain or was only part of the frontal lobe severed? Also, how did Doctor Freeman determine how far and deep he needed to insert his ice picks to sever the frontal lobe and not protrude into the other parts of the brain?
W.T.H.
Falls Church, VA
Answered by Elliot S. Valenstein:
Walter Freeman performed two types of lobotomies. Originally, he performed what came to be called the standard Freeman-Watts lobotomy which enters the brain from the side of the frontal lobes. The transorbital lobotomy was what you referred to as the "ice pick" lobotomy and the instrument entered the brain through the orbit above the eyeball. In both cases, he tried to sever particular connections between the medial thalamus and the ventromedial part of the frontal lobes. The ventromedial part of the frontal lobes and the medial part of the thalamus were (and still are to a certain extent) believed to play a part in emotions. The entire frontal lobe was not disconnected from the rest of the brain.
Question:
I really enjoyed reading Mr. El-Hai's book. Not a topic that you'd think would be a real page-turner, but it was.
From a cultural standpoint what is it about the practice of lobotomy, as opposed to other medical practices that are no longer considered acceptable, that so fascinates us? Books, PBS specials, songs, playground taunts, etc. Why?
Barry Gisser
Omaha, NE
Answered by Jack El-Hai:
You've asked a good question. You're absolutely right that thinking about lobotomy affects us differently than thinking about discarded treatments for such diseases as, say, whooping cough or polio.
We all have a lot of fear built into our response to lobotomy -- fear of tampering with the brain, fear of altering our personalities and souls, and fear of everything that we fail to understand about mental illnesses. In some people the fear makes them shrink, but in others (including me) it produces an attraction that makes them want to look more closely, like at a highway accident. Then there are others who try to channel the fear into affected indifference or ridicule (many of the song lyricists and schoolchildren).
Another cause of lobotomy's fascination is the mystery surrounding the treatment: Why would anyone propose such a treatment, go through it, or condone it? Those were some of the questions that led me to write my book, and I found answers in the contexts of mid-twentieth-century medical practices and in Freeman's own life. The American Experience documentary raises its own wonderful questions, as well.
Question:
Why did the doctor not experiment on animals before operating on humans and be published and reviewed by his peers? How and when did that change? I assume that such a thing could not happen today not just because doctors are not afraid to criticize other doctors in public now. Also at the end of the program it said that the operation is still done today. Where and why?
K.P.
Portland, OR
Answered by Robert Whitaker:
This surgery did, in fact, arise out of a long line of research, including research on animals. The research involved studying the function of the frontal lobes (which were the part of the brain destroyed or disconnected in a lobotomy), and what change resulted from damaging the frontal lobes.
In 1861, the French neurologist Pierre Paul Broca observed that the frontal lobes were much more pronounced in humans than in other animals, and concluded that it was this region of the brain that gave rise to the "superior faculties" of humans. Next, in 1871, England's David Ferrier reported that destroying this brain region in monkeys and apes markedly reduced their intelligence. The animals became "apathetic or dull or dozed off to sleep, responding only to the sensations or impressions of the moment." Italian neurologist Leonardo Bianchi conducted similar experiments in the 1920s with dogs, foxes, and monkeys, and he concluded that the human intelligence responsible for creating civilization could be found in the frontal lobes.
At the same time, many soldiers in World War I suffered frontal lobe injuries, and this led to a number of clinical reports that people with damaged frontal lobes became childish, apathetic, lost their capacity to plan ahead, and could not make sound judgments. Their emotions seemed flattened or out of sync with events. Frontal-lobe injuries led to a recognizable syndrome, dubbed Witzelsucht, that was characterized by childish behavior.
The next step in this line of research came from Carlyle Jacobsen at Yale University. In a study with two chimps, Becky and Lucy, he showed that once their frontal lobes were removed, they lost the capacity to solve simple problems. The frontal lobes, Jacobsen concluded, were responsible for an organism's adjustment to its environment. Jacobsen wrote that this region of the brain synthesized information, including memories formed from recent events, and it was this process that produced intelligent action.
In 1935, neurologists from Europe and the U.S. gathered in London for a congress that included an all-day symposium on frontal-lobe function. Neurologists presented case histories of their patients who had suffered frontal lobe injuries, and Jacobsen presented the results from his chimp studies. Walter Freeman (the lobotomist in the documentary) attended the symposium, and after listening to these presentations, he concluded: "The audience was impressed by the seriously harmful effects of injury to the frontal lobes and came away from the symposium reinforced in their idea that here was the seat of the personality and that any damage to the frontal lobes would inevitably be followed by grave repercussions upon the whole personality."
Now Portuguese neurologist Egas Moniz was also at the meeting. But he was inspired by one other message that was delivered at the meeting. Jacobsen, in his report on Becky and Lucy, noted that the surgery produced a marked emotional change in Becky. Before the surgery, Becky would go into a rage if she couldn't solve a problem (and thus obtain the food that was the reward). She'd roll on the floor, defecate, and otherwise show signs of extreme emotional distress. But after having her frontal lobes removed, Becky wasn't the least bit bothered when she couldn't solve a problem. It was as though she had joined a "happiness cult," or placed her "burdens on the Lord," Jacobsen said. Moniz seized on this kernel of information. This operation, he reasoned, could remove the anguish of mentally ill patients, and he figured that the intellectual deficits produced by destroying the frontal lobes wouldn't be that extreme. He said that humans who had suffered injuries to this region of the brain could "still understand simple elements of intellectual material," and thus concluded that "even after the extirpation of the two frontal lobes, there remains a psychic life which, although deficient, is nevertheless appreciably better than that of the majority of the insane."
So we can see in this history there was a great deal of research that was done prior to this surgery being tried, and it revealed what surgeons could expect from doing it on humans. There would be a diminishment of intellectual faculties, and a diminishment of the person's emotional engagement with the world. That was all very well understood. However, Moniz -- and many others who followed in his footsteps -- concluded that this was a change that would benefit the "mentally ill."
Now while there certainly were doctors and surgeons who worried about doing this surgery, and approached it very cautiously, nearly all of those who initially tried it reported good results, and published their findings in medical journals. Indeed, in 1943, a researcher tallied up the results of 618 lobotomies performed at 18 different sites in the United States and Canada, and concluded that 518 patients were "improved" or "recovered," and that only eight had been made worse by the surgery. The researcher concluded: "We have known for a long time that man may get on with one lung or one kidney, or part of the liver. Perhaps he may get on, and somewhat differently, with fewer frontal fiber tracts in the brain."
Thus, lobotomy arose out of a scientific process. First there was animal research done, and there were discussions about what frontal lobe injury did to people, and then the doctors who tried the surgery reported their results in medical journals, and they said it worked. And it did work, in the sense that it changed people in the expected ways. People operated on did become childish, less emotional, and intellectually dulled. The surgery did what scientists said it did; the question is why did they judge this to be a good thing for those said to be mentally ill? It was that evaluation process that provided a context for Freeman and others to do the surgery.
So, could something like this happen today? Could psychiatry -- or some other branch of medicine -- adopt a form of care that we would later come to see as harmful? The history of medicine certainly warns us that doctors can be deluded about the merits of their therapies, and today that whole decision-making process is greatly influenced by pharmaceutical companies' money, which only increases the possibility of medicine going astray. The lobotomy story really should remind us of that possibility.
In terms of whether the surgery is still being done today, surgeons will occasionally do a bilateral cingulotomy. The cingulate gyrus is a small area in the brain that connects the limbic system to the frontal lobes, and the surgery targets that structure. In the sense that a lobotomy disconnected the frontal lobes from other regions of the brain, there is a certain similarity between the two operations, but obviously this is a much more focused surgery, and it is, I believe, used sparingly as a "last resort," after other treatments have failed.
Question:
What are the side effects of Thorazine and are there any effects to the brain after the medication is no longer being used?
V.C.
Albuquerque, NM
Answered by Anand Pandya:
As with most medications that require a prescription many, many side effects are reported for Thorazine (also known as Chlorpromazine) but only a few are common enough to warrant discussion. Among the most common side effects of Thorazine are sedation (feeling tired or sleepy), dry mouth, constipation and blurred vision. These are side effects that are usually visible very early in treatment so if these do not occur in the first few days, they are less likely to occur. Some people are able to get used to these side effects so sometimes it is worth waiting to see if the medication becomes easier to tolerate with time. Other side effects include feeling restless (known as akathisia), rigidity (people report that they either feel "stiff" or appear "stiff") and a shuffling gait. These side effects can be treated so it is important to let your doctor know if you have any of these side effects. Some patients experience writhing or jutting movements. These are sometimes described as "spasms" and can be quite unnerving because it may feel as if you have momentarily lost control over part of your body. You should contact your doctor immediately, if these side effects occur. There may be medications that can address this side effect or it may require you to change medications. Finally, in the longer run, some people gain weight on Thorazine.
Almost all of these side effects are reversible with two exceptions. One type of jutting/writhing movement caused by Thorazine may become irreversible if it is not addressed promptly. This is relatively rare but it is one of the reasons why it is important to tell your doctor right away if you are having any unusual movements on Thorazine. Also, as we all know, it is usually easier to gain weight than to lose it so people who gain weight on Thorazine may need some time (and a lot of motivation) to shed any extra pounds.
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