Sunday, 17 August 2014

Lessons from history #12: Lobotomy

In the 1940s and 50s (tapering into the 70s and 80s) tens of thousands of prefrontal lobotomies (severing the front part of the brain) were performed in Europe and North America for many types of mental conditions. It was done because doctors at that time believed that it worked, and they didn’t have many effective alternatives. However, it didn’t work, it made people worse and it even killed a few, despite a Nobel prize being awarded to one of the developers of the procedure.

Lobotomy
Prefrontal lobotomy is a medical procedure that disconnects the frontal lobes of the brain from the rest of the brain (think Jack Nicholson in the final scene of One Flew Over the Cuckoo’s Nest). The role of the frontal lobe is complicated, but it is involved with many higher brain functions and an overview can be viewed here.

The “evidence”
A 1942 article titled “Prefrontal lobotomy: the surgical relief of mental pain” (love that title) was an influential paper written by two major proponents of lobotomy and started a wave of lobotomies across the US. The paper is full of biased statements stemming from the authors’ belief that the procedure works, which colours their interpretation of the results that they witnessed. This aspect makes interesting reading (see the quotes at the end of this post). The authors don’t deny that the procedure changes patient personality (see the quote below), but they believe that the patient’s “overall personality” improves. So what happens after a lobotomy? According to the authors:

“... after incision … the patient becomes unresponsive, disoriented, confused and is freed completely from his anxieties.”

Of course it was all thought to be scientific. The operation was based on observations in animal studies and from patients with brain injuries and tumours. Yes, animal studies … for human psychiatric conditions. Don’t get me started on animal research (see my previous post), just read this quote from one of the animal researchers who started it all, observing the effect of a lobotomy on a chimpanzee (link):

If the animal made a mistake, it showed no evidence of emotional disturbance ... It was as if the animal had joined the “happiness cult of the Elder Micheaux,” and had placed its burdens on the Lord!

Outstanding scientific reporting, not. But it was all bad science. There were no comparisons provided, let alone a controlled trial. There were no objective independent tests and no patient-reported outcomes, beyond those filtered through the treating doctors who fitted everything into their belief that the procedure worked. One claim was that many patients became easier to manage – calmer. That part, at least, may be true. But as one critic put it:

“[although] it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier.

The badness
The performance of lobotomy simply to make patients easier to manage was likely to be true, as lobotomy was performed on inpatients of mental institutions and people with behaviours and conditions considered undesirable, like schizophrenia, neurosis, depression, chronic back pain, children with behavioural disorders and homosexuals.

However, the decision-makers at the time were probably just acting on their (erroneous) beliefs rather than through any malice. This is an important point, because the harm done by medicine is often attributed to ill intent, and this is unusual in my experience; it is usually due to ignorance, poor science, fashion, subtle incentives, herd mentality, laziness and other aspects of human nature, but not a desire to harm.

But the lack of desire to harm was not enough to prevent the harm from occurring. Many (including many famous people) died from lobotomies (from severing arteries in the process). The personality changes were often severe. A lobotomy removed higher function and made the patients placid. They may have lost their anxieties and behavioural issues (or at least their ability to express them), but they lost a lot of what made them human in the process: their frontal lobes.

The ice-pick lobotomy
In order to avoid having a general anaesthetic, using an operating theatre, and drilling holes in the head, Freeman (one of the authors of the paper above) developed a technique where an ice pick was passed into the brain through the eye socket and, well, here’s a good description:

“… a patient would be rendered unconscious by electroshock. Freeman would then take a sharp ice pick-like instrument, insert it above the patient’s eyeball through the orbit of the eye, into the frontal lobes of the brain, moving the instrument back and forth. Then he would do the same thing on the other side of the face.”

The prize
One of the pioneers of lobotomy was a Portuguese neurologist named Moniz who developed the procedure for humans in the 1930s. He was awarded a Nobel Prize for this work in 1949; coincidentally the same year he was shot in the spine by one of his patients and was paralysed.

The bottom line
Lobotomy was a common procedure that was based on a biologically plausible mechanism (which was rubbish) and was thought to be effective, based on biased and unreliable observational evidence. In reality, it killed some people and in those who survived, their behaviour and personality was changed, unrelated to their initial complaint – they just complained less.


More quotes.
I was so amazed at the biased reporting by the authors of the article above that I thought the most effective way of getting this message across was by providing selected quotes:

“… we have had the opportunity to examine a few specimens post-mortem from successful and unsuccessful cases.”

beware the anterior cerebral artery!

“Shock is minimal and complications are few.”

“This disorientation is so characteristic that it is used as a yardstick for satisfactory operation.”

“There is no discomfort beyond slight headache, … and aside from vomiting and urinary incontinence, there is little of note on the clinical chart. Patients are often reading, or rather, scanning newspapers or magazines on the second day, and they play with objects such as the bed light or the bell cord…. We have found that a rubber doll will absorb a lot of attention and divert it from the bandages.”

“… those who have been sick for a long time will continue the same complaints if they are asked about them, but without the emotional intensity that marked the preoperative condition.”

“He is apt to be more indolent, … he is outspoken, saying the first thing that comes into his head rather than waiting an instant to judge the effect this response will have upon his audience.”

“One might say that through the operation of prefrontal lobotomy, the destructive imagination of the patient is reduced to the point where he can again live at ease with himself …”

“Old people whose lives are a burden to themselves by reason of psychosis are particularly good subjects for prefrontal lobotomy be- cause of the serenity of disposition that follows operation.”

And according to this glowing report, they only killed 3 patients out of 136 as a direct result of the surgery, although 8 more died later.


4 comments:

  1. "the surgical relief of mental pain" does occur to this day. sympathectomy is offered to treat 'fear of blushing', PTSD, for the treatment of phobias, anxiety disorders, hot flushes, addictions, alcoholism, even schizophrenia and many other conditions. The 'creep' of this procedure is actually very similar to lobotomy. Initially it was only offered for severe cases, but then new and more widespread conditions were 'discovered' that could be 'cured' by sympathectomy. There is even some historical link between lobotomy and sympathectomy...
    There are other procedures that 'attack' the brain itself. The language used in the literature published about these procedures is eerily reminiscent of the glowing success stories that were published in the medical journals a few decades ago about lobotomy...
    Controversial Surgery for Addiction Burns Away Brain’s Pleasure Center
    http://healthland.time.com/2012/12/13/controversial-surgery-for-addiction-burns-away-brains-pleasure-center/

    "How far should doctors go in attempting to cure addiction? In China, some physicians are taking the most extreme measures. By destroying parts of the brain’s “pleasure centers” in heroin addicts and alcoholics, these neurosurgeons hope to stop drug cravings. But damaging the brain region involved in addictive desires risks permanently ending the entire spectrum of natural longings and emotions, including the ability to feel joy.

    In 2004, the Ministry of Health in China banned this procedure due to lack of data on long term outcomes and growing outrage in Western media over ethical issues about whether the patients were fully aware of the risks.

    However, some doctors were allowed to continue to perform it for research purposes—and recently, a Western medical journal even published a new study of the results. In 2007, The Wall Street Journal detailed the practice of a physician who claimed he performed 1000 such procedures to treat mental illnesses such as depression, schizophrenia and epilepsy, after the ban in 2004; the surgery for addiction has also since been done on at least that many people."

    "fashion, subtle incentives, herd mentality, laziness and other aspects of human nature" is bad enough, esp. when there is science that should/could question a procedure and its application in many cases (in evidence/science based medicine) and a moral compass to guide the practitioner. Peer opinion could be also useful if it would not be completely meaningless (but I am biased...)
    If medical professionals want to enjoy the position they have in society, and enjoy the trust and authority of this position, they can not/should not claim 'herd mentality' for bad decisions... I am sorry but that is not good enough. Medical professionals are the best and brightest amongst us, they spend a lot of time in medical school to claim that simply being too lazy to think for themselves landed them in a middle of a very bad trajectory (professionally, ethically) of questionable practice.

    There are many who do a fantastic job, but there are many where:
    Changing clinician beliefs and behaviour in response to credible evidence of lack of treatment efficacy remains highly challenging
    https://www.mja.com.au/journal/2012/197/7/arthroscopy-treat-osteoarthritis-knee
    And this needs to be addressed, and not accepted as simply attributable to human nature... Ignorance harms people, and in no other profession is is more evident than in medicine. So there is higher expectation of accountability. (Sorry for the rant...)

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    1. Thanks. Interesting points there. I hope you weren't thinking that I was using herd mentality and laziness as an excuse - I was just making an observation. I also agree that changing physician behaviour is difficult, but I believe that it is achievable and does occur. The MJA example you provide (which I co-wrote) is an example where the practice is slowly changing (recent AAOS guidelines for OA have come out against arthroscopy) and is likely to be very different in 10 years time. Sometimes practice changes so slowly it is hard to see.

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  2. Thanks, Dr. Skeptic, for your post. I wrote a biography of lobotomy developer Walter Freeman, so I've been long interested in this topic.

    Your nutshell summary is good, but I'd like to clarify a few points. 1) Lobotomy typically didn't involve severing the brain's frontal lobes; instead, the procedure cut key neural pathways between the frontal lobes and the thalamus. 2) The animal study you cite involving two chimps is the only one I know of, and it was not intended to pave the way for surgery on humans. 3) I've heard of only one well-known person, the violinist Josef Hassid, who died as a direct result of a lobotomy. Mortality rates from the procedure ranged from 2 to 4 percent. 4) A small percentage of patients improved after their lobotomies, if you define improvement as feeling relief from their original symptoms, leaving the hospital, and returning to work. 5) Some readers may infer from your post that Egas Moniz was shot by one of his psychosurgery patients, which is not true. And finally 6) it is very important to understand the medical and psychiatric environment in which lobotomy became a mainstream treatment. Despite what you may read in Ken Kesey's fiction, the goal of the surgery was to free patients from hospitalization and their symptoms, not to make them docile. As you say, the results were often horrendous and many lobotomy surgeons let hubris, rather than sound decision making, guide them. It's a complex and educational tale of medicine gone awry.

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  3. Thanks for your comments. I think you are being too generous to think that lobotomy selectively cut key pathways; not with an ice pick through the eye socket, although I accept that this may have been their intention based on a poorly developed biologically plausible mechanism. Point 2 is correct: the animal experimenters were shocked at the suggestion that such a procedure might be suitable for humans, but that is still where they got the idea from. I accept your other points. That mortality rate is unacceptably high - if it happened today there would be an outcry and lawsuits aplenty.

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