lobotomy

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The lobotomy (from ancient Greek λοβός lobós , German 'lobe' and τομή tomé , German 'cutting, incision' ) is a neurosurgical operation in which the nerve tracts between the thalamus and frontal lobes as well as parts of the gray matter are severed ( denervation ). The name is often used synonymously with leukotomy ( λευκός leukós , German 'white' ).

It was originally used to eliminate pain and in extremely severe cases of mental illness, such as psychosis and depression with severe restlessness . As a result of the lobotomy, a personality change occurs with a disruption of drive and emotionality .

After increasing criticism, the lobotomy has largely been replaced by treatment with psychotropic drugs and more minimally invasive operations , e.g. B. the thalamotomy and the cingulotomy .

Origin and delimitation of terms

The term lobotomy was formed from the ancient Greek words lobos (lobe) and temno (stem tom- , cut) and describes a corresponding neocortex section. Strictly speaking, the term should therefore only be used for damage to the gray matter of the cortical lobe.

The term leukotomy is derived from leukos ( Greek white), the name for the fiber connections that form the white matter of the central nervous system , and tome (cut). Therefore, strictly speaking, this term should only be used for damage to the white matter. However, since both gray and white matter are destroyed during the operation, the terms lobotomy and leukotomy are practically used synonymously.

history

This brain surgery technique was tackled simultaneously by Mario Fiamberti (1894–1970) in Italy and António Egas Moniz in Portugal. It was first performed on humans in 1936. Moniz was awarded the Nobel Prize for Medicine for this in 1949 . From 1936 to 1937, the American psychiatrist Walter Freeman (1895-1972) and the neurosurgeon James Winston Watts (1904-1994) performed the first 20 operations and developed the method into a popular standard technique in psychiatry . In 1941 Joseph Kennedy von Freeman had his 23-year-old daughter Rosemary , sister of the future US President John F. Kennedy , performed such an operation, which she was severely disabled and survived until the end of her life in 2005 in need of care. Freemans and Watts brain surgery technique was used under the name lobotomy until about 1955 in most industrialized countries, but especially in the Anglo-American region.

Walter Freeman wrote without glossing over: "Psychosurgery achieves its success by shattering the imagination, dulling feelings, destroying abstract thinking and creating a robot-like, controllable individual."

Freeman is often mentioned in connection with the excessive, exaggerated, and harmful performance of the lobotomy. At first he took over the technology from Egas Moniz and refined it together with Watts. He later developed the transorbital surgical method that could be performed by only one person who did not even need a neurosurgical qualification. With this, Freeman wanted to promote the mass spread of the time and cost-effective method. When the Great Depression and World War II led to a surge in mental and psychiatric illnesses, the lobotomy, hailed as a miracle cure by many experts from the early 1940s to the mid-1950s, was used in thousands of cases in the US - often with negative consequences - carried out. In addition, effective drugs against these diseases were not yet available - chlorpromazine , the first effective psychotropic drug, was brought onto the market in large numbers in 1952. Because of the considerable side effects, the lobotomy fell into disrepute as early as the mid-1950s.

However, even after the introduction of psychotropic drugs and the widespread rejection of irreversible surgical methods in practice, Walter Freeman did not abandon his transorbital lobotomy. His will to disseminate the method and to convince colleagues reached bizarre excesses: So he operated on patients in chord (several dozen per day) in front of the eyes of numerous viewers both on television and in lecture halls. He also traveled from clinic to clinic across the United States in a mobile home, the so-called “Lobotomobil” he baptized, and operated on one patient after the other. Throughout his life, he praised the lobotomy as the optimal form of treatment and operated on a total of around 3,600 patients until his license to operate was revoked in 1967 after a patient died of a lobotomy he had performed.

Civil rights movements began cracking down on the lobotomy around 1960. Ken Kesey's influential and significant novel One Flew Over the Cuckoo's Nest in 1962 dramatically showed the effects of the operation on psychiatric patients. The novel was the following year brought to the stage and 1975 by Milos Forman successfully filmed .

In 1967, Harvard authors V. Mark, F. Ervin, and W. Sweet, in a letter to the editor in the Journal of the American Medical Association , identified the cause of the Detroit race riots in a "focal brain disorder," which only have to be surgically removed to prevent further unrest. In 1970 appeared Marks and Ervin's book Violence and the Brain ( violence and the brain ), which suggest the two psychosurgery as a final solution to the problem of violence, such as incorrigible inmates. The psychiatrist L. G. West called this approach in an article in 1969 "biosocial humanism". The California psychiatrist H. Brown recommended psychosurgery in 1979 for the "rehabilitation" of juvenile offenders. Brown's proposals were discussed in the London Times and the Washington Post , with the suggestion that this type of rehabilitation, at only US $ 6,000, was far more cost-effective than lifelong custody, which costs around US $ 100,000.

A historical study from the 1980s reports lobotomies in the Soviet Union, the United States, the United Kingdom, France, (Western) Germany, Spain, the Netherlands, India, Australia, Japan, Canada, Argentina, and Czechoslovakia. In Sweden, up to 1963, around 4,500 people had been lobotomized, many against their will, according to a report by the Swedish state television broadcaster SVT in April 1998. According to today's reading, at least 500 of them were not psychiatric patients, but a. hyperactive or retarded children. In Finland, around 1,500 people were lobotomized by 1969. Between 1941 and 1981, between 3,000 and 4,000 people were lobotomized in Norway. In Denmark, the country with the largest number of lobotomic surgeries in relation to its population, around 4,500 operations had been performed by 1983. The number of operations performed around the world is estimated at around one million.

In (West) Germany a translation of the standard work "Psychosurgery" by Freeman and Watts by Anton von Braunmühl appeared as early as 1949 . Freeman also personally presented the lobotomy in Freiburg. However, the method was only used sporadically.

technology

Original method

The original method developed by Moniz and refined by Freeman and Watts in the USA is also known as the precision method. It requires the participation of at least two people in the operation: a neurologist and a (neuro) surgeon.

The procedure was as follows: a two-centimeter hole was drilled bilaterally (on both sides of the head) in the skull, using the anterior cranial suture ( sutura coronalis) and other points as a guide. The holes were about three centimeters in front of and five centimeters above the ear - that is, in the area of ​​the prefrontal cortex. The two drill holes were then manually enlarged by a few millimeters. Now the surgeon inserted an oblong knife or a special leukotome into the skull on a (roughly) horizontal plane. Opposite him, on the other side of the head, was the neurologist who directed the direction of advance of the leukotome. First of all, the surgeon pushed it, aiming at the opposite skull hole, until it was just in front of the middle of the skull or brain (before reaching the fissura longitudinalis). Orientation was also based on other internal points of the skull. At this point the surgeon performed the actual lobotomy, during which large parts of the fibrous tracts in the white matter and some areas of the gray matter in the area of ​​the prefrontal cortex were irreversibly destroyed. To do this, he swiveled the inserted leukotome up and down in the coronal plane at the prescribed angles. Thus parts of the brain were simply "cut up". The same procedure was then carried out in the other hemisphere of the brain.

Freeman's Transorbital Method

Ice ax tool

Freeman developed the new surgical method for two reasons: On the one hand, it only required a more or less competent person to perform it; on the other hand, it was much more time-saving and cost-effective, and did not even require anesthesia or opening the skull. The entire operation from the patient's arrival to the patient's departure often took less than an hour. During the operation, the locally or fully anesthetized patient was inserted by the surgeon (who was in the rarest of cases a trained surgeon) a long, pointed tool into the head above the eye socket. To do this, the patient's eyelid was raised, the tip of the tool was inserted above the eyeball and punched through the skull. Since the skull has the thinnest area in the area of ​​the eye sockets, a light blow on the rear end of the tool is usually sufficient to penetrate the brain. As a tool, Freeman developed a device that was modeled on an ice ax - which is why this method is often referred to as the "ice ax method". If the tip of the tool in the brain was pushed to a point left to the subjective assessment, it was swiveled as with the old method in order to destroy the tissue in the targeted brain areas. The same procedure was then followed in the other hemisphere. The only visible damage that patients suffered was mostly just bruises on the eye.

Initially, Freeman had his patients anesthetized. He later performed his operations under local anesthesia. This had the advantage that he could question the patients simultaneously. It seems particularly bizarre that Freeman only considered the extent of substance destruction in the brain to be sufficient if the patient had serious cognitive problems, e.g. B. in arithmetic tasks, showed, because he had observed that apparently only patients who at least temporarily exhibited such impairments really showed a symptom relief of their psychological complaints. Ultimately, Freeman used electric shocks to anesthetize . He borrowed this method from the electroconvulsive treatment of depression. He delivered three consecutive strong shocks to the patient through electrodes attached to the head. This usually leads (in addition to seizures) to temporary loss of consciousness.

Evidence of effectiveness

There is little empirical evidence for the effectiveness of the method. Although there are a number of positive, subjective reports and assessments (mostly from the advocates of the method), no controlled, objective studies have been carried out. The disorders in which the method showed (alleged) effects include, in particular, severe depression and obsessive-compulsive disorders and, to a lesser extent, anxiety and panic disorders. In only a very few cases, successful use in schizophrenia or psychotic symptoms has been reported.

Today's meaning

In Germany , lobotomies in the manner described above have not been performed since the 1970s. Today, microsurgical techniques are referred to as “leukotomies”, in which epileptogenic centers are switched off in a targeted manner (No. 5-013.7 of the operation code currently valid in the Federal Republic of Germany -OPS- ). More recent experiments with brain pacemakers , in turn, aim to shut down overactive nerve pathways.

literature

chronological, newest literature first

  • R. Zalashik, N. Davidovitch: Last resort? Lobotomy operations in Israel, 1946-1960. In: History of psychiatry Volume 17, Number 65 Pt 1, March 2006, pp. 91-106, ISSN  0957-154X . PMID 17153476 .
  • J. Braslow: Therapeutic effectiveness and social context: the case of lobotomy in a California state hospital, 1947-1954. In: The Western journal of medicine Volume 170, Number 5, May 1999, pp. 293-296, ISSN  0093-0415 . PMID 10379224 . PMC 1305592 (free full text). (Review).
  • GJ Diefenbach, D. Diefenbach, A. Baumeister, M. West: Portrayal of lobotomy in the popular press: 1935-1960. In: Journal of the history of the neurosciences Volume 8, Number 1, April 1999, pp. 60-69, ISSN  0964-704X . PMID 11624138 .
  • HH Jasper: A historical perspective. The rise and fall of prefrontal lobotomy. In: Advances in neurology Volume 66, 1995, pp. 97-114, ISSN  0091-3952 . PMID 7771315 . (Review).
  • Hans Bangen: History of the drug therapy of schizophrenia. Berlin 1992, ISBN 3-927408-82-4 , pp. 63-68 (lobotomy).
  • Elliot Valenstein : Great and Desperate Cures. New York 1986, ISBN 0-465-02711-3 ; about this article cut in the mind . In: Der Spiegel . No. 24 , 1986 ( online ).
  • Alick Elithorn, Eric Glithero, Eliot Slater: Leucotomy for Pain. In: J Neurol Neurosurg , Psychiatry. 1958 November, 21 (4), pp. 249-261. PMC 497327 (free full text).

Web links

Commons : Lobotomy  - Collection of Images, Videos, and Audio Files
Wiktionary: leukotomy  - explanations of meanings, word origins, synonyms, translations
Wiktionary: Lobotomy  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ↑ Florian Freistetter: Lobotomy: A Dangerous Error, Crowned with the Nobel Prize , Der Standard , February 13, 2018
  2. ^ A b Society: Frontal lobotomy, a method that has destroyed the lives of many patients , Ärztezeitung, August 1, 2005
  3. ↑ a b Ronald D. Gerste: The Lobotomy: Like a Relict from Dark Times , Dtsch Arztebl 2008; 105 (18): A-945 / B-821 / C-809
  4. ↑ Dr. James Watts, 90, Pioneer In Use of Frontal Lobotomy , The New York Times , November 11, 1994
  5. ↑ Rosemary Kennedy: “What did we do to you?” One day , October 21, 2015; accessed on July 21, 2017
  6. ↑ PR Breggin: electric shock is not therapy . Urban & Schwarzenberg, 1989, p. 175.
  7. ↑ a b E. S. Valenstein: The psycho surgery debate , Freeman & Co., San Francisco 1980
  8. ^ Role of Brain Disease in Riots and Urban Violence . In: JAMA . September 1967, p. 895 ( online ).
  9. ↑ Vernon H. Mark, Frank R. Ervin: Violence and the Brain . Harpercollins College Div, 1970, ISBN 978-0-06-141698-9
  10. ^ Der Kurier , Vienna, April 7, 1998
  11. ↑ mat & helse , No. 3/06, p. 18
  12. ↑ Jesper Vaczy Kragh: Sidste udvej? Træk af psykokirurgiens historie i Danmark . (PDF; 664 kB) In: Dansk Medicinhistorisk Årbog , 2007
  13. ↑ Hans Bangen: History of the drug therapy of schizophrenia. Berlin 1992, ISBN 3-927408-82-4 page 66
  14. ↑ Stereotaxic / Brain Pacemaker: Return of Psychosurgery . In: Deutsches Ärzteblatt . October 2004, p. 472 ( online ).