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The loss of sadness in the human being: XIXth century psychosurgery (part II): Hippocrates cried....

INTRODUCTION

The neurosurgical treatment of mental illnesses has a long and controversial history, beginning in prehistoric and ancient history, followed by a considerable development at the beginning of the XIXth century, when Hippocrates's main dictum (primum non nocere) was not applied by physicians in their daily work (2, 3).

1935 was an important year in the history of psychosurgery, when the American physiologist John Farquhar Fulton (1899 1960) presented the result of a personal experiment, at the Second World Congress of Neurology in London, to the entire world. Following the frontal cortex resection in two chimpanzees, Fulton noticed that they had become "devoid of emotional expression". Moreover, the resection of the anterior frontal association cortex led to calming behavioural changes. The participants in the congress included the European neuroscientists Antonio Egas Moniz, Almeida Lima and the American Walter Freeman, who introduced what they saw and experienced into medical practice, thus having a major influence on the appearance of frontal lobotomies and leucotomies in the surgical treatment of mental illnesses (2, 4).

THE FATHER OF PSYCHOSURGERY

At the beginning of the XIXth century, the term "psychosurgery" was coined by the Portuguese Antonio Egas Moniz (1874-1955) (Figure 1.A.), a professor of neurosurgery and dean of the Faculty of Medicine from Lisbon (4, 5). Moniz was influenced in his research by the neurophysiologist John Farquhar Fulton (1899-1960) and by the psychologist Carlyle Jacobsen (1902-1974), both from Yale University. In 1935, they performed a bilateral frontal lobectomy in two chimpanzees, noticing that they became less aggressive postoperatively. Moreover, after the surgical intervention, the two neuroscientists noticed that one of the chimpanzees showed behavioural changes: if before, it was forced to enter the experiment cage, now it went in voluntarily (6, 7, 8).

Moniz considered their experiment to be "extremely valuable" (9, 10, 11). Moreover, noticing behavioural changes in patients who suffered frontal lobe injuries during the world wars, he thought to apply this new method on mentally ill patients (12). In order to make this method as effective as possible, Moniz believed that the afferent and efferent fibres of the frontal lobe should be interrupted during surgery. In this regard, he said that one must "change the synaptic facilities and also the path which is chosen by the stimuli in their continuous process, in order to change the corresponding thoughts and to force them into other channels. For this reason, (...) I decided to cut the connecting fibres of the neurons concerned." (5, 8, 9, 10, 11)

ANTONIO EGAS MONIZ (1874-1955) AND PEDRO ALMEIDA LIMA (1903-1985)

Ever since his work on the discovery of cerebral angiography, Moniz became friend with the young neurosurgeon Pedro Almeida Lima (1903-1985) (Figure 1.B), who became his close collaborator. Due to the fact that Moniz suffered from severe gouty arthritis, all neurosurgical work was left to his collaborator, Lima (13, 14). Therefore, together with him, Moniz conducted, for the first time, a series of surgical experiments that were predecessors to frontal lobotomies, which included the injection with ethyl alcohol in the white matter underlying the motor cortex (11, 15, 16, 17).

Due to Moniz and Lima, the frontal leucotomy technique evolved, by introducing a new instrument, leukotome. This was, in fact, a rod, which had, at its end, a retractable wire loop, which could have been introduced and rotated in the frontal brain. This procedure was named by Moniz leukotomy (from the Greek [phrase omitted] leukos "clear", "white"), and created more stir than the cerebral angiography, which he has discovered (10). Moniz and Lima thought to test a new technique on a group of 20 patients suffering from schizophrenia, neurosis, and cyclothymia (8), selected from the Bombarda Psychiatry Clinic from Lisbon (13, 18).

MONIZ AND LIMA: THE FIRST OPERATIONS

On 27th, December 1925, Moniz and Lima conducted the surgery on two patients suffering from paranoid schizophrenia (19). Initially, 10 of the 20 interventions were performed by the neurosurgeon Lima who, at Moniz's suggestion, injected alcohol into the patient's frontal lobes, believing that it would destroy the nerve fibres.

The two scientists concluded that the destruction of neurons was imprecise, therefore, they developed a new alternative procedure with the help of the leukotome, which they had patented (i.e. a cannula of 11 cm in length, 2 mm in diameter, with a retractable wire loop that was introduced 4 cm into brain tissue). By rotating this instrument, considerable parts of the white brain substance could be cut. Upon closing, the leukotome retreated 1-1.5 cm, and the procedure was repeated (8, 16). Moniz and Lima's technical descriptions were evasive, lacking information about the angle of rotation, depth of insertion, or the quantity destroyed by the brain parenchyma (8).

POSTOPERATIVE RESULTS

One month after the first surgeries, on 3rd March, 1936, Moniz presented his results in Paris, and then communicated them in the "Bulletin de l'Academie de Medecine" (15). During the same year, Moniz published the work Tentatives operatoires dans le traitement de certaines psychoses (16), in which, from the 20 surgeries, "35% (seven cases) healed, 35% (seven cases) improved, 30% (six cases) unchanged, no worsening and no cases of death". Moniz claimed that there had been no deaths, that the patients' intelligence did not decrease, and that they suffered no memory disorders, as a result. Among the side effects, he noted psychiatric disorders such as apathy, lethargy, disorientation, kleptomania, as well as fever, diarrhea, vomiting, sphincter incontinence, eyelid ptosis or nystagmus (16).

Moniz and Lima performed approximately 100 such surgeries (14, 20) with postoperative psychiatric exams conducted by the psychiatry professor Barahona Fernandes, one of the best Portuguese psychiatrists of that time. The surgical operations were considered to be a success and Moniz began to make his surgical procedure known to the whole world (20). In reality, however, Moniz "kept sparse records of the follow-up" and some of his patients returned to the asylums where they came from in Lisbon and were never seen again (5, 20).

THE NOBEL PRIZE FOR PREFRONTAL LEUKOTOMY (1949)

Nominated in 1928 and in 1933, Moniz won the Nobel Prize for physiology or medicine on 27th, October 1949, for the new surgical procedure that he introduced, pre frontal leucotomy, and not for his discovery of cerebral angiography. The Nobel authorities described his achievement as "one of the most important discoveries ever made in psychiatric medicine" (19) and awarded him the Nobel Prize for the "discovery of the therapeutic value of leucotomy in certain psychoses" (21). Even though it was received with much enthusiasm, this award has sparked controversy ever since. In his laudatory speech, the Swedish neurosurgeon Axel Herbert Olivecrona (1891-1980), member of the professorial staff of the Karolinska Institute, described Moniz's therapeutic procedure as follows: "Many of these patients, in particular the group of schizophrenics, are very difficult patients and often constitute a danger to the persons in their surroundings. Considering that other treatment methods have failed or that, after some time, there had been a relapse, the immense importance of Moniz's discovery for the problematic" (22). A year before receiving the Nobel Prize, Moniz organised in Lisbon the First International Conference on Psychosurgery.

LOBOTOMY ARRIVES ON THE AMERICAN CONTINENT. THE PERIOD OF FREEMAN AND WATTS

If it can be said that the Europeans Moniz and Lima brought fame to psychosurgery, then the Americans Freeman and Watts brought infamy (5). Walter Jackson Freeman (1895-1972) (Figure 2) was a neurologist, and James Winston Watts (1904-1994) (Figure 2) was a neurosurgeon at the George Washington Medical School. In 1936, they conducted their first psychosurgical intervention on a 63-year old patient who suffered from depression, anxiety, and agitation (23), successfully reporting the disappearance of the symptoms.

One year later, in 1937, they reported a series of six patients operated following Moniz and Lima's technique (24, 25). They were also present at the Second World Congress of Neurology in London, in 1935, where they changed the Moniz-Lima procedure, believing that it would have more favourable and more spectacular results: they conducted a closed procedure in which they interrupted the frontal white matter tracts with the help of a leukotome inserted through a 1 cm burr-hole, located along the coronal suture, superior to the zygomatic arch (25). The technique they developed seemed to be more accurate, due to the fact that they used X-ray guidance and landmarks of the skull in order to locate the white matter tracts more appropriately (26) (Figure 2).

They called their new procedure (Freeman-Watts) lobotomy (from the Greek: Aopo--lobos = "lobe" and [phrase omitted] tome = "to cut"), and it quickly spread throughout the world, especially in the United States of America and in England, until 1955 (27). Their first series of several hundreds of patients was considered to be a success, yet the later consequences of the procedure started to become more and more obvious, i.e. from postoperative convulsions to infections and death (20, 28).

LARGE-SCALE DISSEMINATION OF PSYCHOSURGERY

The crucial transformation of psychosurgery took place in 1947, when Freeman developed another, more minimally invasive procedure, which required no anaesthetic. It consisted in a trans-orbital approach ("ice-pick"), in which a sharp in strument was inserted through the eye socket to reach the frontal brain tissue without requiring craniotomy performed with the drill (29). The procedure was simple; it did not require anaesthesia and would soon be practiced by physicians, even by those without any surgical training, such as neurologists, psychiatrists and general practitioners. Moreover, the procedure could be performed not only in hospitals, but also in the psychiatrist's office or at the patient's home (28, 29, 30).

Watts did not agree with Freeman's transorbital approach, which started to be practiced by all physicians, regardless of their specialty. Therefore, in 1947, they ended their collaboration (23). Nonetheless, the new trans-orbital approach was received with enthusiasm and was easily disseminated, in the absence of a coherent psychiatric drug treatment.

In 1937, one year after the first lobotomy was performed on American territory by Freeman and Watts, over 400,000 patients could be found in 477 psychiatric hospitals (31). Half of the hospital beds in the US were occupied by psychiatric patients, whose care and treatment costs reached US$ 1,5 billion (30). In this situation, frontal lobotomy was regarded by the physicians as a "blessing" as regards the reduction of the economic costs.

The appearance of this new procedure, crowned with the Nobel Prize in 1949, the existence of effective psychoactive medication in hospitals, used in the treatment of mental illnesses, as well as the high maintenance and treatment costs of psychiatric patients, led to the use of frontal leucotomy "en masse", followed by an attempt to reintegrate into society (32).

It is estimated that 10.000 leucotomies were performed in the US, in 1949, similar figures being found in the UK (33).

NEW HORIZONS

In the following years, lobotomy and leucotomy interventions started to fall out of favour due to the neurological and psychiatric sequela they left, as well as to numerous studies which questioned their effectiveness. Gradually, psychiatrists concluded that the treatment was more devastating than the disease itself. What is more, neurosurgeons began to consider the intervention as inaccurate and potentially dangerous, while psychologists regarded it as inefficient and unnecessarily invasive (34).

Thus, lobotomies started to become less popular and even illegal in many countries, influenced by the appearance, in 1950, of the first drug that was found to be effective in treating psychosis: chlorpromazine. After it was approved, in 1954, on the pharmaceutical market by US Food and Drug Administration, chlorpromazine was administered to two million patients that year alone (35). The drug proved to be effective in controlling psychotic episodes and Freeman even described it as a "chemical lobotomy" (30). In the following years, its effectiveness in mental illnesses led to the development of other antipsychotic drugs, such as lithium or haloperidol, which proved their safety and efficiency in time, in contrast to lobotomy. Thus, in 1972, over 90% of the patients with schizophrenia were treated with psychoactive drugs, such as chlorpromazine or reserpine (36).

THE END OF FREEMAN'S LOBOTOMY AND THE BEGINNING OF MODERN PSYCHOSURGERY

In 1967, Walter Freeman performed his last leukotomy at the Herrick Memorial Hospital of Berkeley, California. During surgery, he injured a cerebral vessel and the patient died, a moment which represented the end of leukotomy in medical practice and the decline of classical psychosurgery (34). Later on, various neuroscientists around the world started patenting newer and safer modern psychosurgical procedures, such as: anterior cingulotomy (37), subcaudate tractotomy (38), limbic leukotomy (39), anterior capsulotomy (40) and, more recently, deep brain stimulation.

[Please note: Some non-Latin characters were omitted from this article.]

ACKNOWLEDGEMENTS AND DISCLOSURES

The authors state that they are no declared conflicts of interest regarding this paper.

FIGURES

REFERENCES

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Correspondence:

Claudia Florida COSTEA

M. D., Ph. D., Assistant Ophthalmology, Senior Ophthalmologist "Gr. T. Popa" University of Medicine and Pharmacy Iasi, "Prof. Dr. N. Oblu" Emergency Clinical Hospital No. 2 Ateneului Street, zip code 700309, Iasi, Romania

E-mail: costea10@yahoo.com

Submission: February, 20th, 2017

Acceptance: April, 14th, 2017

Caption: Figure 1: Antonio Egas Moniz (1874-1955) (1. A) and Pedro Almeida Lima (1903-1985) (1. B)
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Author:Turliuc, Serban; Costea, Claudia Florida; Cucu, Andrei Ionut; Hutanu, Roxana; Turliuc, Dana Mihaela
Publication:Bulletin of Integrative Psychiatry
Article Type:Essay
Geographic Code:4EUPR
Date:Jun 1, 2017
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