"Do you want to be a living monster, or a dead good person?"
--"Forbidden Island"
In 1949, the Nobel Prize in Physiology or Medicine was awarded to the Swiss scientist Walter Hess and the Portuguese neurologist Egas Moniz, who was awarded the award for "discovering the therapeutic value of forebrain leukotomy for certain psychiatric disorders" (Figure 1). Because the technology is more ruined than prestigious, this award is often called the most "blind" in the history of the Nobel Prize.
Figure 1. Moniz, winner of the 1949 Nobel Prize in Physiology or Medicine (left), with his invention of frontal lobectomy (right).
Psychosis: Devil possessed?
Mental illness in Moniz's award refers to the general term for diseases that cause different degrees of impairment of mental activities such as cognition, emotion, behavior and will due to disorders of human brain function. Common psychosis are: schizophrenia, bipolar disorder, persistent delusional disorder, and so on. Due to the complex pathogenesis, most psychosis remains untreatable or preventable to this day.
Many psychopaths often have the ability to harm themselves and others due to cognitive and behavioral abnormalities. Therefore, for a long time, people have been actively looking for a cure for mental illness, but unfortunately they have never been able to find it. In ancient times, it was believed that mental illness was possessed by the devil. So someone invented cranial drilling, and they believed that by drilling a hole in the brain, they could release the demon possessed in the body. In modern times, people have also tried strange methods such as electric shock, hydrotherapy, opium, bondage, and rotation therapy, but none of them have achieved the desired effect (Figure 2). After all attempts have failed, mental patients often end up locked up.
Figure 2: People have been trying to treat the mentally ill, but they have not been able to do so. Left: Craniodrill; Right: restraint device [14].
In the 19th century, it was well understood that the brain is the organ that controls human thinking and consciousness. At that time, human cognition of brain function was still very superficial, and the specific functions of each brain region were unknown. However, attempts have begun to treat psychiatric patients through brain surgery. In 1892, a doctor named Gottlieb Burkhardt wanted to surgically remove the cerebral cortex to treat six patients with severe schizophrenia who developed hallucinations and agitation. After the operation, although some patients became quieter, two others unfortunately died. Burkhardt was then strongly criticized and opposed by the authorities. As a result, few similar surgeries were performed over the next 40 years [15].
Origin of frontal lobectomy
That changed again until several laboratories in the United States made surprising discoveries in the regulation of emotions and aggressive behavior in the Prefrontal Cortex (PFC). At the Second International Congress of Neurology, held in London in August 1935, Carlyle Jacobsen and others reported the results of a study. They destroyed the prefrontal cortex of two chimpanzees by cutting the lobes. One of the chimpanzees, Becky, appears to have a "personality" change. Becky did not work well before the operation, and had a strong temper, became docile and peaceful after the operation, harmless to humans and animals, and did not hesitate to participate in experimental tests [1]. Monis, who also attended the conference, speculated that a specific excision of the prefrontal lobe might be a boon for the severely mentally ill. Therefore, he decided to try a similar operation on the human body.
On November 12 of the same year, shortly after returning from London, Monis made his first attempt. Under his guidance, his assistant Almeida Lima carefully sawed an opening in the patient's skull, and then injected alcohol into the frontal lobe through this opening, which destroyed the nerve fibers of that piece by dissolving lipids in that area, thereby damaging the connection between the prefrontal cortex and other brain regions [2]. Subsequently, he discovered that ethanol could easily affect other brain regions, so he made a series of improvements to the operation: a device called a "leucotome" was designed to mechanically destroy the nerve fibers that connect the forebrain lobe to other brain regions. Therefore, this surgical method came to be known as lobotomy (hereinafter referred to as "frontal lobectomy").
Figure 3. Schematic diagram of early leukotomy (left) and frontal lobectomy (right).
The specific operation is to insert a white matter cutter (left side of Figure 3) into the patient's skull, then extend the guidewire, and resect the connection between the prefrontal lobe and other brain regions by rotating the cutoff. The three concentric rings on the right side of Figure 3 indicate where the cutter was inserted, and the dotted line indicates the extent of damage estimated by Monis. In the absence of any auxiliary examination (such as imaging technology) at that time, the extent and extent of brain area damage after surgery were very imprecise [2].
Fortunately, Monis's first 20 patients survived. After surgery, patients basically lost their previous mania, agitation, depression and other behaviors, and did not leave any serious sequelae. Moreover, because Monis was internationally famous in the early years for his invention of cerebral angiography (another Nobel Prize-level achievement). Therefore, when he published the study in 1936, it immediately attracted worldwide attention. Countries such as Brazil, Italy and the United States began to have doctors try the new procedure with gratifying success. Therefore, Monis hastily concluded that "frontal lobectomy is a simple, safe procedure, and most likely a surgical procedure that can effectively treat mental disorders." ”
The heyday of frontal lobectomy
Because he can "cure" mental illness, which has not been cured for thousands of years, Monis immediately became the idol of many neurosurgeons around the world. Among his followers, the most creative was Dr. Freeman of the United States. In 1945, Dr. Freeman refined the procedure, developing a much faster and simpler procedure that even any small clinic doctor could perform, the so-called ice-pick lobotomy (Figure 4).
The specific operation is: first paralyze the patient with severe electric shock; After the patient enters an unconscious state, the prefrontal lobe is removed by piercing an icebreaker through the top of each eye and stirring the icebreaker with bare hands. Not only was this procedure simple and fast, but it did not require strict sterilization measures, requiring only simple electric shock tools, icebreakers, small hammers and a simple operating table, so it became very popular (Figure 5).
Figure 4. Dr. Freeman (left) and his invention of transorbital prefrontal white matter tomy (right) [16].
What's even scarier is that Freeman is very good at propaganda. He succeeded in persuading the press to promote the procedure almost unilaterally to psychiatric hospitals, hospitals and clinics across the United States. He also often toured with portable toolboxes including shock tools, ice cubes and small hammers in order to promote his "brilliant" inventions. This caused a stir among the public and the scientific community. Suddenly, this supposed last resort to treat severe mental illness became a panacea for all problems in the minds of the public. Freeman's oversimplification of the procedure and advocacy of efficacy also attracted opposition from many in the industry at the time, and his partner, James Watts, even parted ways with him.
In this way, frontal lobectomy began to be misused with the help of Freeman, which is the main reason why the procedure is notorious today. In the second half of the 40s of the 20th century, coupled with the large number of mental illness patients caused by World War II, the operation swept through Europe and the United States. Sadly, the subject of frontal lobectomy has changed from the previous "severe psychopath" to "violent, mentally handicapped, criminal" and other social undesirable elements. In Japan, the main surgical subjects are children, many of whom are sent by their parents to have their prefrontal lobe removed simply because they are mischievous or have poor academic performance. In Denmark, the government has built a large number of hospitals specifically for these "new treatments", and the diseases range from mental retardation to anorexia [3].
Figure 5. Freeman is teaching. The clothing of the onlookers shows how casual the operation is.
The worst situation is in the United States, where thousands of people have been pulled into this surgery without careful examination because Freeman and others advocate that "mental illness should be strangled in the cradle".[4] Many violent criminals, political prisoners and homosexuals have also been innocently shot as a result. According to statistics, between 1936 and the fifties of the 20th century, about 40,000 to 50,000 such surgeries were performed in the United States, and tens of thousands in other countries.
Freeman himself performed about 3,500 such surgeries in his lifetime. He once boasted that with a hammer and an awl, he could remove the frontal lobe in less than 10 minutes, without even the need for anesthesia. He even recommended frontal lobe surgery for headaches. There are documentaries on the Internet about this operation, the content is cruel, please carefully decide whether to watch it: https://www.youtube.com/watch?v=T7W3Z1_1QMg&has_verified=1
Moreover, Moniz was awarded the 1949 Nobel Prize in Physiology or Medicine. This undoubtedly branded the operation as "green and pollution-free", further amplifying the tragedy.
The decline of frontal lobectomy
1
Manifestation of side effects
As early as the late 30s of the 20th century, the negative effects of frontal lobectomy on personality began to be reported sporadically. With the popularization of surgery, especially after the advent of "ice pick therapy", the situation became worse: the patient's psychotic symptoms were reduced but also serious sequelae: these patients were disrupted by their advanced thinking activities, became like the walking dead, docile, lethargic, dull, indifferent, listless, masterless, sluggish, at the mercy of others, and lived in endless nothingness all their lives [5]. One mother even described her daughter, who had undergone a lobotomy: "My daughter has become a completely different person, her body is still with me but her soul is gone. ”[14]
"She is my daughter but yet a different person. She is with me in body but her soul is in some way lost."
Figure 6: President Kennedy's sister was unable to take care of herself for the rest of her life due to a frontal lobectomy.
A well-known example is Rose Marie Kennedy, sister of President Kennedy. To treat her intellectual disability, Freeman performed a frontal lobectomy in 1941.[6] The result of the operation was very bad, Miss Kennedy's intelligence did not increase but decreased after the operation, and she was said to have only the IQ of a 2-year-old child, and finally ended up unable to take care of herself for the rest of her life (Figure 6).
Finally, around 1950, opposition to frontal lobectomy finally attracted the attention of the whole society. A large number of scholars believe that the scientific evidence for the benefits of frontal lobectomy is not sufficient. A survey of 9284 patients who underwent frontal lobectomy in England and Wales between 1942 and 1954 showed that 41% recovered or showed significant improvement, 28% showed a slight improvement, 25% showed no change, 2% worsened and 4% died. This result is heart-wrenching because even without any treatment, about 63 percent of people with mental illness will spontaneously improve, compared with about 30 percent of people with schizophrenia. As a result, it is not necessary for most of these patients to have their prefrontal lobe removed [15].
Later generations of literary and artistic works have discussed the ethical aspects of frontal lobectomy. In 1962, after the publication of the book "One Flew Over the Madhouse", Europe and the United States launched a series of campaigns against the abuse of electric shock therapy and abuse of mental patients, and passed laws restricting the power of mental hospitals, and the living conditions of mental patients were greatly improved. In many film and television works, such as the famous movie "One Flew Over the Madhouse" (Figure 7), "Forbidden Island" and "Pretty Girl Special Assault Team", the American dramas "American Horror Story" and "Westworld" have used this kind of surgery.
Figure 7.In the movie "One Flew Over the Madhouse", the male protagonist Murphy was executed like a dead ash after undergoing frontal lobectomy (two surgical cuts on the forehead). Before fleeing, the chief could not bear to see him live like a living dead, and after saying "I wouldn't leave you here this way. You’re coming with me.” After that, tearfully suffocated it with a pillow.
2
Dissent in academia
A parallel story line to this story is neuroscientists' study of the function of the prefrontal cortex. Jacobson, who also attended the 1935 International Congress of Neurology, and his later followers made outstanding contributions to humanity's exploration of the mysteries of higher cognitive function. As early as 1937, Jacobson published a paper that ushered in a new era in the study of prefrontal cortex function: Primate Brain Function Study IV: The Effect of Frontal Lobe Injury on Delayed Alternating Habits in Monkeys [7].
Figure 8. Delay-reactive behavioral tasks.
In this study, they trained monkeys to perform delayed-response tasks (Figure 8). In the delay-response task, the monkey first sees the experimenter placing food into one of the two grooves on the left and right of the table, and each groove is covered with a lid. Then pull a curtain between the monkey and the tabletop, blocking the monkey's view so that the monkey cannot see the desktop. This period is called the deferral period. At the end of the delay period, the experimenter closes the curtain so that the monkey can see the table top and can open the lid to feed. To do this correctly, the monkey needs to remember the location of the groove where the food is placed during the delay period. This short-term memory of random locations is later defined as working memory and is thought to underlie the brain's advanced cognitive functions. The removal of the prefrontal cortex severely damaged the monkey's ability to operate the delayed response task, and the longer the delay period, the worse the monkey's operational performance. This suggests that the prefrontal cortex plays a crucial role in working memory.
Follow-up part of the work: https://www.zhihu.com/question/59280144/answer/174195133
With the deepening of neuroscience research, the functional connection between the frontal cortex and the thalamus and limbic system has gradually been revealed. With this new evidence, more and more scientists are realizing that simply destroying the connection between the forebrain lobe and the rest of the brain can cause irreversible and unknowable damage to personality. As early as 1944, some scholars wrote that forebrain lobotomy would lead to violent tendencies or servility and blind obedience.[8] In 1947, Swedish psychopathologist Snorre Wohlfahrt repeatedly stressed that "lobotomy is too dangerous to treat schizophrenia or other psychiatric symptoms." However, these sporadic objections only stirred up a small ripple and could not stop the storm.[9]
Today, we have understood that if the brain is the "headquarters" of the human body, the prefrontal lobe is the "commander-in-chief" of the headquarters. The human prefrontal lobe accounts for about one-third of the total area of the cerebral cortex and is not fully developed until about the age of 25. The neural connections between the prefrontal lobe and other brain structures are complex and versatile, involving a wide range of behaviors that psychopaths need to improve. But roughly speaking, the prefrontal lobe is mainly responsible for higher cognitive functions, such as attention, thinking, reasoning, decision-making, performing tasks, and so on [10] (Figure 9).
Figure 9. The prefrontal cortex is responsible for higher cognitive functions, providing "top-down" control over human behavior, thoughts, and emotions [10].
The prefrontal lobe is responsible for the higher cognitive function of human beings, and its presence or absence and the quality of its function affect the highest thinking ability of people. However, the prefrontal lobe does not actively control breathing, heartbeat and other physiological characteristics that are essential for human survival. Therefore, even if the prefrontal cortex is removed surgically, it will only cause people to lose high-level cognitive and emotional abilities, and will not affect a person's life as a living body. This is why people with schizophrenia generally survive after frontal lobectomy.
3
The rise of new approaches
The voice of the academic community and the public has indeed accelerated the withdrawal of frontal lobectomy from the historical stage. However, the real end of the operation was the emergence of new treatments, especially the development of new drugs.
In 1950, a new antipsychotic drug, chlorpromazine, was successfully synthesized and used in the treatment of schizophrenia and bipolar disorder. Since then, psychiatric disorders have moved into the era of drug treatment, and frontal lobectomy has quickly lost its market [11]. The invention of chlorpromazine has sparked a dehospitalization movement in Western countries, saving many mentally ill people from being forced to be locked up in hospitals for life. By around 1960, the number of people with schizophrenia was much lower than before. Today, the new generation of antidepressants and antipsychotics is more selective and has fewer side effects, and the treatment conditions for mental illness have made great progress compared with the boom of psychosurgery. Although in the era of drug treatment, there are still some patients whose symptoms are not effectively relieved, but at least they do not have to face cruel surgery.
Figure 10.The advent of the era of drug therapy ended frontal lobectomy.
Finally, in 1950, the Soviet government took the lead in announcing a total ban on frontal lobectomy. By 1970, most countries, as well as many U.S. states, had enacted legislation banning frontal lobectomy. The remaining countries that have not banned the procedure also have extremely strict regulatory regimes [2].
rethink
Now it is difficult for us to imagine that this barbaric and cruel operation will be popular in the world for more than ten years, and even won the Nobel Prize, which is known as the laurel of science. However, when calmly examining the rise and fall of this operation, it is not difficult to find that the emergence of frontal lobectomy can be said to be a historical inevitability in a sense.
People with severe mental illness often bring great disasters to themselves and their families due to personality changes. At this time, suddenly an emerging technology claims to cure this stubborn disease that mankind has been helpless for thousands of years, and scholars will of course be so happy that they flock to it. For the families of patients, this technology brings unlimited hope to their families on the verge of destruction: perhaps, with a few simple cuts, the family will become happy. For those with severe mental illness, the operation can indeed eliminate emotional symptoms such as mania, agitation, and depression, allowing them to escape the nightmares of their lives. After all, for some of them, being alive may be more important than the soul. Moreover, if only partial removal of the prefrontal lobe, the patient does not lose all of his higher cognitive functions.
From the history of the operation's prosperity, we know that what really deserves our criticism is the driving force behind the global abuse of the operation. First of all, the research of brain science was still superficial, surgical experts often relied on personal experience to perform surgery, and there was no objective and credible standard for evaluating the postoperative effect. After all, it was Monis's rash statement that "frontal lobectomy is a safe and reliable procedure" that opened this tragedy. Then, some scholars are selfish and over-boastful. Dr. Freeman oversimplified the procedure, and despite widespread skepticism in the industry, he continued to promote his improved "ice pick therapy." This has undoubtedly accelerated the occurrence of the tragedy and expanded the scope of its damage. Finally, the special context of the times has caused special tragedies. The Second World War not only swallowed tens of millions of lives on the battlefield, but also killed countless people outside the war. Had it not been for the large number of mentally ill people caused by World War II to overwhelm an otherwise difficult health system and tear families apart, frontal lobectomy would not have been so popular.
Similarly, by looking back at the decline of this technology, we can understand the importance of scientific and technological progress to humanity. Until reliable drugs were developed, there was no effective treatment for mental illness. No matter how big the side effects of frontal lobectomy, no matter how fiercely scientists and the public criticize the operation, there will still be patients who have nowhere else to choose this last straw. Moreover, the end of this tragedy is also the result of scientific and technological progress. At the same time, it is a pity that during the epidemic of the operation, many scholars have revealed the importance of the prefrontal cortex for human advanced cognitive functions and called for the cessation of the operation. Rather, the voice of reason is drowned out in a torrent of fanaticism. It can be seen how important it is to promote the exchange and dissemination of academic ideas!
Today, frontal lobectomy has been abandoned and written into various textbooks as a classic case, warning the world of what kind of disasters the underdevelopment of science and technology may bring. Today, it is easy to dismiss frontal lobectomy and joke that awarding the scientific laurels to Monis, who invented the technology, is the "black history" of the Nobel Prize. But we also need to remember that the current good life is based on many "black histories" of past technological developments. Moreover, the consciousness and capital that we can now have to ridicule is also the result of scientific and technological progress.
The end！
bibliography
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(Source: Brain Renyan WeChat public account)