The two main figures in psychosurgery were Antonio Egas Moniz, the Portuguese neurologist who invented lobotomy, and the well-known American neuropathologist and neuropsychiatrist Walter Freeman, who roamed the world convincing others to carry out the operations. The imperfect state of knowledge of the brain in relation to insanity was expressed in two theories of mental illness. A somatic (organic) theory of insanity proposed it to be of biological origin. In contrast, a functional theory supposed life experiences to cause the problems.
The somatic theory was shaped most by Emil Kraepelin, the foremost authority on psychiatry in the first half of the twentieth century. Kraepelin distinguished twenty types of mental disorder, including dementia praecox (schizophrenia) and manic-depressive (bipolar) disorder. Kraepelin and his colleagues viewed these diseases as genetically determined, and practitioners of psychiatry developed complex physical diagnostic schema that identified people with various types of psychoses. In contrast, Sigmund Freud was the main proponent of the functional theory. Attempts to help mental patients included ECT as well as surgical removal of tonsils, sex organs, and parts of the digestive system. All these methods had widely varied success rates that were often subjective. Further differences depended on which surgeon used them. By the 1930's, the most widely effective curative procedures were several types of ECT and lobotomy (psychosurgery).
The first lobotomy was carried out on November 12, 1935, at a hospital in Lisbon, Portugal. There, Pedro A. Lima, Egas Moniz's neurosurgeon collaborator, drilled two holes into the skull of a mental patient and injected ethyl alcohol directly into the frontal lobes of her brain to destroy nerve cells. After similar operations on several patients, the tissue-killing procedure was altered to use an instrument called a leucotome. After its insertion into the brain, the knifelike instrument, designed by Egas Moniz, was rotated like an apple corer to destroy chosen lobe areas.
Egas Moniz—already a famous neurologist—named the procedure prefrontal leucotomy. He won a Nobel Prize in Physiology or Medicine in 1949 for his invention of the procedure. Within a year of his first leucotomy, psychosurgery (another term invented by Egas Moniz) spread through Europe. Justification for its wide use was the absence of any other effective somatic treatment and the emerging concept that the cerebral frontal lobes were the site of intellectual activity and mental problems. The selection of leucotomy target sites was based on two considerations using the position in the frontal lobes where nerve fibers—not nerve cells—were most concentrated and avoiding damage to large blood vessels. Thus, Egas Moniz targeted the frontal lobe's centrum ovale, which contains few blood vessels.
After eight operations—50 percent performed on schizophrenics—Egas Moniz and Lima stated that their cure rates were good. Several other psychiatric physicians disagreed strongly. After twenty operations, it became fairly clear that psychosurgery worked best on patients suffering from anxiety and depression, while schizophrenics did not benefit very much. The main effect of the surgery was to calm patients and make them docile. Retrospec tively, it is believed that Egas Moniz's evidence for serious improvement in many cases was very sketchy. However, many psychiatric and neurological practitioners were impressed, and the stage was set for wide dissemination of psychosurgery.
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