Editing Lobotomy (section)

====Frontal lobes====
The source of inspiration for Moniz's decision to hazard psychosurgery has been clouded by contradictory statements made on the subject by Moniz and others both contemporaneously and retrospectively.{{sfn|Berrios|1997|p=72|ps=}} The traditional narrative addresses the question of why Moniz targeted the frontal lobes by way of reference to the work of the Yale neuroscientist [[John Farquhar Fulton|John Fulton]] and, most dramatically, to a presentation Fulton made with his junior colleague Carlyle Jacobsen at the Second International Congress of Neurology held in London in 1935.<ref>{{harvnb|Pressman|2002|pp=13–14, 48–51, 54–55}}; {{harvnb|Berrios|1997|pp=72–73}}; {{harvnb|Shorter|1997|p=226}}; {{harvnb|Heller|Amar|Liu|Apuzzo|2006|p=721}}</ref> Fulton's primary area of research was on the cortical function of primates and he had established America's first primate neurophysiology laboratory at Yale in the early 1930s.{{sfn|Heller|Amar|Liu|Apuzzo|2006|p=721|ps=}} At the 1935 Congress, with Moniz in attendance,{{refn|group=n|The American neuropsychiatrist Walter Freeman also attended the Congress where he presented his research findings on [[cerebral ventriculography]]. Freeman, who would later play a central role in the popularisation and practice of leucotomy in America, also had an interest in personality changes following frontal lobe surgery.{{sfn|Feldman|Goodrich|2001|p=649|ps=}}}} Fulton and Jacobsen presented two [[Common chimpanzee|chimpanzees]] named Becky and Lucy who had had frontal lobectomies and subsequent changes in behaviour and intellectual function.{{sfn|Pressman|2002|p=48}} According to Fulton's account of the congress, they explained that before surgery, both animals, and especially Becky, the more emotional of the two, exhibited "frustrational behaviour"{{snd}}that is, have tantrums that could include rolling on the floor and defecating{{snd}}if, because of their poor performance in a set of experimental tasks, they were not rewarded.<ref>{{harvnb|Pressman|2002|p=48}}; {{harvnb|Heller|Amar|Liu|Apuzzo|2006|p=721}}</ref> Following the surgical removal of their frontal lobes, the behaviour of both primates changed markedly and Becky was pacified to such a degree that Jacobsen apparently stated it was as if she had joined a "happiness cult".{{sfn|Pressman|2002|p=48}} During the question and answer section of the paper, Moniz, it is alleged, "startled" Fulton by inquiring if this procedure might be extended to human subjects suffering from mental illness. Fulton stated that he replied that while possible in theory it was surely "too formidable" an intervention for use on humans.<ref>{{harvnb|Pressman|2002|p=48}}; {{harvnb|Berrios|1997|p=73}}</ref>
[[File:Frontal lobe animation.gif|thumb|[[Human brain|Brain]] animation: left [[frontal lobe]] highlighted in red. Moniz targeted the frontal lobes in the leucotomy procedure he first conceived in 1933.]]

Moniz began his experiments with leucotomy just three months after the congress had reinforced the apparent cause-and-effect relationship between the Fulton and Jacobsen presentation and the Portuguese neurologist's resolve to operate on the frontal lobes.{{sfn|Berrios|1997|p=73|ps=}} As the author of this account Fulton, who has sometimes been claimed as the father of lobotomy, was later able to record that the technique had its true origination in his laboratory.{{sfn|Pressman|2002|pp=48–50|ps=}} Endorsing this version of events, in 1949, the Harvard neurologist [[Stanley Cobb]] remarked during his presidential address to the [[American Neurological Association]] that "seldom in the history of medicine has a laboratory observation been so quickly and dramatically translated into a therapeutic procedure". Fulton's report, penned ten years after the events described, is, however, without corroboration in the historical record and bears little resemblance to an earlier unpublished account he wrote of the congress. In this previous narrative, he mentioned an incidental, private exchange with Moniz, but it is likely that the official version of their public conversation he promulgated is without foundation.{{sfn|Pressman|2002|p=50|ps=}} In fact, Moniz stated that he had conceived of the operation sometime before his journey to London in 1935, having told in confidence his junior colleague, the young [[neurosurgeon]] Pedro Almeida Lima, as early as 1933 of his psychosurgical idea.{{sfn|Berrios|1997|pp=72–73|ps=}} The traditional account exaggerates the importance of Fulton and Jacobsen to Moniz's decision to initiate frontal lobe surgery, and omits the fact that a detailed body of neurological research that emerged at this time suggested to Moniz and other neurologists and neurosurgeons that surgery on this part of the brain might yield significant personality changes in the mentally ill.<ref>{{harvnb|Pressman|2002|pp=48–55}}; {{harvnb|Valenstein|1997|p=541}}</ref>

The frontal lobes have been the object of scientific inquiry and speculation since the late 19th century. Fulton's contribution, while it may have functioned as a source of intellectual support, is in itself unnecessary and inadequate as an explanation of Moniz's resolution to operate on this section of the brain.{{sfn|Pressman|2002|pp=51, 55|ps=}} Under an evolutionary and hierarchical model of brain development it had been hypothesized that those regions associated with the more recent development, such as the [[mammalian brain]] and, most especially, the frontal lobes, were responsible for more complex cognitive functions.{{sfn|Pressman|2002|p=51|ps=}} However, this theoretical formulation found little laboratory support, as 19th-century experimentation found no significant change in animal behaviour following surgical removal or electrical stimulation of the frontal lobes.{{sfn|Pressman|2002|p=51|ps=}} This picture of the so-called "silent lobe" changed in the period after World War I with the production of clinical reports of ex-servicemen with [[traumatic brain injury|brain trauma]]. The refinement of neurosurgical techniques also facilitated increasing attempts to remove brain tumours, and treat [[focal epilepsy]] in humans and led to more precise experimental neurosurgery in animal studies.{{sfn|Pressman|2002|p=51|ps=}} Cases were reported where mental symptoms were alleviated following the surgical removal of diseased or damaged brain tissue.{{sfn|Feldman|Goodrich|2001|p=649|ps=}} The accumulation of medical case studies on behavioural changes following damage to the frontal lobes led to the formulation of the concept of ''[[Witzelsucht#Frontal lobe|Witzelsucht]]'', which designated a neurological condition characterised by a certain hilarity and childishness in those with the condition.{{sfn|Pressman|2002|p=51|ps=}} The picture of frontal lobe function that emerged from these studies was complicated by the observation that neurological deficits attendant on damage to a single lobe might be compensated for if the opposite lobe remained intact.{{sfn|Pressman|2002|p=51|ps=}} In 1922, the Italian neurologist [[Leonardo Bianchi]] published a detailed report on the results of bilateral lobectomies in animals that supported the contention that the frontal lobes were both integral to intellectual function and that their removal led to the disintegration of the subject's personality.<ref>{{harvnb|Bianchi|1922}}; {{harvnb|Pressman|2002|p=51}}; {{harvnb|Levin|Eisenberg|1991|p=14}}</ref> This work, while influential, was not without its critics due to deficiencies in experimental design.{{sfn|Pressman|2002|p=51|ps=}}

The first bilateral lobectomy of a human subject was performed by the American neurosurgeon [[Walter Dandy]] in 1930.{{refn|The patient had [[meningioma]], a rare form of brain tumour arising in the [[meninges]].<ref name="Pressman02p52Kotowiczp85">{{harvnb|Pressman|2002|p=52}}; {{harvnb|Kotowicz|2005|p=84}}</ref>|group=n}}<ref name="Pressman02p52Kotowiczp85" /> The neurologist Richard Brickner reported on this case in 1932,{{sfn|Brickner|1932|ps=}} relating that the recipient, known as "Patient A", while experiencing a [[blunted affect|blunting of affect]], had no apparent decrease in intellectual function and seemed, at least to the casual observer, perfectly normal.{{sfn|Kotowicz|2005|p=84|ps=}} Brickner concluded from this evidence that "the frontal lobes are not 'centers' for the intellect".<ref name="QuotePressman02p52">Quoted in {{harvnb|Pressman|2002|p=52}}</ref> These clinical results were replicated in a similar operation undertaken in 1934 by the neurosurgeon [[Roy Glenwood Spurling]] and reported on by the neuropsychiatrist [[S. Spafford Ackerly|Spafford Ackerly]].{{sfn|Pressman|2002|p=52|ps=}} By the mid-1930s, interest in the function of the frontal lobes reached a high-water mark. This was reflected in the 1935 neurological congress in London, which hosted{{sfn|Pressman|2002|p=52|ps=}} as part of its deliberations,{{sfn|Pressman|2002|p=52|ps=}} "a remarkable symposium&nbsp;... on the functions of the frontal lobes".<ref>Quoted in {{harvnb|Freeman|Watts|1944|p=532}}</ref> The panel was chaired by [[Henri Claude]], a French neuropsychiatrist, who commenced the session by reviewing the state of research on the frontal lobes, and concluded that "altering the frontal lobes profoundly modifies the personality of subjects".<ref name="QuotePressman02p52" /> This parallel symposium contained numerous papers by neurologists, neurosurgeons and psychologists; amongst these was one by Brickner, which impressed Moniz greatly,{{sfn|Kotowicz|2005|p=84|ps=}} that again detailed the case of "Patient A".{{sfn|Pressman|2002|p=52|ps=}} Fulton and Jacobsen's paper, presented in another session of the conference on experimental physiology, was notable in linking animal and human studies on the function of the frontal lobes.{{sfn|Pressman|2002|p=52|ps=}} Thus, at the time of the 1935 Congress, Moniz had available to him an increasing body of research on the role of the frontal lobes that extended well beyond the observations of Fulton and Jacobsen.{{sfn|Pressman|2002|p=53|ps=}}

Nor was Moniz the only medical practitioner in the 1930s to have contemplated procedures directly targeting the frontal lobes.{{sfn|Valenstein|1990|p=541|ps=}} Although ultimately discounting brain surgery as carrying too much risk, physicians and neurologists such as [[William James Mayo|William Mayo]], Thierry de Martel, Richard Brickner, and [[Leo M. Davidoff|Leo Davidoff]] had, before 1935, entertained the proposition.{{refn|group=n|Brickner and Davidoff had planned, before Moniz's first leucotomies, to operate on the frontal lobes to relieve depression.{{sfn|Valenstein|1997|p=503|ps=}}}}{{sfn|Feldman|Goodrich|2001|p=650|ps=}} Inspired by [[Julius Wagner-Jauregg]]'s development of malarial therapy for the treatment of [[general paresis of the insane]], the French physician Maurice Ducosté reported in 1932 that he had injected 5&nbsp;ml of malarial blood directly into the frontal lobes of over 100 paretic patients through holes drilled into the skull.{{sfn|Valenstein|1990|p=541|ps=}} He claimed that the injected paretics showed signs of "uncontestable mental and physical amelioration" and that the results for psychotic patients undergoing the procedure were also "encouraging".<ref>Quoted in {{harvnb|Valenstein|1990|p=541}}</ref> The experimental injection of fever-inducing malarial blood into the frontal lobes was also replicated during the 1930s in the work of Ettore Mariotti and M. Sciutti in Italy and Ferdière Coulloudon in France.<ref>{{harvnb|Valenstein|1990|p=541}}; {{harvnb|Feldman|Goodrich|2001|p=650}}; {{harvnb|Kotowicz|2008|p=478}}</ref> In Switzerland, almost simultaneously with the commencement of Moniz's leucotomy programme, the neurosurgeon François Ody had removed the entire right frontal lobe of a [[Catatonic Schizophrenia|catatonic schizophrenic]] patient.<ref>{{harvnb|Berrios|1997|p=77}}; {{harvnb|Valenstein|1990|p=541}}; {{harvnb|Valenstein|1997|p=503}}</ref> In Romania, Ody's procedure was adopted by Dimitri Bagdasar and Constantinesco working out of the Central Hospital in Bucharest.{{sfn|Valenstein|1997|p=503|ps=}} Ody, who delayed publishing his own results for several years, later rebuked Moniz for claiming to have cured patients through leucotomy without waiting to determine if there had been a "lasting remission".<ref>Quoted in {{harvnb|Valenstein|1997|p=503}}</ref>