The most barbaric treatment in the history of medicine

On the lobotomy and phantom limbs

Twenty-five-year-old Phineas Gage was an ordinary man, as far as mankind goes. The year was 1848, and Gage was a foreman on a project to build a new railroad near the American town of Cavendish.

While working on the railroad, Gage's team encountered a stubborn rock blocking the way. In accordance with the standard work procedure, the workers drilled a deep hole in the rock to insert an explosive material into it. Gage was to pour the gunpowder into the hole, add the explosive that would ignite the combustion, then seal the hole with sand and secure it with a long iron rod.

Gage did this - but made a serious mistake: he forgot to fill the hole with sand. He inserted the iron rod into the hole and applied direct pressure to the explosive. The result was a sudden igniting of the gunpowder as the rock, and the iron rod shot out of it as if it were a shell from a cannon - which was not far from the truth.

Gage didn't have time to dodge. The iron rod drove into his face, under the left cheekbone, penetrated the brain and then fractured the skull on its way out. The rod, which was about five feet long, passed through Gage's mind - then stuck in the ground, twenty five meters away. Ninety-nine point nine percent of the time, such an injury is an instant death sentence as a result of massive bleeding. But Phineas Gage is not dead. He didn't even lose consciousness. He was a little stunned, and let his fellow workers lead him - on his feet, mind you - to the carriage that took him to town.

A local doctor, Dr. Edward Williams, was called to the injured. He found Gage sitting on the steps of a local hotel, his head in his hands, spitting blood from his mouth. "What happened?" the doctor asked Gage. Hela lifted his hat over his head, revealing the hole that had opened at the end of his head, and replied - "There's a job for you here, Doctor."

Dr. Williams did his best, cleaned the wound and put some of the bones back in place, and a short time later he was joined by another doctor, Dr. John Harlow. Harlow was the senior doctor of the two, and took Jage under his wing. Against all odds, Phineas Gage seemed to be on his way to a full recovery - but was it really a full recovery?

The iron rod that impaled Gage passed through an area of ​​his brain known as the Frontal Lobes. The frontal lobes are the part of our brain that is located at the front of the skull, right behind the eyes and forehead, and they deal, among other things, with distinguishing between harmful and beneficial actions, preventing impulsive and unsocial behavior, and understanding the meaning of the things we do today in relation to our future. The frontal lobes continue to develop even beyond adolescence, into our twenties, and it is likely that the wild and impulsive behavior of the foolish teens has something to do with the immaturity of their frontal lobes. Not that it helps parents deal with them: someone once said that only mothers of teenage children really understand why there are animals in the wild that eat their offspring.

The doctor in charge of Gage, Dr. Harlow, was the first to notice the change in his behavior. He wrote that Gage behaves very childishly, and is difficult to control. When Gage recovered and returned home, his family members and acquaintances also discovered how profound the effect of the injury was. From a balanced, sound and responsible person, Gage became restless, subject to changing moods and inconsiderate of his friends. He was unable to plan ahead, and stick to predetermined plans. He even began to curse profusely, something he had never dared to do before. His friends summed up the matter in one sad sentence - 'He is no longer Phineas Gage.'
Not much is known about what happened to Gage after he recovered from his injury. The railway company that employed him refused to accept him back to work due to the change in his character. Gage was forced to find alternative employment as a carriage driver, wandered to South America for several years, and finally passed away some twelve years later, in 1861.

The story of Phineas Gage has become one of the most famous medical cases in the history of brain research. However, Gage's miracle did not make a significant contribution to understanding how the brain works. No doctor examined his behavior in depth, and above all there was a lack of accurate comparison between his character before and after the injury, since until the moment of the injury Gage was completely anonymous. Neurobiologists continued to grope in the dark in their attempts to decipher the role of the frontal lobes. They got the first real opportunity to examine the full range of severe effects of damage to the frontal lobes only about sixty years later, with the invention of the 'lobotomy' operation - the medical procedure that received the unflattering description: 'one of the most barbaric mistakes in the history of modern medicine'.

In 1890, a Swiss doctor in a mental hospital decided to try a revolutionary treatment on his patients. He operated on six patients and removed parts of their frontal lobes. One of the operated on died on the spot, another committed suicide ten days later, but the other four had substantial character changes. This initial experiment encouraged other researchers to examine the possibilities inherent in such treatment in patients with severe mental disabilities: insane, retarded who exhibit violent behavior, extreme sexual perverts, and the like. The hope was that the change in character caused by the damage to the frontal lobes would have a positive effect on them, because it couldn't be much worse.

Dr. Antonio Muniz improved the medical procedure significantly, but the doctor whose name became associated with the worlds with the "lobotomy" operation was the American Dr. Walter Freeman. Freeman began performing lobotomies when the matter was in its infancy, in the thirties. He was not satisfied with the conventional surgical methods, which only expert surgeons could perform in hospitals with advanced medical equipment. Freeman wanted to bring the lobotomy to the place that needed it the most - to the mental hospitals. There were the people who might have benefited from this treatment, but there were no expert doctors or expensive medical equipment. Dr. Freeman hoped to find a way to perform a lobotomy under 'field conditions', one might say.

His solution to this problem was amazing in its simplicity. All the other surgeons tried to reach the frontal lobes by the shortest way - that is, through the forehead. Freeman decided to reach the goal from a completely different direction - from the eyes. The following description will sound quite creepy to most of you, but from a surgical point of view it was a real brilliance. He took a long, sharp needle, inserted it above the eye and through the thin bones and then penetrated into the frontal lobes below. Once the needle was in the right place, all Freeman had to do was shake it from side to side, windshield wiper style, and cut the tissue.

The effect of the lobotomy was extremely dramatic. In some cases the change was for the better, and the extreme behaviors disappeared as if they were not together with the radical change in the character of the patient. In another part of the cases the lobotomy had an incomparably destructive effect. Many operated on became retarded, unable to speak, gazing at the air without thinking. empty shells.

A few minutes - that's all the time it took to perform the surgery. Freeman was absolutely in love with the medical procedure he invented. He was also more than a doctor - he was a showman. He asked his assistants to measure how quickly he could enter, cut and exit the brain. He inserted two needles into both eyes at the same time or in two patients at once, and performed marathons of mass surgeries - up to twenty-five surgeries a day.

But the doctors who performed the lobotomy operations, tens of thousands of operations within a period of about thirty years, did not do what they did out of malice. The opposite is true: at a time when there was no medicine and no balm for severe and cruel mental illnesses, lobotomy was the only way to alleviate the suffering of the patient and those around him. In a situation where the alternative to a lobotomy was to lock the mentally ill in a padded cell, cuffed in a straitjacket for the rest of his life, there were those who saw the logic in performing it. Nevertheless, the controversy surrounding the lobotomy did not subside for a moment within the United States and abroad. In the Soviet Union, the medical bodies forbade the operation, on the grounds that it is inhumane and makes a mentally ill person an idiot.

In the second half of the twentieth century, there was a gradual decrease in the number of lobotomy surgeries, with the appearance of effective drug treatments. The doctors stopped recommending the operation except in extreme cases only. Finally, the lobotomy was outlawed in many countries around the world. Dr. Walter Freeman was also forced to stop operating following the death of a patient on his operating table.

The frontal lobes have another important role in the brain, beyond determining personality. At the back of the frontal lobes there is an area called the 'motor cortex', and it is the abode of the 'little man'. The little man, or in Latin homonoculus, is the name given to a narrow strip of brain cells that are linked to the various body organs: they control them and receive the sensory data from them. The neurologists' interest in the motor cortex arose following a strange and disturbing phenomenon, for which no one could find an acceptable explanation: the 'phantom organs'.

During the days of the American Civil War, many soldiers suffered injuries that required doctors to amputate the damaged organs. Tens of thousands of soldiers who returned to their homes in the midst of the battles with amputated arms or legs, then began to complain that they felt their amputated limbs. I want to emphasize - they did not imagine, or missed or fantasized. They literally felt the missing arms or the lost legs, the same way you and I feel the existence of our arms and legs.

The stories told by the patients would be considered finger-sucking, if it weren't for such a large number of people reporting the exact same symptoms. One woman said that when she goes to the door, her phantom arm tries to press the handle. A former professional tennis player described how on the opening stroke, his phantom hand tries to throw the ball in the air, or stop it if it has fallen to the floor. Lots of patients felt very real pain in their phantom limbs.

The first real insight into the phantom limb phenomenon appeared only about fifteen years ago, as a result of a study conducted by Dr. V.S. Ramachandran. I took the stories about the phantom limbs that I brought in this chapter from his excellent and recommended story 'Mind Illusions', which he wrote together with Sandra Blakeslee.

Ramachandran discovered that in those who had a limb amputated, the area of ​​the motor cortex that was responsible for that limb degenerated. But the brain is not a static organ: it learns and adapts, and the free space is quickly taken up by the areas of the motor cortex that border the atrophied area. Thus, for example, the representation area of ​​the face spreads into the area that was previously responsible for the absent hand, and the representation area of ​​the genitals occupies parts of the leg area. In this way, when the patient feels sexual stimulation, for example, the brain mistakenly understands that there are messages coming from the leg - or more precisely, from the area of ​​the motor cortex that the rest of the brain is used to recognizing as the leg area. When the patient moves the facial muscles, this movement is mistakenly interpreted as a movement of the hand, and the brain tries to control it as best it can.

These ideas also provided logical answers to cases where phantom limbs appeared throughout the rest of the body, and not just in the limbs. Women who have had mastectomies have reported ghost breasts. One patient insisted that he feels his appendix continues to hurt and bother - even after the appendectomy. There is even a ghost penis, with a phantom erection. One lucky patient reported a phantom leg that comes alive during intercourse. He felt in his phantom leg the same sexual stimulation as his penis - and as a result experienced strong orgasms above and beyond anything he knew before the injury. I'm sure he didn't really want medical attention. He was just trying to show off.

(The article is taken from the program 'Making history!', A bi-weekly podcast about science, technology and history)