Psychosurgery

-step-by-step of how to do lobotomies

-logo of black butterflies (depression for france) and trepanated skull

-drilled hole manually

-rongeur (curved needle nose priors) and snapped skull bone to largen hole

-metal rod through head

-push in tool lots of time to mess up tissue

-always took before/after pics

-mainly in state hospitals

-also in private hospitals, universities, VAs

-McClean hospital (private) outside of Boston did a lot

-mainly on backwards schizophrenics

-conditions in mental hospitals (overcrowding) 

-economics

-professional forces

Trans-orbital lobotomy or ice pick lobotomy

-eye socket broke a lot in deep frontal cut

-Louptone- ice pick like tool 

-shock to head as preperation

Complications- brain infections (not sterile) and instrument getting stuck

-heath

-put electrodes into schizos heads

-thought central area of brain had dimished activity in schizophrenic patients

-1950s

-Heath

-treat schizophrenia by stimulating the septal region of the brain

-mental hospitals in crisis

-movement to root psychiatry in bio medicine

-drastic somatic therapies were widely used and accepted

1. 1st heart transplant led to ethical dilemnas (who gets next heart) 
2. federal funding of research
3. centralization of medicine (hospital facilities) 
4. increased medical specialization
5. civil rights and consumerism (awareness from Nazi Drs., untrusted strangers not providing treatment) 
6. awareness of mistreatment of research subjects (Tuskeegee)

-biomethics movement- 1960s

-patients rights by courts and federal regulations

-biomedical ethics- 1970s

1. hippocratic oath "I will keep them from harm"
2. declaration of Geneva (1948) : before Heath
3. International code of medical ethics (1949) 
4. AMA's Principles of medical ethics (etiquette between doctors)
5. patient consent (needed even in 50s, Heath didn't get it) 
6. Therapeutic privilege (catch of consent, not needed if consent will do patient harm)
7. Research Ethics 

-Tx stops and R begins when the research is an unproven technique or the goal is to get info that will help others instead of only the individual 

-Nuremberg- case against 20 doctors resulted in voluntary consent and enlightened decision

Informed consent- technical legal doctrine needed for research to be ethical (1957-while Heath was doing studies) 

-Heath claimed he had informed consent but never went through process so he didn't

-dangerous

-ill conceived (not reason to think it would work)

-inhumane (neg stimulation to see bx) 

-unethical (by standards of the time) 

nerve tracts (white matter) of frontal lobes

-promoted by well trained respected physicians

Moniz (2nd nobel prize)

-lobotomies

-cerebral angiography (see blood in brain)

-2nd international neurological congress (frontal lobes changed a lot w/out person changing, silent lobes)

-Fulton & Jacobson "Function of Frontal Lobes" (delayed response task)

-monkeys find item after hidden then screen dropped

-monkeys wrong they got really upset (called experimental neurosis) 

-first animal model of neuroses

-Becky: monkey got really upset when wrong

-did lobotomy and no longer upset

-Moniz suggested with humans

-Almedia Lima- Surgeon

-pen into morgue brain for practice

-63 year old women w/ melancholia, alchol in frontal lobes

-cured after 2 months

Lucotone- knife used

-insert through 2 holes in top of head

-deploy plunger to poke out wire loop

-turn loop to cut tissue which was left in

7 cured (all affective)

7 improved

6 unchanged

Acute

-vomitting

-urination/fecal incontinenence

-disorientation

Chronic

-apathy (dont care) 

-akinesia (diminished movement)

-loss of initiative

-mutism

-abnormal hunger

-puerility (no social inhibition, childish)

Freeman - 1st US lobotomy

Worked with Watts (surgeon)

-63 female w/ severe agitated depression

-operation 6 cores per side

-successfull

Southern Medical Association

- 6 cases presented - success

-complications (perseveration of speech, increased reflexes, disturbances of vesical control)

-freeman was reasonable, said not good for everyone and ppl lose something

-Meyer & NEJM sanctioned lobotomies

Chicago neurological society

-20 lobotomies

-torrent of criticism from psychoanalysits 

-8 of 20 needed reoperation

-2 died of hemorraghe

-variable location of damage

-leucotone breaking off in brain

-dead tissue left in brain caused epilepsy

-pharmacotherapy

-defocalization

-insulin coma therapy

-metrazol convulsive therapy

-ECT

-psychosurgery

-stimulants (amphetamine)

-antihistamines

-LSD
-Barbiturates 

-Thorizine

-most imp drug in psychiatry

-sedative and led to other drugs

Barbital-1st one (Fisher & Mering)

-narcoanalysis, prolonged narcosis, depatterning

- Macleod used diff drugs (bromide) to ship patients

- Klaesi popularized using barbiturates w/ it

-Baily & Sargant had competition (Baily charged w/ murder)

-1st somatic theory of 20th century 

-book says 1st truly effective psychological treatment ever produced

-fix patterns in the brain

-Cameron:prolonged narcosis, ECT, & prerecorded message

Cotton

Focal Infection Theory/sergical antisepsis

-bacteria from infection is causing mental illness so cutting out the bacteria will cure the illness

-okay for teeth not organs

-1st ever clinical control trial to show it was ineffective

-didn't spread widely like other treatments

-cotton said 80% effective

Jauregg

-fever therapy (led to aggressive medical treatments of mental illness) 

-discovered by patient w/ strep

-Started with tuberculin therapy (too toxic) 

Prob worked w/ GPI

Jauregg- 1st nobel prize in psychiatry

-Penicillin (antibiotic) made malaria therapy obsolete

Sakel 

-insulin takes glucose into tissue, not enough for brain (hypoglycemia) 

-started w/ drug addiction

-widely accepted, hard needed lots of staff

88% success

-daily for weeks, glucose to wake up

side-effects (seizures & foaming)

Meduna

-antagonism between epilepsy & schizophrenia

-metrazol produced seizures

-severity fo seizures too bad, never caught on, ECT made it obsolete 

Cerletti

-studied epilepsy in animals

-dogs head to butt killed them

-pigs before slaughtering on the head

-1st trial w/ homeless schizophrenia and it produced seizures, he almost died from apnea

-less deaths than insulin (brain damage) 

-less complications than metrazol (broken bones)

Curare- prevents muscle spasms

used w/ everyone (43% of hospitals) 

1950s tx for depression

Indications

-major depression

-acute mania

-psychosis

3x/week, 6-12 total sessions, maintanence at 1-3 wk intervals

complications

-cardiovascular (hypertension, arrhythmia)

-cognitive disorientation (acute) 

-memory impariment

-prolonged seizure & apnea

natural occuring substance w/ nitrogen

-"alkaloid era" beginning of asylum psychopharmacology

(belladonna alkaloid) cocaine, morphine 

Hashish and mental illness (1st psychopharm book) 

-Maroe

-extract of marijuana

Chloral hydrate

-one of the first sedatives