From the monthly archives:

November 2007

Lobotomy Revisited

by Brian Carty, MD, MSPH

Do you remember Rosemary Kennedy, John F. Kennedy’s sister? Maybe not, since she spent most of her life hidden away in an institution in the Midwest. She had a lobotomy, a brain operation for mental illness, in 1941 when she was 23. Her father, Joseph Kennedy, arranged the operation. The procedure left her mentally incapacitated. Whether she was mentally ill, mentally retarded, or both, is unclear, but her disruptive behavior led to the operation and its unfortunate outcome. She died of natural causes on January 7, 2005 at the age of 86.

The lobotomy, also called leucotomy, was devised in 1935 by the Portuguese neurologist Egas Moniz for the treatment of various psychiatric disorders. In this procedure, holes were drilled in the skull and a blade was used to cut nerve fibers from the frontal lobes (the front of the brain, just behind the forehead) to the rest of the brain. The term lobotomy came to include a variety of surgical procedures on the frontal lobes which were performed for psychiatric disorders.

An estimated 50,000 lobotomies were performed in the US in the 1930s and 40s. Although electroconvulsive therapy was introduced in the 1930s, it is useful mainly for the treatment of depression. Otherwise, before effective psychiatric drugs were available in the 1950s, the only other treatments for the severely mentally ill were incarceration and physical restraint.

By today’s standards, conditions in the mental hospitals of the time were unimaginable. Many patients were severely agitated, extremely violent, and incontinent. The hospitals were dirty, overcrowded, and understaffed.

Many severely ill patients benefited from lobotomy with decreases in violence and agitation. However, lobotomy often caused serious adverse effects, including disturbances of mood and personality, euphoria, poor judgment, impulsivity, loss of initiative, intellectual deficits, and seizures.

For many patients, however, a decrease in agitation and violence, even when accompanied by neurologic injury from frontal lobe surgery, was understandably considered an improvement. When the first effective antipsychotic drug, Thorazine (chlorpromazine), was introduced in the US in 1954, the number of lobotomies performed plummeted.

Surgery for psychiatric disorders is still performed rarely today. The procedures have become more selective and less extensive and now include deep brain stimulation with implanted electrodes. Similar surgical procedures and deep brain stimulation are sometimes done for movement disorders and chronic pain. Surgery for psychiatric disorders is still controversial and, when performed, is most often used for treatment-refractory obsessive-compulsive disorder (OCD). OCD is a disorder characterized by obsessive thoughts and compulsive behaviors such as repeated hand washing or checking to see if doors are locked. OCD can severely affect functioning and quality of life.

It is worth noting again that surgery for psychiatric disorders must be judged with reference to conditions which existed at the time the procedures were introduced. Although lobotomy is viewed by many as barbaric, the operation gave many patients a limited improvement which was otherwise unobtainable. The wisdom of hindsight should be applied sparingly; newly introduced medical treatments often cause unintended harm. The history of lobotomy should remind us that future generations will inevitably view our current best treatments as primitive.

Historic Video: Lobotomy, 1942


“MANOPAUSE” - Testosterone Deficiency in Older Males

by Brian Carty, MD, MSPH

A 66 year old man saw his doctor for trouble with erections and low sexual desire. His doctor found nothing abnormal on examination, but the blood concentration of testosterone, a male hormone, was low. The patient was given testosterone supplementation in the form of a gel applied to the skin. Several months later, he had normal sexual function and improved strength, energy, and mood.

Testosterone deficiency like this is not rare in middle aged and older males. Because testosterone levels in men gradually decrease with age, abnormally low levels are seen in 4% of males between ages 40 and 70, and in a higher proportion of men over age 70.

Testosterone deficiency in males can cause loss of energy, depression, decreased sexual desire, trouble with erections, decreased strength, increased fat mass, and low bone density. Testosterone supplements improve most of these problems.

However, there hasn’t been enough good quality research on testosterone deficiency in older males to give us clear guidelines on how to diagnose and treat this problem. For example, there is no agreement among experts on what should be considered a low testosterone level. Some experts use 300 ng/ml and some use 200 ng/ml. Neither is there agreement on how many symptoms of testosterone deficiency should be present before testosterone supplementation is justified.

There are potential risks associated with testosterone treatment. The potential risk of most concern is a possible increase in the risk of prostate cancer. Other potential risks are an increase in the red blood cell count, breast enlargement, acne, mild weight gain, leg swelling, appearance of or worsening of sleep apnea, and a decrease in the size of the testicles. Fertility is impaired while testosterone supplements are given. Patients must be monitored carefully during testosterone supplementation.

Men who definitely should not receive testosterone supplementation include those with prostate cancer, a history of prostate cancer, an elevated PSA (the blood test for possible prostate cancer), or an abnormal prostate exam (nodule or enlargement) without an evaluation by a urologist to rule out prostate cancer. There are some other medical conditions which may make testosterone supplementation inadvisable, but the risks of not treating testosterone deficiency are also potentially serious. In general, testosterone supplementation is well tolerated in men with testosterone deficiency and is often dramatically effective.


Anti-Sicko: The Dark Side of Government Health Care

by Brian Carty, MD, MSPH

Web addresses for some short videos on socialized health care: