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    • 117 LESSONS AND 33  other lessons FOREX traders can use to learn Forex posting genius And lead the pied pips piper into your wallet dont forget to like and subscribe Visual impairment From Wikipedia, the free encyclopedia   (Redirected from Blind man)   Jump to navigation Jump to search "Blindness" redirects here. For other uses, see Blindness (disambiguation). Visual impairment Other names Vision impairment, vision loss A white cane, the international symbol of blindness Specialty Ophthalmology Symptoms Decreased ability to see[1][2] Complications Non-24-hour sleep–wake disorder[3] Causes Uncorrected refractive errors, cataracts, glaucoma[4] Diagnostic method Eye examination[2] Treatment Vision rehabilitation, changes in the environment, assistive devices (eyeglasses, white cane)[2] Frequency 940 million / 13% (2015)[5] Visual impairment, also known as vision impairment or vision loss, is a decreased ability to see to a degree that causes problems not fixable by usual means, such as glasses.[1][2] Some also include those who have a decreased ability to see because they do not have access to glasses or contact lenses.[1] Visual impairment is often defined as a best corrected visual acuity of worse than either 20/40 or 20/60.[6] The term blindness is used for complete or nearly complete vision loss.[6] Visual impairment may cause people difficulties with normal daily activities such as driving, reading, socializing, and walking.[2] The most common causes of visual impairment globally are uncorrected refractive errors (43%), cataracts (33%), and glaucoma (2%).[4] Refractive errors include near-sightedness, far-sightedness, presbyopia, and astigmatism.[4] Cataracts are the most common cause of blindness.[4] Other disorders that may cause visual problems include age-related macular degeneration, diabetic retinopathy, corneal clouding, childhood blindness, and a number of infections.[7] Visual impairment can also be caused by problems in the brain due to stroke, premature birth, or trauma among others.[8] These cases are known as cortical visual impairment.[8] Screening for vision problems in children may improve future vision and educational achievement.[9] Screening adults without symptoms is of uncertain benefit.[10] Diagnosis is by an eye exam.[2] The World Health Organization (WHO) estimates that 80% of visual impairment is either preventable or curable with treatment.[4] This includes cataracts, the infections river blindness and trachoma, glaucoma, diabetic retinopathy, uncorrected refractive errors, and some cases of childhood blindness.[11] Many people with significant visual impairment benefit from vision rehabilitation, changes in their environment, and assistive devices.[2] As of 2015 there were 940 million people with some degree of vision loss.[5] 246 million had low vision and 39 million were blind.[4] The majority of people with poor vision are in the developing world and are over the age of 50 years.[4] Rates of visual impairment have decreased since the 1990s.[4] Visual impairments have considerable economic costs both directly due to the cost of treatment and indirectly due to decreased ability to work.[12] Contents 1 Classification 1.1 United Kingdom 1.2 United States 2 Health effects 2.1 Associated problems 3 Cause 3.1 Cataracts 3.2 Glaucoma 3.3 Infections 3.4 Injuries 3.5 Genetic defects 3.6 Poisoning 3.7 Other 4 Diagnosis 5 Prevention 6 Management 6.1 Mobility 6.2 Reading and magnification 6.3 Computers and mobile technology 6.4 Other aids and techniques 6.5 Communication 6.6 Healthcare access 7 Epidemiology 8 Society and culture 8.1 Legal definition 8.2 Literature and art 8.3 Sports 8.4 Metaphorical uses 9 Research 10 Other animals 11 See also 12 References 13 External links Classification   A typical Snellen chart that is frequently used for visual acuity testing. The definition of visual impairment is reduced vision not corrected by glasses or contact lenses. The World Health Organization uses the following classifications of visual impairment. When the vision in the better eye with best possible glasses correction is: 20/30 to 20/60 : is considered mild vision loss, or near-normal vision 20/70 to 20/160 : is considered moderate visual impairment, or moderate low vision 20/200 to 20/400 : is considered severe visual impairment, or severe low vision 20/500 to 20/1,000 : is considered profound visual impairment, or profound low vision More than 20/1,000 : is considered near-total visual impairment, or near total blindness No light perception (NLP) : is considered total visual impairment, or total blindness Blindness is defined by the World Health Organization as vision in a person's best eye with best correction of less than 20/500 or a visual field of less than 10 degrees.[6] This definition was set in 1972, and there is ongoing discussion as to whether it should be altered to officially include uncorrected refractive errors.[1] United Kingdom Severely sight impaired Defined as having central visual acuity of less than 3/60 with normal fields of vision, or gross visual field restriction. Unable to see at 3 metres (10 ft) what the normally sighted person sees at 60 metres (200 ft). Sight impaired Able to see at 3 metres (10 ft), but not at 6 metres (20 ft), what the normally sighted person sees at 60 metres (200 ft) Less severe visual impairment is not captured by registration data, and its prevalence is difficult to quantify Low vision A visual acuity of less than 6/18 but greater than 3/60. Not eligible to drive and may have difficulty recognising faces across a street, watching television, or choosing clean, unstained, co-ordinated clothing.[13] In the UK, the Certificate of Vision Impairment (CVI) is used to certify patients as severely sight impaired or sight impaired.[14] The accompanying guidance for clinical staff states: "The National Assistance Act 1948 states that a person can be certified as severely sight impaired if they are "so blind as to be unable to perform any work for which eye sight is essential". Certification is based on whether a person can do any work for which eyesight is essential, not just one particular job (such as their job before becoming blind).[15] In practice, the definition depends on individuals' visual acuity and the extent to which their field of vision is restricted. The Department of Health identifies three groups of people who may be classified as severely visually impaired.[15] Those below 3/60 (equivalent to 20/400 in US notation) Snellen (most people below 3/60 are severely sight impaired). Those better than 3/60 but below 6/60 Snellen (people who have a very contracted field of vision only). Those 6/60 Snellen or above (people in this group who have a contracted field of vision especially if the contraction is in the lower part of the field). The Department of Health also state that a person is more likely to be classified as severely visually impaired if their eyesight has failed recently or if they are an older individual, both groups being perceived as less able to adapt to their vision loss.[15] United States In the United States, any person with vision that cannot be corrected to better than 20/200 in the best eye, or who has 20 degrees (diameter) or less of visual field remaining, is considered legally blind or eligible for disability classification and possible inclusion in certain government sponsored programs. In the United States, the terms partially sighted, low vision, legally blind and totally blind are used by schools, colleges, and other educational institutions to describe students with visual impairments.[16] They are defined as follows: Partially sighted indicates some type of visual problem, with a need of person to receive special education in some cases. Low vision generally refers to a severe visual impairment, not necessarily limited to distance vision. Low vision applies to all individuals with sight who are unable to read the newspaper at a normal viewing distance, even with the aid of eyeglasses or contact lenses. They use a combination of vision and other senses to learn, although they may require adaptations in lighting or the size of print, and, sometimes, Braille. Myopic – unable to see distant objects clearly, commonly called near-sighted or short-sighted. Hyperopic – unable to see close objects clearly, commonly called far-sighted or long-sighted. Legally blind indicates that a person has less than 20/200 vision in the better eye after best correction (contact lenses or glasses), or a field of vision of less than 20 degrees in the better eye. Totally blind students learn via Braille or other non-visual media. In 1934, the American Medical Association adopted the following definition of blindness: The United States Congress included this definition as part of the Aid to the Blind program in the Social Security Act passed in 1935.[17][18] In 1972, the Aid to the Blind program and two others combined under Title XVI of the Social Security Act to form the Supplemental Security Income program[19] which states: Health effects Visual impairments may take many forms and be of varying degrees. Visual acuity alone is not always a good predictor of the degree of problems a person may have. Someone with relatively good acuity (e.g., 20/40) can have difficulty with daily functioning, while someone with worse acuity (e.g., 20/200) may function reasonably well if their visual demands are not great. The American Medical Association has estimated that the loss of one eye equals 25% impairment of the visual system and 24% impairment of the whole person;[21][22] total loss of vision in both eyes is considered to be 100% visual impairment and 85% impairment of the whole person.[21] Some people who fall into this category can use their considerable residual vision – their remaining sight – to complete daily tasks without relying on alternative methods. The role of a low vision specialist (optometrist or ophthalmologist) is to maximize the functional level of a patient's vision by optical or non-optical means. Primarily, this is by use of magnification in the form of telescopic systems for distance vision and optical or electronic magnification for near tasks. People with significantly reduced acuity may benefit from training conducted by individuals trained in the provision of technical aids. Low vision rehabilitation professionals, some of whom are connected to an agency for the blind, can provide advice on lighting and contrast to maximize remaining vision. These professionals also have access to non-visual aids, and can instruct patients in their uses. The subjects making the most use of rehabilitation instruments, who lived alone, and preserved their own mobility and occupation were the least depressed, with the lowest risk of suicide and the highest level of social integration. Those with worsening sight and the prognosis of eventual blindness are at comparatively high risk of suicide and thus may be in need of supportive services. Many studies have demonstrated how rapid acceptance of the serious visual handicap has led to a better, more productive compliance with rehabilitation programs. Moreover, psychological distress has been reported to be at its highest when sight loss is not complete, but the prognosis is unfavorable. Therefore, early intervention is imperative for enabling successful psychological adjustment.[23] Associated problems Blindness can occur in combination with such conditions as intellectual disability, autism spectrum disorders, cerebral palsy, hearing impairments, and epilepsy.[24][25] Blindness in combination with hearing loss is known as deafblindness. It has been estimated that over half of completely blind people have non-24-hour sleep–wake disorder, a condition in which a person's circadian rhythm, normally slightly longer than 24 hours, is not entrained (synchronized) to the light–dark cycle.[26][27] Cause The most common causes of visual impairment globally in 2010 were: Refractive error (42%) Cataract (33%) Glaucoma (2%) Age-related macular degeneration (1%) Corneal opacification (1%) Diabetic retinopathy (1%) Childhood blindness Trachoma (1%) Undetermined (18%)[7] The most common causes of blindness worldwide in 2010 were: Cataracts (51%) Glaucoma (8%) Age-related macular degeneration (5%) Corneal opacification (4%) Childhood blindness (4%) Refractive errors (3%) Trachoma (3%) Diabetic retinopathy (1%) Undetermined (21%)[7] About 90% of people who are visually impaired live in the developing world.[4] Age-related macular degeneration, glaucoma, and diabetic retinopathy are the leading causes of blindness in the developed world.[28] Among working-age adults who are newly blind in England and Wales the most common causes in 2010 were:[29] Hereditary retinal disorders (20.2%) Diabetic retinopathy (14.4%) Optic atrophy (14.1%) Glaucoma (5.9%) Congenital abnormalities (5.1%) Disorders of the visual cortex (4.1%) Cerebrovascular disease (3.2%) Degeneration of the macula and posterior pole (3.0%) Myopia (2.8%) Corneal disorders (2.6%) Malignant neoplasms of the brain and nervous system (1.5%) Retinal detachment (1.4%) Cataracts Cataracts is the congenital and pediatric pathology that describes the greying or opacity of the crystalline lens, which is most commonly caused by intrauterine infections, metabolic disorders, and genetically transmitted syndromes.[30] Cataracts are the leading cause of child and adult blindness that doubles in prevalence with every ten years after the age of 40.[31] Consequently, today cataracts are more common among adults than in children.[30] That is, people face higher chances of developing cataracts as they age. Nonetheless, cataracts tend to have a greater financial and emotional toll upon children as they must undergo expensive diagnosis, long term rehabilitation, and visual assistance.[32] Also, according to the Saudi Journal for Health Sciences, sometimes patients experience irreversible amblyopia[30] after pediatric cataract surgery because the cataracts prevented the normal maturation of vision prior to operation.[33] Despite the great progress in treatment, cataracts remain a global problem in both economically developed and developing countries.[34] At present, with the variant outcomes as well as the unequal access to cataract surgery, the best way to reduce the risk of developing cataracts is to avoid smoking and extensive exposure to sun light (i.e. UV-B rays).[31] Glaucoma Glaucoma is a congenital and pediatric eye disease characterized by increased pressure within the eye or intraocular pressure (IOP).[35] Glaucoma causes visual field loss as well as severs the optic nerve.[36] Early diagnosis and treatment of glaucoma in patients is imperative because glaucoma is triggered by non-specific levels of IOP.[36] Also, another challenge in accurately diagnosing glaucoma is that the disease has four causes: 1) inflammatory ocular hypertension syndrome (IOHS); 2) severe uveitic angle closure; 3) corticosteroid-induced; and 4) a heterogonous mechanism associated with structural change and chronic inflammation.[35] In addition, often pediatric glaucoma differs greatly in cause and management from the glaucoma developed by adults.[37] Currently, the best sign of pediatric glaucoma is an IOP of 21 mm Hg or greater present within a child.[37] One of the most common causes of pediatric glaucoma is cataract removal surgery, which leads to an incidence rate of about 12.2% among infants and 58.7% among 10-year-olds.[37] Infections   The burden of onchocerciasis: children leading blind adults in Africa Childhood blindness can be caused by conditions related to pregnancy, such as congenital rubella syndrome and retinopathy of prematurity. Leprosy and onchocerciasis each blind approximately 1 million individuals in the developing world. The number of individuals blind from trachoma has decreased in the past 10 years from 6 million to 1.3 million, putting it in seventh place on the list of causes of blindness worldwide. Central corneal ulceration is also a significant cause of monocular blindness worldwide, accounting for an estimated 850,000 cases of corneal blindness every year in the Indian subcontinent alone. As a result, corneal scarring from all causes is now the fourth greatest cause of global blindness.[38] Injuries   Re-educating wounded. Blind French soldiers learning to make baskets, World War I. Eye injuries, most often occurring in people under 30, are the leading cause of monocular blindness (vision loss in one eye) throughout the United States. Injuries and cataracts affect the eye itself, while abnormalities such as optic nerve hypoplasia affect the nerve bundle that sends signals from the eye to the back of the brain, which can lead to decreased visual acuity. Cortical blindness results from injuries to the occipital lobe of the brain that prevent the brain from correctly receiving or interpreting signals from the optic nerve. Symptoms of cortical blindness vary greatly across individuals and may be more severe in periods of exhaustion or stress. It is common for people with cortical blindness to have poorer vision later in the day. Blinding has been used as an act of vengeance and torture in some instances, to deprive a person of a major sense by which they can navigate or interact within the world, act fully independently, and be aware of events surrounding them. An example from the classical realm is Oedipus, who gouges out his own eyes after realizing that he fulfilled the awful prophecy spoken of him. Having crushed the Bulgarians, the Byzantine Emperor Basil II blinded as many as 15,000 prisoners taken in the battle, before releasing them.[39] Contemporary examples include the addition of methods such as acid throwing as a form of disfigurement. Genetic defects People with albinism often have vision loss to the extent that many are legally blind, though few of them actually cannot see. Leber congenital amaurosis can cause total blindness or severe sight loss from birth or early childhood. Recent advances in mapping of the human genome have identified other genetic causes of low vision or blindness. One such example is Bardet–Biedl syndrome. Poisoning Rarely, blindness is caused by the intake of certain chemicals. A well-known example is methanol, which is only mildly toxic and minimally intoxicating, and breaks down into the substances formaldehyde and formic acid which in turn can cause blindness, an array of other health complications, and death.[40] When competing with ethanol for metabolism, ethanol is metabolized first, and the onset of toxicity is delayed. Methanol is commonly found in methylated spirits, denatured ethyl alcohol, to avoid paying taxes on selling ethanol intended for human consumption. Methylated spirits are sometimes used by alcoholics as a desperate and cheap substitute for regular ethanol alcoholic beverages. Other Amblyopia: is a category of vision loss or visual impairment that is caused by factors unrelated to refractive errors or coexisting ocular diseases.[41] Amblyopia is the condition when a child's visual systems fail to mature normally because the child either suffers from a premature birth, measles, congenital nubella syndrome, vitamin A deficiency, or meningitis.[42] If left untreated during childhood, amblyopia is currently incurable in adulthood because surgical treatment effectiveness changes as a child matures.[42] Consequently, amblyopia is the world's leading cause of child monocular vision loss, which is the damage or loss of vision in one eye.[41] In the best case scenario, which is very rare, properly treated amblyopia patients can regain 20/40 acuity.[41] Corneal opacification Degenerative myopia Diabetic retinopathy: is one of the manifestation microvascular complications of diabetes, which is characterized by blindness or reduced acuity. That is, diabetic retinopathy describes the retinal and vitreous hemorrhages or retinal capillary blockage caused by the increase of A1C,[43] which a measurement of blood glucose or sugar level.[44] In fact, as A1C increases, people tend to be at greater risk of developing diabetic retinopathy than developing other microvascular complications associated with diabetes (e.g. chronic hyperglycemia, diabetic neuropathy, and diabetic nephropathy).[43] Despite the fact that only 8% of adults 40 years and older experience vision-threatening diabetic retinopathy (e.g. nonproliferative diabetic retinopathy or NPDR and proliferative diabetic retinopathy or PDR), this eye diseased accounted for 17% of cases of blindness in 2002.[43] Retinitis pigmentosa Retinopathy of prematurity: The most common cause of blindness in infants worldwide. In its most severe form, ROP causes retinal detachment, with attendant visual loss. Treatment is aimed mainly at prevention, via laser or Avastin therapy. Stargardt's disease Uveitis: is a group of 30 intraocular inflammatory diseases[45] caused by infections, systemic diseases, organ-specific autoimmune processes, cancer or trauma.[46] That is, uveitis refers to a complex category of ocular diseases that can cause blindness if either left untreated or improperly diagnosed.[46] The current challenge of accurately diagnosing uveitis is that often the cause of a specific ocular inflammation is either unknown or multi-layered.[45] Consequently, about 3–10% uveitis victims in developed countries, and about 25% of victims in the developing countries, become blind from incorrect diagnosis and from ineffectual prescription of drugs, antibiotics or steroids.[46] In addition, uveitis is a diverse category of eye diseases that are subdivided as granulomatous (or tumorous) or non-granulomatous anterior, intermediate, posterior or pan uveitis.[46] In other words, uveitis diseases tend to be classified by their anatomic location in the eye (e.g. uveal tract, retina, or lens), as well as can create complication that can cause cataracts, glaucoma, retinal damage, age-related macular degeneration or diabetic retinopathy.[46] Xerophthalmia, often due to vitamin A deficiency, is estimated to affect 5 million children each year; 500,000 develop active corneal involvement, and half of these go blind. Diagnosis Play media   Scientists track eye movements in glaucoma patients to check vision impairment while driving It is important that people be examined by someone specializing in low vision care prior to other rehabilitation training to rule out potential medical or surgical correction for the problem and to establish a careful baseline refraction and prescription of both normal and low vision glasses and optical aids. Only a doctor is qualified to evaluate visual functioning of a compromised visual system effectively.[47] The American Medical Association provides an approach to evaluating visual loss as it affects an individual's ability to perform activities of daily living.[21] Screening adults who have no symptoms is of uncertain benefit.[10] Prevention The World Health Organization estimates that 80% of visual loss is either preventable or curable with treatment.[4] This includes cataracts, onchocerciasis, trachoma, glaucoma, diabetic retinopathy, uncorrected refractive errors, and some cases of childhood blindness.[11] The Center for Disease Control and Prevention estimates that half of blindness in the United States is preventable.[2] Management   Tommy Edison, a blind film critic, demonstrates for his viewers how a blind person can cook alone. Mobility   Folded long cane   A blind man is assisted by a guide dog in Brasília, Brazil   Blind girl feels shape of vehicle near Mana village, Uttarakhand   Visually impaired girl negotiating a rock while rock climbing Many people with serious visual impairments can travel independently, using a wide range of tools and techniques. Orientation and mobility specialists are professionals who are specifically trained to teach people with visual impairments how to travel safely, confidently, and independently in the home and the community. These professionals can also help blind people to practice travelling on specific routes which they may use often, such as the route from one's house to a convenience store. Becoming familiar with an environment or route can make it much easier for a blind person to navigate successfully. Tools such as the white cane with a red tip – the international symbol of blindness – may also be used to improve mobility. A long cane is used to extend the user's range of touch sensation. It is usually swung in a low sweeping motion, across the intended path of travel, to detect obstacles. However, techniques for cane travel can vary depending on the user and/or the situation. Some visually impaired persons do not carry these kinds of canes, opting instead for the shorter, lighter identification (ID) cane. Still others require a support cane. The choice depends on the individual's vision, motivation, and other factors. A small number of people employ guide dogs to assist in mobility. These dogs are trained to navigate around various obstacles, and to indicate when it becomes necessary to go up or down a step. However, the helpfulness of guide dogs is limited by the inability of dogs to understand complex directions. The human half of the guide dog team does the directing, based upon skills acquired through previous mobility training. In this sense, the handler might be likened to an aircraft's navigator, who must know how to get from one place to another, and the dog to the pilot, who gets them there safely. GPS devices can also be used as a mobility aid. Such software can assist blind people with orientation and navigation, but it is not a replacement for traditional mobility tools such as white canes and guide dogs. Some blind people are skilled at echolocating silent objects simply by producing mouth clicks and listening to the returning echoes. It has been shown that blind echolocation experts use what is normally the "visual" part of their brain to process the echoes.[48][49] Government actions are sometimes taken to make public places more accessible to blind people. Public transportation is freely available to the blind in many cities. Tactile paving and audible traffic signals can make it easier and safer for visually impaired pedestrians to cross streets. In addition to making rules about who can and cannot use a cane, some governments mandate the right-of-way be given to users of white canes or guide dogs. Reading and magnification   Braille watch Most visually impaired people who are not totally blind read print, either of a regular size or enlarged by magnification devices. Many also read large-print, which is easier for them to read without such devices. A variety of magnifying glasses, some handheld, and some on desktops, can make reading easier for them. Others read Braille (or the infrequently used Moon type), or rely on talking books and readers or reading machines, which convert printed text to speech or Braille. They use computers with special hardware such as scanners and refreshable Braille displays as well as software written specifically for the blind, such as optical character recognition applications and screen readers. Some people access these materials through agencies for the blind, such as the National Library Service for the Blind and Physically Handicapped in the United States, the National Library for the Blind or the RNIB in the United Kingdom. Closed-circuit televisions, equipment that enlarges and contrasts textual items, are a more high-tech alternative to traditional magnification devices. There are also over 100 radio reading services throughout the world that provide people with vision impairments with readings from periodicals over the radio. The International Association of Audio Information Services provides links to all of these organizations. Computers and mobile technology Access technology such as screen readers, screen magnifiers and refreshable Braille displays enable the blind to use mainstream computer applications and mobile phones. The availability of assistive technology is increasing, accompanied by concerted efforts to ensure the accessibility of information technology to all potential users, including the blind. Later versions of Microsoft Windows include an Accessibility Wizard & Magnifier for those with partial vision, and Microsoft Narrator, a simple screen reader. Linux distributions (as live CDs) for the blind include Vinux and Adriane Knoppix, the latter developed in part by Adriane Knopper who has a visual impairment. macOS and iOS also come with a built-in screen reader called VoiceOver, while Google TalkBack is built in to most Android devices. The movement towards greater web accessibility is opening a far wider number of websites to adaptive technology, making the web a more inviting place for visually impaired surfers. Experimental approaches in sensory substitution are beginning to provide access to arbitrary live views from a camera. Modified visual output that includes large print and/or clear simple graphics can be of benefit to users with some residual vision.[50] Other aids and techniques   A tactile feature on a Canadian banknote Blind people may use talking equipment such as thermometers, watches, clocks, scales, calculators, and compasses. They may also enlarge or mark dials on devices such as ovens and thermostats to make them usable. Other techniques used by blind people to assist them in daily activities include: Adaptations of coins and banknotes so that the value can be determined by touch. For example: In some currencies, such as the euro, the pound sterling and the Indian rupee, the size of a note increases with its value. On US coins, pennies and dimes, and nickels and quarters are similar in size. The larger denominations (dimes and quarters) have ridges along the sides (historically used to prevent the "shaving" of precious metals from the coins), which can now be used for identification. Some currencies' banknotes have a tactile feature to indicate denomination. For example, the Canadian currency tactile feature is a system of raised dots in one corner, based on Braille cells but not standard Braille.[51] It is also possible to fold notes in different ways to assist recognition. Labeling and tagging clothing and other personal items Placing different types of food at different positions on a dinner plate Marking controls of household appliances Most people, once they have been visually impaired for long enough, devise their own adaptive strategies in all areas of personal and professional management. For the blind, there are books in braille, audio-books, and text-to-speech computer programs, machines and e-book readers. Low vision people can make use of these tools as well as large-print reading materials and e-book readers that provide large font sizes. Computers are important tools of integration for the visually impaired person. They allow, using standard or specific programs, screen magnification and conversion of text into sound or touch (Braille line), and are useful for all levels of visual handicap. OCR scanners can, in conjunction with text-to-speech software, read the contents of books and documents aloud via computer. Vendors also build closed-circuit televisions that electronically magnify paper, and even change its contrast and color, for visually impaired users. For more information, consult Assistive technology. In adults with low vision there is no conclusive evidence supporting one form of reading aid over another.[52] In several studies stand-mounted devices allowed faster reading than hand-held or portable optical aids.[52] While electronic aids may allow faster reading for individuals with low vision, portability, ease of use, and affordability must be considered for people.[52] Children with low vision sometimes have reading delays, but do benefit from phonics-based beginning reading instruction methods. Engaging phonics instruction is multisensory, highly motivating, and hands-on. Typically students are first taught the most frequent sounds of the alphabet letters, especially the so-called short vowel sounds, then taught to blend sounds together with three-letter consonant-vowel-consonant words such as cat, red, sit, hot, sun. Hands-on (or kinesthetically appealing) VERY enlarged print materials such as those found in "The Big Collection of Phonics Flipbooks" by Lynn Gordon (Scholastic, 2010) are helpful for teaching word families and blending skills to beginning readers with low vision. Beginning reading instructional materials should focus primarily on the lower-case letters, not the capital letters (even though they are larger) because reading text requires familiarity (mostly) with lower-case letters. Phonics-based beginning reading should also be supplemented with phonemic awareness lessons, writing opportunities, and lots of read-alouds (literature read to children daily) to stimulate motivation, vocabulary development, concept development, and comprehension skill development. Many children with low vision can be successfully included in regular education environments. Parents may need to be vigilant to ensure that the school provides the teacher and students with appropriate low vision resources, for example technology in the classroom, classroom aide time, modified educational materials, and consultation assistance with low vision experts. Communication Communication with the visually impaired can be more difficult than communicating with someone who doesn't have vision loss. However, many people are uncomfortable with communicating with the blind, and this can cause communication barriers. One of the biggest obstacles in communicating with visually impaired individuals comes from face-to-face interactions.[53] There are many factors that can cause the sighted to become uncomfortable while communicating face to face. There are many non-verbal factors that hinder communication between the visually impaired and the sighted, more often than verbal factors do. These factors, which Rivka Bialistock[53] mentions in her article, include: Lack of facial expressions, mimics, or body gestures/responses Non-verbal gestures that could imply the visually impaired individual not appearing interested Speaking when not anticipated or not speaking when anticipated Fear of offending the visually impaired Standing too close and invading the personal comfort level Having to exercise or ignore feelings of pity Being uncomfortable with touching objects or people A look of detachment or disengagement Dependency Being reminded of the fear of becoming blind The blind person sends these signals or types of non-verbal communication without being aware that they are doing so. These factors can all affect the way an individual would feel about communicating with the visually impaired. This leaves the visually impaired feeling rejected and lonely. Adjusting attitude In the article Towards better communication, from the interest point of view. Or—skills of sight-glish for the blind and visually impaired, the author, Rivka Bialistock [53] comes up with a method to reduce individuals being uncomfortable with communicating with the visually impaired. This method is called blind-glish or sight-glish, which is a language for the blind, similar to English. For example, babies, who are not born and able to talk right away, communicate through sight-glish, simply seeing everything and communicating non-verbally. This comes naturally to sighted babies, and by teaching this same method to babies with a visual impairment can improve their ability to communicate better, from the very beginning. To avoid the rejected feeling of the visually impaired, people need to treat the blind the same way they would treat anyone else, rather than treating them like they have a disability, and need special attention. People may feel that it is improper to, for example, tell their blind child to look at them when they are speaking. However, this contributes to the sight-glish method.[53] It is important to disregard any mental fears or uncomfortable feelings people have while communicating (verbally and non-verbally) face-to-face. Surroundings Individuals with a visual disability not only have to find ways to communicate effectively with the people around them, but their environment as well. The blind or visually impaired rely largely on their other senses such as hearing, touch, and smell in order to understand their surroundings.[54] Sound Sound is one of the most important senses that the blind or visually impaired use in order to locate objects in their surroundings. A form of echolocation is used, similarly to that of a bat.[55] Echolocation from a person's perspective is when the person uses sound waves generated from speech or other forms of noise such as cane tapping, which reflect off of objects and bounce back at the person giving them a rough idea of where the object is. This does not mean they can depict details based on sound but rather where objects are in order to interact, or avoid them. Increases in atmospheric pressure and humidity increase a person's ability to use sound to their advantage as wind or any form of background noise impairs it.[54] Touch Touch is also an important aspect of how blind or visually impaired people perceive the world. Touch gives immense amount of information in the person's immediate surrounding. Feeling anything with detail gives off information on shape, size, texture, temperature, and many other qualities. Touch also helps with communication; braille is a form of communication in which people use their fingers to feel elevated bumps on a surface and can understand what is meant to be interpreted.[56] There are some issues and limitations with touch as not all objects are accessible to feel, which makes it difficult to perceive the actual object. Another limiting factor is that the learning process of identifying objects with touch is much slower than identifying objects with sight. This is due to the fact the object needs to be approached and carefully felt until a rough idea can be constructed in the brain.[54] Smell Certain smells can be associated with specific areas and help a person with vision problems to remember a familiar area. This way there is a better chance of recognizing an area's layout in order to navigate themselves through. The same can be said for people as well. Some people have their own special odor that a person with a more trained sense of smell can pick up. A person with an impairment of their vision can use this to recognize people within their vicinity without them saying a word.[54] Communication development Visual impairment can have profound effects on the development of infant and child communication. The language and social development of a child or infant can be very delayed by the inability to see the world around them. Social development Social development includes interactions with the people surrounding the infant in the beginning of its life. To a child with vision, a smile from a parent is the first symbol of recognition and communication, and is almost an instant factor of communication. For a visually impaired infant, recognition of a parent's voice will be noticed at approximately two months old, but a smile will only be evoked through touch between parent and baby. This primary form of communication is greatly delayed for the child and will prevent other forms of communication from developing. Social interactions are more complicated because subtle visual cues are missing and facial expressions from others are lost. Due to delays in a child's communication development, they may appear to be disinterested in social activity with peers, non-communicative and uneducated on how to communicate with other people. This may cause the child to be avoided by peers and consequently overprotected by family members. Language development With sight, much of what is learned by a child is learned through imitation of others, whereas a visually impaired child needs very planned instruction directed at the development of postponed imitation. A visually impaired infant may jabber and imitate words sooner than a sighted child, but may show delay when combining words to say themselves, the child may tend to initiate few questions and their use of adjectives is infrequent. Normally the child's sensory experiences are not readily coded into language and this may cause them to store phrases and sentences in their memory and repeat them out of context. The language of the blind child does not seem to mirror their developing knowledge of the world, but rather their knowledge of the language of others. A visually impaired child may also be hesitant to explore the world around them due to fear of the unknown and also may be discouraged from exploration by overprotective family members. Without concrete experiences, the child is not able to develop meaningful concepts or the language to describe or think about them.[57] Healthcare access Visual impairment has the ability to create consequences for health and well being. Visual impairment is increasing, especially among older people. It is recognized that those individuals with visual impairment are likely to have limited access to information and healthcare facilities, and may not receive the best care possible because not all health care professionals are aware of specific needs related to vision. Accommodation may require alternative means of communication.[58] Epidemiology The WHO estimates that in 2012 there were 285 million visually impaired people in the world, of which 246 million had low vision and 39 million were blind.[4] Of those who are blind 90% live in the developing world.[58] Worldwide for each blind person, an average of 3.4 people have low vision, with country and regional variation ranging from 2.4 to 5.5.[59] By age: Visual impairment is unequally distributed across age groups. More than 82% of all people who are blind are 50 years of age and older, although they represent only 19% of the world's population. Due to the expected number of years lived in blindness (blind years), childhood blindness remains a significant problem, with an estimated 1.4 million blind children below age 15. By gender: Available studies consistently indicate that in every region of the world, and at all ages, females have a significantly higher risk of being visually impaired than males. By geography: Visual impairment is not distributed uniformly throughout the world. More than 90% of the world's visually impaired live in developing countries.[59] Since the estimates of the 1990s, new data based on the 2002 global population show a reduction in the number of people who are blind or visually impaired, and those who are blind from the effects of infectious diseases, but an increase in the number of people who are blind from conditions related to longer life spans.[59] In 1987, it was estimated that 598,000 people in the United States met the legal definition of blindness.[60] Of this number, 58% were over the age of 65.[60] In 1994–1995, 1.3 million Americans reported legal blindness.[61] Society and culture See also: List of blind people and Blind musicians Legal definition To determine which people qualify for special assistance because of their visual disabilities, various governments have specific definitions for legal blindness.[62] In North America and most of Europe, legal blindness is defined as visual acuity (vision) of 20/200 (6/60) or less in the better eye with best correction possible. This means that a legally blind individual would have to stand 20 feet (6.1 m) from an object to see it—with corrective lenses—with the same degree of clarity as a normally sighted person could from 200 feet (61 m). In many areas, people with average acuity who nonetheless have a visual field of less than 20 degrees (the norm being 180 degrees) are also classified as being legally blind. Approximately fifteen percent of those deemed legally blind, by any measure, have no light or form perception. The rest have some vision, from light perception alone to relatively good acuity. Low vision is sometimes used to describe visual acuities from 20/70 to 20/200.[63] Literature and art See also: Blindness in literature Antiquity The Moche people of ancient Peru depicted the blind in their ceramics.[64] In Greek myth, Tiresias was a prophet famous for his clairvoyance. According to one myth, he was blinded by the gods as punishment for revealing their secrets, while another holds that he was blinded as punishment after he saw Athena naked while she was bathing. In the Odyssey, the one-eyed Cyclops Polyphemus captures Odysseus, who blinds Polyphemus to escape. In Norse mythology, Loki tricks the blind god Höðr into killing his brother Baldr, the god of happiness. The New Testament contains numerous instances of Jesus performing miracles to heal the blind. According to the Gospels, Jesus healed the two blind men of Galilee, the blind man of Bethsaida, the blind man of Jericho and the man who was born blind. The parable of the blind men and an elephant has crossed between many religious traditions and is part of Jain, Buddhist, Sufi and Hindu lore. In various versions of the tale, a group of blind men (or men in the dark) touch an elephant to learn what it is like. Each one feels a different part, but only one part, such as the side or the tusk. They then compare notes and learn that they are in complete disagreement. "Three Blind Mice" is a medieval English nursery rhyme about three blind mice whose tails are cut off after chasing the farmer's wife. The work is explicitly incongruous, ending with the comment Did you ever see such a sight in your life, As three blind mice? Modern times   Blind Woman by Diego Velázquez   The Sense of Touch by Jusepe de Ribera depicts a blind man holding a marble head in his hands. Poet John Milton, who went blind in mid-life, composed On His Blindness, a sonnet about coping with blindness. The work posits that [those] who best Bear [God]'s mild yoke, they serve him best. The Dutch painter and engraver Rembrandt often depicted scenes from the apocryphal Book of Tobit, which tells the story of a blind patriarch who is healed by his son, Tobias, with the help of the archangel Raphael.[65] Slaver-turned-abolitionist John Newton composed the hymn Amazing Grace about a wretch who "once was lost, but now am found, Was blind, but now I see." Blindness, in this sense, is used both metaphorically (to refer to someone who was ignorant but later became knowledgeable) and literally, as a reference to those healed in the Bible. In the later years of his life, Newton himself would go blind. H. G. Wells' story "The Country of the Blind" explores what would happen if a sighted man found himself trapped in a country of blind people to emphasise society's attitude to blind people by turning the situation on its head. Bob Dylan's anti-war song "Blowin' in the Wind" twice alludes to metaphorical blindness: How many times can a man turn his head // and pretend that he just doesn't see... How many times must a man look up // Before he can see the sky? Contemporary fiction contains numerous well-known blind characters. Some of these characters can see by means of devices, such as the Marvel Comics superhero Daredevil, who can see via his super-human hearing acuity, or Star Trek's Geordi La Forge, who can see with the aid of a VISOR, a fictional device that transmits optical signals to his brain. Sports Blind and partially sighted people participate in sports, such as swimming, snow skiing and athletics. Some sports have been invented or adapted for the blind, such as goalball, association football, cricket, golf, tennis, bowling, and beep baseball.[66][67] The worldwide authority on sports for the blind is the International Blind Sports Federation.[68][69] People with vision impairments have participated in the Paralympic Games since the 1976 Toronto summer Paralympics.[70] Metaphorical uses The word "blind" (adjective and verb) is often used to signify a lack of knowledge of something. For example, a blind date is a date in which the people involved have not previously met; a blind experiment is one in which information is kept from either the experimenter or the participant to mitigate the placebo effect or observer bias. The expression "blind leading the blind" refers to incapable people leading other incapable people. Being blind to something means not understanding or being aware of it. A "blind spot" is an area where someone cannot see: for example, where a car driver cannot see because parts of his car's bodywork are in the way; metaphorically, a topic on which an individual is unaware of their own biases, and therefore of the resulting distortions of their own judgements (see Bias blind spot). Research Main article: Visual prosthesis A 2008 study tested the effect of using gene therapy to help restore the sight of patients with a rare form of inherited blindness, known as Leber's congenital amaurosis or LCA.[71] Leber's Congenital Amaurosis damages the light receptors in the retina and usually begins affecting sight in early childhood, with worsening vision until complete blindness around the age of 30. The study used a common cold virus to deliver a normal version of the gene called RPE65 directly into the eyes of affected patients. Remarkably, all 3 patients, aged 19, 22 and 25, responded well to the treatment and reported improved vision following the procedure. Due to the age of the patients and the degenerative nature of LCA, the improvement of vision in gene therapy patients is encouraging for researchers. It is hoped that gene therapy may be even more effective in younger LCA patients who have experienced limited vision loss, as well as in other blind or partially blind individuals. Two experimental treatments for retinal problems include a cybernetic replacement and transplant of fetal retinal cells.[72] Other animals Main article: Blindness in animals Statements that certain species of mammals are "born blind" refers to them being born with their eyes closed and their eyelids fused together; the eyes open later. One example is the rabbit. In humans, the eyelids are fused for a while before birth, but open again before the normal birth time; however, very premature babies are sometimes born with their eyes fused shut, and opening later. Other animals, such as the blind mole rat, are truly blind and rely on other senses.[citation needed] The theme of blind animals has been a powerful one in literature. Peter Shaffer's Tony Award-winning play, Equus, tells the story of a boy who blinds six horses. Theodore Taylor's classic young adult novel, The Trouble With Tuck, is about a teenage girl, Helen, who trains her blind dog to follow and trust a seeing-eye dog. See also Acute visual loss Blindness and education Color blindness Diplopia Nyctalopia Recovery from blindness Stereoblindness Tactile alphabet Tactile graphic Tangible symbol systems Visual agnosia Visual impairment due to intracranial pressure World Blind Union References   "Change the Definition of Blindness" (PDF). World Health Organization. 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Massachusetts Medical Society. 358 (21): 2231–9. doi:10.1056/NEJMoa0802268. PMID 18441371.   Hamilton, Jon (20 October 2009). "Bionic Eye Opens New World Of Sight For Blind". NPR. Retrieved 9 March 2019. External links Wikimedia Commons has media related to Visual disturbances and blindness. Blindness at Curlie Chisholm, Hugh, ed. (1911). "Blindness" . Encyclopædia Britannica (11th ed.). Cambridge University Press
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    • Dont forget to like and subscribe to the scammer section on traders labotomy   Lobotomy From Wikipedia, the free encyclopedia     Jump to navigation Jump to search Not to be confused with Lobectomy. Lobotomy "Dr. Walter Freeman, left, and Dr. James W. Watts study an X ray before a psychosurgical operation. Psychosurgery is cutting into the brain to form new patterns and rid a patient of delusions, obsessions, nervous tensions and the like." Waldemar Kaempffert, "Turning the Mind Inside Out", Saturday Evening Post, 24 May 1941.[1] Other names Leukotomy, leucotomy ICD-9-CM 01.32 MeSH D011612 [edit on Wikidata] A lobotomy, or leucotomy, is a form of psychosurgery, a neurosurgical treatment of a mental disorder that involves severing connections in the brain's prefrontal cortex.[2] Most of the connections to and from the prefrontal cortex, the anterior part of the frontal lobes of the brain, are severed. It was used for psychiatric and occasionally other conditions as a mainstream procedure in some Western countries for more than two decades, despite general recognition of frequent and serious side effects. While some people experienced symptomatic improvement with the operation, the improvements were achieved at the cost of creating other impairments. The procedure was controversial from its initial use in part due to the balance between benefits and risks. Today, lobotomy has become a disparaged procedure, a byword for medical barbarism and an exemplary instance of the medical trampling of patients' rights.[3] The originator of the procedure, Portuguese neurologist António Egas Moniz, shared the Nobel Prize for Physiology or Medicine of 1949 for the "discovery of the therapeutic value of leucotomy in certain psychoses",[n 1] although the awarding of the prize has been subject to controversy.[5] The use of the procedure increased dramatically from the early 1940s and into the 1950s; by 1951, almost 20,000 lobotomies had been performed in the United States and proportionally more in the United Kingdom.[6] The majority of lobotomies were performed on women; a 1951 study of American hospitals found nearly 60% of lobotomy patients were women; limited data shows 74% of lobotomies in Ontario from 1948–1952 were performed on women.[7][8][9] From the 1950s onward lobotomy began to be abandoned,[10] first in the Soviet Union[11] and Europe.[12] The term is derived from Greek: λοβός lobos "lobe" and τομή tomē "cut, slice". Contents 1 Effects 2 History 2.1 Early psychosurgery 2.2 Development 3 Reception 3.1 Italian leucotomy 3.2 American leucotomy 3.3 Transorbital lobotomy 4 Prevalence 5 Criticism 6 Notable cases 7 Literary and cinematic portrayals 8 See also 9 Notes 10 Citations 11 Sources 12 External links Effects I fully realize that this operation will have little effect on her mental condition but am willing to have it done in the hope that she will be more comfortable and easier to care for. Comments added to the consent form for a lobotomy operation on "Helaine Strauss",[n 2] "a patient at an elite private hospital".[13] The purpose of the operation was to reduce the symptoms of mental disorders, and it was recognized that this was accomplished at the expense of a person's personality and intellect. British psychiatrist Maurice Partridge, who conducted a follow-up study of 300 patients, said that the treatment achieved its effects by "reducing the complexity of psychic life". Following the operation, spontaneity, responsiveness, self-awareness, and self-control were reduced. The activity was replaced by inertia, and people were left emotionally blunted and restricted in their intellectual range.[14] The consequences of the operation have been described as "mixed".[15] Some patients died as a result of the operation and others later committed suicide. Some were left severely brain-damaged. Others were able to leave the hospital, or became more manageable within the hospital.[15] A few people managed to return to responsible work, while at the other extreme people were left with severe and disabling impairments.[16] Most people fell into an intermediate group, left with some improvement of their symptoms but also with emotional and intellectual deficits to which they made a better or worse adjustment.[16] On average, there was a mortality rate of approximately 5 percent during the 1940s.[16] The lobotomy procedure could have severe negative effects on a patient's personality and ability to function independently.[17] Lobotomy patients often show a marked reduction in initiative and inhibition.[18] They may also exhibit difficulty putting themselves in the position of others because of decreased cognition and detachment from society.[19] Immediately following surgery, patients were often stuporous, confused, and incontinent. Some developed an enormous appetite and gained considerable weight. Seizures were another common complication of surgery. Emphasis was put on the training of patients in the weeks and months following surgery.[20] Walter Freeman coined the term "surgically induced childhood" and used it constantly to refer to the results of lobotomy. The operation left people with an "infantile personality"; a period of maturation would then, according to Freeman, lead to recovery. In an unpublished memoir, he described how the "personality of the patient was changed in some way in the hope of rendering him more amenable to the social pressures under which he is supposed to exist". He described one 29-year-old woman as being, following lobotomy, a "smiling, lazy and satisfactory patient with the personality of an oyster" who could not remember Freeman's name and endlessly poured coffee from an empty pot. When her parents had difficulty dealing with her behavior, Freeman advised a system of rewards (ice-cream) and punishment (smacks).[21] History   Insulin shock therapy administered in Helsinki in the 1950s In the early 20th century, the number of patients residing in mental hospitals increased significantly[n 3] while little in the way of effective medical treatment was available.[n 4][27] Lobotomy was one of a series of radical and invasive physical therapies developed in Europe at this time that signaled a break with a psychiatric culture of therapeutic nihilism that had prevailed since the late nineteenth-century.[28] The new "heroic" physical therapies devised during this experimental era,[29] including malarial therapy for general paresis of the insane (1917),[30]deep sleep therapy (1920), insulin shock therapy (1933), cardiazol shock therapy (1934), and electroconvulsive therapy (1938),[31] helped to imbue the then therapeutically moribund and demoralised psychiatric profession with a renewed sense of optimism in the curability of insanity and the potency of their craft.[32] The success of the shock therapies, despite the considerable risk they posed to patients, also helped to accommodate psychiatrists to ever more drastic forms of medical intervention, including lobotomy.[29] The clinician-historian Joel Braslow argues that from malarial therapy onward to lobotomy, physical psychiatric therapies "spiral closer and closer to the interior of the brain" with this organ increasingly taking "center stage as a source of disease and site of cure."[33] For Roy Porter, once the doyen of medical history,[34] the often violent and invasive psychiatric interventions developed during the 1930s and 1940s are indicative of both the well-intentioned desire of psychiatrists to find some medical means of alleviating the suffering of the vast number of patients then in psychiatric hospitals and also the relative lack of social power of those same patients to resist the increasingly radical and even reckless interventions of asylum doctors.[35] Many doctors, patients and family members of the period believed that despite potentially catastrophic consequences, the results of lobotomy were seemingly positive in many instances or, at least they were deemed as such when measured next to the apparent alternative of long-term institutionalisation. Lobotomy has always been controversial, but for a period of the medical mainstream, it was even feted and regarded as a legitimate last resort remedy for categories of patients who were otherwise regarded as hopeless.[36] Today, lobotomy has become a disparaged procedure, a byword for medical barbarism and an exemplary instance of the medical trampling of patients' rights.[3] Early psychosurgery   Gottlieb Burckhardt (1836–1907) Before the 1930s, individual doctors had infrequently experimented with novel surgical operations on the brains of those deemed insane. Most notably in 1888, the Swiss psychiatrist, Gottlieb Burckhardt, initiated what is commonly considered the first systematic attempt at modern human psychosurgery.[37] He operated on six chronic patients under his care at the Swiss Préfargier Asylum, removing sections of their cerebral cortex. Burckhardt's decision to operate was informed by three pervasive views on the nature of mental illness and its relationship to the brain. First, the belief that mental illness was organic in nature, and reflected an underlying brain pathology; next, that the nervous system was organized according to an associationist model comprising an input or afferent system (a sensory center), a connecting system where information processing took place (an association center), and an output or efferent system (a motor center); and, finally, a modular conception of the brain whereby discrete mental faculties were connected to specific regions of the brain.[38] Burckhardt's hypothesis was that by deliberately creating lesions in regions of the brain identified as association centers a transformation in behavior might ensue.[38] According to his model, those mentally ill might experience "excitations abnormal in quality, quantity and intensity" in the sensory regions of the brain and this abnormal stimulation would then be transmitted to the motor regions giving rise to mental pathology.[39] He reasoned, however, that removing material from either of the sensory or motor zones could give rise to "grave functional disturbance".[39] Instead, by targeting the association centers and creating a "ditch" around the motor region of the temporal lobe, he hoped to break their lines of communication and thus alleviate both mental symptoms and the experience of mental distress.[40]   Ludvig Puusepp c. 1920 Intending to ameliorate symptoms in those with violent and intractable conditions rather than effect a cure,[41] Burckhardt began operating on patients in December 1888,[42] but both his surgical methods and instruments were crude and the results of the procedure were mixed at best.[39] He operated on six patients in total and, according to his own assessment, two experienced no change, two patients became quieter, one patient experienced epileptic convulsions and died a few days after the operation, and one patient improved.[n 5] Complications included motor weakness, epilepsy, sensory aphasia and "word deafness".[44] Claiming a success rate of 50 percent,[45] he presented the results at the Berlin Medical Congress and published a report, but the response from his medical peers was hostile and he did no further operations.[46] In 1912, two physicians based in Saint Petersburg, the leading Russian neurologist Vladimir Bekhterev and his younger Estonian colleague, the neurosurgeon Ludvig Puusepp, published a paper reviewing a range of surgical interventions that had been performed on the mentally ill.[47] While generally treating these endeavours favorably, in their consideration of psychosurgery they reserved unremitting scorn for Burckhardt's surgical experiments of 1888 and opined that it was extraordinary that a trained medical doctor could undertake such an unsound procedure.[48] The authors neglected to mention, however, that in 1910 Puusepp himself had performed surgery on the brains of three mentally ill patients,[n 6][51] sectioning the cortex between the frontal and parietal lobes.[52] He had abandoned these attempts because of unsatisfactory results and this experience probably inspired the invective that was directed at Burckhardt in the 1912 article.[48] By 1937, Puusepp, despite his earlier criticism of Burckhardt, was increasingly persuaded that psychosurgery could be a valid medical intervention for the mentally disturbed.[n 7][54] In the late 1930s he worked closely with the neurosurgical team of the Racconigi Hospital near Turin to establish it as an early and influential centre for the adoption of leucotomy in Italy.[55] Development   Egas Moniz Leucotomy was first undertaken in 1935 under the direction of the Portuguese neurologist (and inventor of the term psychosurgery) António Egas Moniz.[n 8][59] First developing an interest in psychiatric conditions and their somatic treatment in the early 1930s,[60] Moniz apparently conceived a new opportunity for recognition in the development of a surgical intervention on the brain as a treatment for mental illness.[41] 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.[61] 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 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.[62] 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.[63] At the 1935 Congress, with Moniz in attendance,[n 9] Fulton and Jacobsen presented two chimpanzees, named Becky and Lucy who had had frontal lobectomies and subsequent changes in behaviour and intellectual function.[64] 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" – that is, have tantrums that could include rolling on the floor and defecating – if, because of their poor performance in a set of experimental tasks, they were not rewarded.[65] 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".[64] 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.[66]   Brain animation: left frontal lobe highlighted in red. Moniz targeted the frontal lobes in the leucotomy procedure he first conceived in 1933. That Moniz began his experiments with leucotomy just three months after the congress has 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.[67] 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.[68] 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.[69] In fact, Moniz stated that he had conceived of the operation some time 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.[70] 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.[71] As the frontal lobes had been the object of scientific inquiry and speculation since the late 19th century, Fulton's contribution, while it may have functioned as source of intellectual support, is of itself unnecessary and inadequate as an explanation of Moniz's resolution to operate on this section of the brain.[72] Under an evolutionary and hierarchical model of brain development it had been hypothesized that those regions associated with more recent development, such as the mammalian brain and, most especially, the frontal lobes, were responsible for more complex cognitive functions.[73] 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.[73] 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 who had suffered brain trauma. The refinement of neurosurgical techniques also facilitated increasing attempts to remove brain tumours, treat focal epilepsy in humans and led to more precise experimental neurosurgery in animal studies.[73] Cases were reported where mental symptoms were alleviated following the surgical removal of diseased or damaged brain tissue.[52] The accumulation of medical case studies on behavioural changes following damage to the frontal lobes led to the formulation of the concept of Witzelsucht, which designated a neurological condition characterised by a certain hilarity and childishness in the afflicted.[73] 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.[73] 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.[74] This work, while influential, was not without its critics due to deficiencies in experimental design.[73] The first bilateral lobectomy of a human subject was performed by the American neurosurgeon Walter Dandy in 1930.[n 10][75] The neurologist Richard Brickner reported on this case in 1932,[76] relating that the recipient, known as "Patient A", while experiencing a flattening of affect, had suffered no apparent decrease in intellectual function and seemed, at least to the casual observer, perfectly normal.[77] Brickner concluded from this evidence that "the frontal lobes are not 'centers' for the intellect".[78] These clinical results were replicated in a similar operation undertaken in 1934 by the neurosurgeon Roy Glenwood Spurling and reported on by the neuropsychiatrist Spafford Ackerly.[79] 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[79] as part of its deliberations,[79] "a remarkable symposium ... on the functions of the frontal lobes."[80] 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".[78] This parallel symposium contained numerous papers by neurologists, neurosurgeons and psychologists; amongst these was one by Brickner, which impressed Moniz greatly,[77] that again detailed the case of "Patient A".[79] 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.[79] 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.[81] Nor was Moniz the only medical practitioner in the 1930s to have contemplated procedures directly targeting the frontal lobes.[82] Although ultimately discounting brain surgery as carrying too much risk, physicians and neurologists such as William Mayo, Thierry de Martel, Richard Brickner, and Leo Davidoff had, before 1935, entertained the proposition.[n 11][84] 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 ml of malarial blood directly into the frontal lobes of over 100 paretic patients through holes drilled into the skull.[82] He claimed that the injected paretics showed signs of "uncontestable mental and physical amelioration" and that the results for psychotic patients undergoing the procedure was also "encouraging".[85] 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.[86] 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 schizophrenic patient.[87] In Romania, Ody's procedure was adopted by Dimitri Bagdasar and Constantinesco working out of the Central Hospital in Bucharest.[83] 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".[88] Neurological model The theoretical underpinnings of Moniz's psychosurgery were largely commensurate with the nineteenth century ones that had informed Burckhardt's decision to excise matter from the brains of his patients. Although in his later writings Moniz referenced both the neuron theory of Ramón y Cajal and the conditioned reflex of Ivan Pavlov,[89] in essence he simply interpreted this new neurological research in terms of the old psychological theory of associationism.[61] He differed significantly from Burckhardt, however in that he did not think there was any organic pathology in the brains of the mentally ill, but rather that their neural pathways were caught in fixed and destructive circuits leading to "predominant, obsessive ideas."[n 12][91] As Moniz wrote in 1936: For Moniz, "to cure these patients," it was necessary to "destroy the more or less fixed arrangements of cellular connections that exist in the brain, and particularly those which are related to the frontal lobes,"[93] thus removing their fixed pathological brain circuits. Moniz believed the brain would functionally adapt to such injury.[94] A significant advantage of this approach was that, unlike the position adopted by Burckhardt, it was unfalsifiable according to the knowledge and technology of the time as the absence of a known correlation between physical brain pathology and mental illness could not disprove his thesis.[95] First leucotomies The hypotheses underlying the procedure might be called into question; the surgical intervention might be considered very audacious; but such arguments occupy a secondary position because it can be affirmed now that these operations are not prejudicial to either physical or psychic life of the patient, and also that recovery or improvement may be obtained frequently in this way Egas Moniz (1937)[96] On 12 November 1935 at the Hospital Santa Marta in Lisbon, Moniz initiated the first of a series of operations on the brains of the mentally ill.[97] The initial patients selected for the operation were provided by the medical director of Lisbon's Miguel Bombarda Mental Hospital, José de Matos Sobral Cid.[98] As Moniz lacked training in neurosurgery and his hands were crippled from gout, the procedure was performed under general anaesthetic by Pedro Almeida Lima, who had previously assisted Moniz with his research on cerebral angiography.[n 13][100] The intention was to remove some of the long fibres that connected the frontal lobes to other major brain centres.[101] To this end, it was decided that Lima would trephine into the side of the skull and then inject ethanol into the "subcortical white matter of the prefrontal area"[96] so as to destroy the connecting fibres, or association tracts,[102] and create what Moniz termed a "frontal barrier".[n 14][103] After the first operation was complete, Moniz considered it a success and, observing that the patient's depression had been relieved, he declared her "cured" although she was never, in fact, discharged from the mental hospital.[104] Moniz and Lima persisted with this method of injecting alcohol into the frontal lobes for the next seven patients but, after having to inject some patients on numerous occasions to elicit what they considered a favourable result, they modified the means by which they would section the frontal lobes.[104] For the ninth patient they introduced a surgical instrument called a leucotome; this was a cannula that was 11 centimetres (4.3 in) in length and 2 centimetres (0.79 in) in diameter. It had a retractable wire loop at one end that, when rotated, produced a 1 centimetre (0.39 in) diameter circular lesion in the white matter of the frontal lobe.[105] Typically, six lesions were cut into each lobe, but, if they were dissatisfied by the results, Lima might perform several procedures, each producing multiple lesions in the left and right frontal lobes.[104] By the conclusion of this first run of leucotomies in February 1936, Moniz and Lima had operated on twenty patients with an average period of one week between each procedure; Moniz published his findings with great haste in March of the same year.[106] The patients were aged between 27 and 62 years of age; twelve were female and eight were male. Nine of the patients were diagnosed as suffering from depression, six from schizophrenia, two from panic disorder, and one each from mania, catatonia and manic-depression with the most prominent symptoms being anxiety and agitation. The duration of the illness before the procedure varied from as little as four weeks to as much as 22 years, although all but four had been ill for at least one year.[107] Patients were normally operated on the day they arrived at Moniz's clinic and returned within ten days to the Miguel Bombarda Mental Hospital.[108] A perfunctory post-operative follow-up assessment took place anywhere from one to ten weeks following surgery.[109] Complications were observed in each of the leucotomy patients and included: "increased temperature, vomiting, bladder and bowel incontinence, diarrhea, and ocular affections such as ptosis and nystagmus, as well as psychological effects such as apathy, akinesia, lethargy, timing and local disorientation, kleptomania, and abnormal sensations of hunger".[110] Moniz asserted that these effects were transitory and,[110] according to his published assessment, the outcome for these first twenty patients was that 35%, or seven cases, improved significantly, another 35% were somewhat improved and the remaining 30% (six cases) were unchanged. There were no deaths and he did not consider that any patients had deteriorated following leucotomy.[111] Reception Moniz rapidly disseminated his results through articles in the medical press and a monograph in 1936.[103] Initially, however, the medical community appeared hostile to the new procedure.[112] On 26 July 1936, one of his assistants, Diogo Furtado, gave a presentation at the Parisian meeting of the Société Médico-Psychologique on the results of the second cohort of patients leucotomised by Lima.[103] Sobral Cid, who had supplied Moniz with the first set of patients for leucotomy from his own hospital in Lisbon, attended the meeting and denounced the technique,[112] declaring that the patients who had been returned to his care post-operatively were "diminished" and had suffered a "degradation of personality".[113] He also claimed that the changes Moniz observed in patients were more properly attributed to shock and brain trauma, and he derided the theoretical architecture that Moniz had constructed to support the new procedure as "cerebral mythology."[113] At the same meeting the Parisian psychiatrist, Paul Courbon, stated he could not endorse a surgical technique that was solely supported by theoretical considerations rather than clinical observations.[114] He also opined that the mutilation of an organ could not improve its function and that such cerebral wounds as were occasioned by leucotomy risked the later development of meningitis, epilepsy and brain abscesses.[115] Nonetheless, Moniz's reported successful surgical treatment of 14 out of 20 patients led to the rapid adoption of the procedure on an experimental basis by individual clinicians in countries such as Brazil, Cuba, Italy, Romania and the United States during the 1930s.[116] Italian leucotomy In the present state of affairs if some are critical about lack of caution in therapy, it is, on the other hand, deplorable and inexcusable to remain apathetic, with folded hands, content with learned lucubrations upon symptomatologic minutiae or upon psychopathic curiosities, or even worse, not even doing that. Amarro Fiamberti[117] Throughout the remainder of the 1930s the number of leucotomies performed in most countries where the technique was adopted remained quite low. In Britain, which was later a major centre for leucotomy,[n 15] only six operations had been undertaken before 1942.[119] Generally, medical practitioners who attempted the procedure adopted a cautious approach and few patients were leucotomised before the 1940s. Italian neuropsychiatrists, who were typically early and enthusiastic adopters of leucotomy, were exceptional in eschewing such a gradualist course.[55] Leucotomy was first reported in the Italian medical press in 1936 and Moniz published an article in Italian on the technique in the following year.[55] In 1937, he was invited to Italy to demonstrate the procedure and for a two-week period in June of that year he visited medical centres in Trieste, Ferrara, and one close to Turin – the Racconigi Hospital – where he instructed his Italian neuropsychiatric colleagues on leucotomy and also oversaw several operations.[55] Leucotomy was featured at two Italian psychiatric conferences in 1937 and over the next two years a score of medical articles on Moniz's psychosurgery was published by Italian clinicians based in medical institutions located in Racconigi, Trieste, Naples, Genoa, Milan, Pisa, Catania and Rovigo.[55] The major centre for leucotomy in Italy was the Racconigi Hospital, where the experienced neurosurgeon Ludvig Puusepp provided a guiding hand.[n 16][55] Under the medical directorship of Emilio Rizzatti, the medical personnel at this hospital had completed at least 200 leucotomies by 1939.[121] Reports from clinicians based at other Italian institutions detailed significantly smaller numbers of leucotomy operations.[55] Experimental modifications of Moniz's operation were introduced with little delay by Italian medical practitioners.[122] Most notably, in 1937 Amarro Fiamberti, the medical director of a psychiatric institution in Varese,[123] first devised the transorbital procedure whereby the frontal lobes were accessed through the eye sockets.[122] Fiamberti's method was to puncture the thin layer of orbital bone at the top of the socket and then inject alcohol or formalin into the white matter of the frontal lobes through this aperture.[124] Using this method, while sometimes substituting a leucotome for a hypodermic needle, it is estimated that he leucotomised about 100 patients in the period up to the outbreak of World War II.[123] Fiamberti's innovation of Moniz's method would later prove inspirational for Walter Freeman's development of transorbital lobotomy.[124] American leucotomy   Site of borehole for the standard pre-frontal lobotomy/leucotomy operation as developed by Freeman and Watts The first prefrontal leucotomy in the United States was performed at the George Washington University Hospital on 14 September 1936 by the neurologist Walter Freeman and his friend and colleague, the neurosurgeon, James W. Watts.[125] Freeman had first encountered Moniz at the London-hosted Second International Congress of Neurology in 1935 where he had presented a poster exhibit of the Portuguese neurologist's work on cerebral angiography.[126] Fortuitously occupying a booth next to Moniz, Freeman, delighted by their chance meeting, formed a highly favourable impression of Moniz, later remarking upon his "sheer genius".[126] According to Freeman, if they had not met in person it is highly unlikely that he would have ventured into the domain of frontal lobe psychosurgery.[127] Freeman's interest in psychiatry was the natural outgrowth of his appointment in 1924 as the medical director of the Research Laboratories of the Government Hospital for the Insane in Washington, known colloquially as St Elizabeth's.[128] Ambitious and a prodigious researcher, Freeman, who favoured an organic model of mental illness causation, spent the next several years exhaustively, yet ultimately fruitlessly, investigating a neuropathological basis for insanity.[129] Chancing upon a preliminary communication by Moniz on leucotomy in the spring of 1936, Freeman initiated a correspondence in May of that year. Writing that he had been considering psychiatric brain surgery previously, he informed Moniz that, "having your authority I expect to go ahead".[130] Moniz, in return, promised to send him a copy of his forthcoming monograph on leucotomy and urged him to purchase a leucotome from a French supplier.[131] Upon receipt of Moniz's monograph, Freeman reviewed it anonymously for the Archives of Neurology and Psychiatry.[131] Praising the text as one whose "importance can scarcely be overestimated",[131] he summarised Moniz's rationale for the procedure as based on the fact that while no physical abnormality of cerebral cell bodies was observable in the mentally ill, their cellular interconnections may harbour a "fixation of certain patterns of relationship among various groups of cells" and that this resulted in obsessions, delusions and mental morbidity.[132] While recognising that Moniz's thesis was inadequate, for Freeman it had the advantage of circumventing the search for diseased brain tissue in the mentally ill by instead suggesting that the problem was a functional one of the brain's internal wiring where relief might be obtained by severing problematic mental circuits.[132] In 1937 Freeman and Watts adapted Lima and Moniz's surgical procedure, and created the Freeman-Watts technique, also known as the Freeman-Watts standard prefrontal lobotomy, which they styled the "precision method".[133] Transorbital lobotomy   Orbitoclast, used in transorbital lobotomy[n 17] The Freeman-Watts prefrontal lobotomy still required drilling holes in the scalp, so surgery had to be performed in an operating room by trained neurosurgeons. Walter Freeman believed this surgery would be unavailable to those he saw as needing it most: patients in state mental hospitals that had no operating rooms, surgeons, or anesthesia and limited budgets. Freeman wanted to simplify the procedure so that it could be carried out by psychiatrists in psychiatric hospitals.[135] Inspired by the work of Italian psychiatrist Amarro Fiamberti, Freeman at some point conceived of approaching the frontal lobes through the eye sockets instead of through drilled holes in the skull. In 1945 he took an icepick[n 18] from his own kitchen and began testing the idea on grapefruit[n 19] and cadavers. This new "transorbital" lobotomy involved lifting the upper eyelid and placing the point of a thin surgical instrument (often called an orbitoclast or leucotome, although quite different from the wire loop leucotome described above) under the eyelid and against the top of the eyesocket. A mallet was used to drive the orbitoclast through the thin layer of bone and into the brain along the plane of the bridge of the nose, around 15 degrees toward the interhemispherical fissure. The orbitoclast was malleted 5 centimeters (2 in) into the frontal lobe, and then pivoted 40 degrees at the orbit perforation so the tip cut toward the opposite side of the head (toward the nose). The instrument was returned to the neutral position and sent a further 2 centimeters (4⁄5 in) into the brain, before being pivoted around 28 degrees each side, to cut outwards and again inwards. (In a more radical variation at the end of the last cut described, the butt of the orbitoclast was forced upwards so the tool cut vertically down the side of the cortex of the interhemispherical fissure; the "Deep Frontal Cut".) All cuts were designed to transect the white fibrous matter connecting the cortical tissue of the prefrontal cortex to the thalamus. The leucotome was then withdrawn and the procedure repeated on the other side.[citation needed] Freeman performed the first transorbital lobotomy on a live patient in 1946. Its simplicity suggested the possibility of carrying it out in mental hospitals lacking the surgical facilities required for the earlier, more complex procedure. (Freeman suggested that, where conventional anesthesia was unavailable, electroconvulsive therapy be used to render the patient unconscious.)[137] In 1947, the Freeman and Watts partnership ended, as the latter was disgusted by Freeman's modification of the lobotomy from a surgical operation into a simple "office" procedure.[138] Between 1940 and 1944, 684 lobotomies were performed in the United States. However, because of the fervent promotion of the technique by Freeman and Watts, those numbers increased sharply towards the end of the decade. In 1949, the peak year for lobotomies in the US, 5,074 procedures were undertaken, and by 1951 over 18,608 individuals had been lobotomized in the US.[139] Prevalence In the United States, approximately 40,000 people were lobotomized. In England, 17,000 lobotomies were performed, and the three Nordic countries of Denmark, Norway, and Sweden had a combined figure of approximately 9,300 lobotomies.[140] Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the US.[141] Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women. This figure includes young children.[142] In Norway, there were 2,005 known lobotomies.[143] In Denmark, there were 4,500 known lobotomies.[144] In Japan, the majority of lobotomies were performed on children with behavior problems. The Soviet Union banned the practice in 1950 on moral grounds and Japan soon followed suit. In Germany it was performed only a few times.[145] By the late 1970s, the practice of lobotomy had generally ceased, although it continued as late as the 1980s in France.[146] Criticism As early as 1944 an author in the Journal of Nervous and Mental Disease remarked: "The history of prefrontal lobotomy has been brief and stormy. Its course has been dotted with both violent opposition and with slavish, unquestioning acceptance." Beginning in 1947 Swedish psychiatrist Snorre Wohlfahrt evaluated early trials, reporting that it is "distinctly hazardous to leucotomize schizophrenics" and that lobotomy was "still too imperfect to enable us, with its aid, to venture on a general offensive against chronic cases of mental disorder", stating further that "Psychosurgery has as yet failed to discover its precise indications and contraindications and the methods must unfortunately still be regarded as rather crude and hazardous in many respects."[147] In 1948 Norbert Wiener, the author of Cybernetics: Or the Control and Communication in the Animal and the Machine, said: "[P]refrontal lobotomy ... has recently been having a certain vogue, probably not unconnected with the fact that it makes the custodial care of many patients easier. Let me remark in passing that killing them makes their custodial care still easier."[148] Concerns about lobotomy steadily grew. Soviet psychiatrist Vasily Gilyarovsky criticized lobotomy and the mechanistic brain localization assumption used to carry out lobotomy: "It is assumed that the transection of white substance of the frontal lobes impairs their connection with the thalamus and eliminates the possibility to receive from it stimuli which lead to irritation and on the whole derange mental functions. This explanation is mechanistic and goes back to the narrow localizationism characteristic of psychiatrists of America, from where leucotomy was imported to us."[149] The USSR officially banned the procedure in 1950[150] on the initiative of Gilyarovsky.[151] Doctors in the Soviet Union concluded that the procedure was "contrary to the principles of humanity" and "'through lobotomy' an insane person is changed into an idiot."[152] By the 1970s, numerous countries had banned the procedure as had several US states.[153] In 1977 the US Congress, during the presidency of Jimmy Carter, created the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery—including lobotomy techniques—was used to control minorities and restrain individual rights. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects.[154] There have been calls in the early 21st century for the Nobel Foundation to rescind the prize it awarded to Moniz for developing lobotomy, a decision that has been called an astounding error of judgment at the time and one that psychiatry might still need to learn from, but the Foundation declined to take action and has continued to host an article defending the results of the procedure.[155][5] Notable cases See also: Category:Lobotomised people. Rosemary Kennedy, sister of President John F. Kennedy, underwent a lobotomy in 1941 that left her incapacitated and institutionalized for the rest of her life.[156] Howard Dully wrote a memoir of his late-life discovery that he had been lobotomized in 1960 at age 12.[157] New Zealand author and poet Janet Frame received a literary award in 1951 the day before a scheduled lobotomy was to take place, and it was never performed.[158] Josef Hassid, a Polish violinist and composer, was diagnosed with schizophrenia and died at the age of 26 following a lobotomy.[159] Swedish modernist painter Sigrid Hjertén died following a lobotomy in 1948.[160] American playwright Tennessee Williams' older sister Rose received a lobotomy that left her incapacitated for life; the episode is said to have inspired characters and motifs in certain works of his.[161] It is often said that when an iron rod was accidentally driven through the head of Phineas Gage in 1848, this constituted an "accidental lobotomy", or that this event somehow inspired the development of surgical lobotomy a century later. According to the only book-length study of Gage, careful inquiry turns up no such link.[162] In 2011, Daniel Nijensohn, an Argentine-born neurosurgeon at Yale, examined X-rays of Eva Peron and concluded that she underwent a lobotomy for the treatment of pain and anxiety in the last months of her life.[163] Literary and cinematic portrayals Lobotomies have been featured in several literary and cinematic presentations that both reflected society's attitude towards the procedure and, at times, changed it. Writers and film-makers have played a pivotal role in turning public sentiment against the procedure.[5] Robert Penn Warren's 1946 novel All the King's Men describes a lobotomy as making "a Comanche brave look like a tyro with a scalping knife," and portrays the surgeon as a repressed man who cannot change others with love, so he instead resorts to "high-grade carpentry work".[164] Tennessee Williams criticized lobotomy in his play Suddenly, Last Summer (1958) because it was sometimes inflicted on homosexuals—to render them "morally sane".[5] In the play a wealthy matriarch offers the local mental hospital a substantial donation if the hospital will give her niece a lobotomy, which she hopes will stop the niece's shocking revelations about the matriarch's son.[165] Warned that a lobotomy might not stop her niece's "babbling," she responds, "That may be, maybe not, but after the operation who would believe her, Doctor?"[166] In Ken Kesey's 1962 novel One Flew Over the Cuckoo's Nest and its 1975 film adaptation, lobotomy is described as "frontal-lobe castration", a form of punishment and control after which "There's nothin' in the face. Just like one of those store dummies." In one patient, "You can see by his eyes how they burned him out over there; his eyes are all smoked up and gray and deserted inside."[164] In Sylvia Plath's 1963 novel The Bell Jar, the protagonist reacts with horror to the "perpetual marble calm" of a lobotomized young woman.[164] Elliott Baker's 1964 novel and 1966 film version, A Fine Madness, portrays the dehumanizing lobotomy of a womanizing, quarrelsome poet who, afterwards, is just as aggressive as ever. The surgeon is depicted as an inhumane crackpot.[167] The 1982 biopic film Frances depicts actress Frances Farmer (the subject of the film) undergoing transorbital lobotomy (though the idea[168] that a lobotomy was performed on Farmer, and that Freeman performed it, has been criticized as having little or no factual foundation).[169] See also Psychiatry portal Bilateral cingulotomy destruction of a part of the brain Bioethics and Medical ethics Frontal lobe disorder Frontal lobe injury Psychosurgery History of psychosurgery in the United Kingdom Notes   Walter Rudolf Hess, who was the joint winner with Moniz of the Nobel Prize in 1949 for his work on the function of the midbrain, had no involvement with leucotomy.[4]   A pseudonym   A 1937 report detailed that in the United States there were then 477 psychiatric institutions with a total population of approximately 451,672 patients, almost half of whom had been resident for a period of five years or more.[22] The report also observed that psychiatric patients occupied 55 per cent of all hospital beds in America.[22] Conditions within US mental hospitals became the subject of public debate as a series of exposes were published in the 1940s.[23] A 1946 Life magazine article remarked that the nation's system of mental hospitals resembled "little more than concentration camps on the Belsen pattern";[24] a point the piece emphasized with documentary photography that depicted patient neglect and dilapidated material conditions within psychiatric institutions.[25]   Ugo Cerletti, the Italian psychiatrist and joint inventor with Lucio Bini of electroconvulsive therapy, described psychiatry during the interwar period as a "funereal science".[26] Likewise Egas Moniz, the inventor of leucotomy, referred to the "impotência terapeutica" (therapeutic impotence) of existing therapeutic remedies during the 1930s.[27]   The patient he thought improved subsequently committed suicide.[43]   According to Puusepp, the three patients were suffering from manic depression or considered "epileptic equivalents".[50]   Puusepp admitted to his 1910 experimentation with psychosurgery in a 1937 publication.[53] At that point he had completed a series of 14 leucotomies to relieve aggressive symptoms in patients. Convinced that the results had been positive in these cases, he felt that further research into psychosurgery was warranted.[52]   Professor of neurology at the University of Lisbon from 1911 to 1944, Moniz was also for several decades a prominent parliamentarian and diplomat. He was Portugal's ambassador to Spain during World War I and represented Portugal at the postwar Versailles Treaty negotiations,[56] but after the Portuguese coup d'état of 1926, which ushered in the Ditadura Nacional (National Dictatorship), the Republican Moniz, then 51 years old, devoted his considerable talents and energies to neurological research entirely. Throughout his career he published on topics as diverse as neurology, sexology, historical biography, and the history of card games.[57] For his 1927 development of cerebral angiography, which allowed routine visualisation of the brain's peripheral blood vessels for the first time, he was twice nominated, unsuccessfully, for a Nobel Prize. Some have attributed his development of leucotomy to a determination on his part to win the Nobel after these disappointments.[58]   The American neuropsychiatrist Walter Freman 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.[52]   The patient suffered from meningioma, a rare form of brain tumour arising in the meninges.[75]   Brickner and Davidoff had planned, before Moniz's first leucotomies, to operate on the frontal lobes to relieve depression.[83]   Moniz wrote in 1948: 'sufferers from melancholia, for instance, are distressed by fixed and obsessive ideas ... and live in a permanent state of anxiety caused by a fixed idea which predominates over all their lives ... in contrast to automatic actions, these morbid ideas are deeply rooted in the synaptic complex which regulates the functioning of consciousness, stimulating it and keeping it in constant activity ... all these considerations led me to the following conclusion: it is necessary to alter these synaptic adjustments and change the paths chosen by the impulses in their constant passage so as to modify the corresponding ideas and force thoughts along different paths ...'[90]   Lima described his role as that of an "instrument handled by the Master".[99]   Before operating on live subjects, they practised the procedure on a cadaver head.[84]   It was estimated by William Sargant and Eliot Slater that 15,000 leucotomies had been performed in the UK by 1962.[118]   The 14 leucotomies reported by Puusepp in his 1937 paper were performed at the Racconigi Hospital.[120]   Walter Freeman had originally used ice picks for his modified form of the leucotomy operation that he termed transorbital lobotomy. However, because the ice picks would occasionally break inside the patient's head and have to be retrieved, he had the very durable orbitoclast specially commissioned in 1948.[134]   Frank Freeman, Walter Freeman's son, stated in an interview with Howard Dully that: "He had several ice-picks that just cluttered the back of the kitchen drawer. The first ice-pick came right out of our drawer. A humble ice-pick to go right into the frontal lobes. It was, from a cosmetic standpoint, diabolical. Just observing this thing was horrible, gruesome." When Dully asked Frank Freeman, then a 79-year-old security guard, whether he was proud of his father, he replied: "Oh yes, yes, yeah. He was terrific. He was really quite a remarkable pioneer lobotomist. I wish he could have gotten further."[136]   Rodney Dully, whose son Howard Dully had had a transorbital lobotomy performed on him by Walter Freeman when he was twelve years old, stated in an interview with his son that: "I only met him [Freeman] I think the one time. He described how accurate it [transorbital lobotomy] was and that he had practised the cutting on, literally, a carload of grapefruit, getting the right move and the right turn. That's what he told me."[136] Citations   Kaempffert 1941, p. 18.   "Lobotomy: Definition, Procedure & History". Live Science. Retrieved 28 June 2018.   Raz 2009, p. 116   Nobelprize.org 2013.   Sutherland 2004   Levinson, Hugh (8 November 2011). "The strange and curious history of lobotomy". BBC News. BBC.   Johnson, Jenell (17 October 2014). American Lobotomy: A Rhetorical History. University of Michigan Press. pp. 50–60. ISBN 978-0472119448. Retrieved 12 August 2017.   El-Hai, Jack (21 December 2016). "Race and Gender in the Selection of Patients for Lobotomy". Wonders & Marvels. Retrieved 12 August 2017.   "Lobotomies". Western University. Retrieved 12 August 2017.   Kalat, James W. (2007). Biological psychology (9th ed.). Belmont, California: Wadsworth/Thomson Learning. p. 101. ISBN 9780495090793. Retrieved 21 December 2015.   Zajicek, Benjamin (2017). "Banning the Soviet Lobotomy: Psychiatry, Ethics, and Professional Politics during Late Stalinism". Bulletin of the History of Medicine. 91 (1): 33–61. doi:10.1353/bhm.2017.0002. ISSN 1086-3176. PMID 28366896.   Gallea, Michael (Summer 2017). "A brief reflection on the not-so-brief history of the lobotomy". BCMedical Journal. 59: 302–304. Archived from the original on 7 February 2019. 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