When was the International Hydrographic Organization founded?

The IHO was established in 1921 as the International Hydrographic Bureau (IHB). The present name was adopted in 1970 as part of a new international Convention on the IHO adopted by the then member nations. The former name International Hydrographic Bureau was retained to describe the IHO secretariat until 8 November 2016, when a revision to the Convention on the IHO entered into force. Thereafter the IHB became known as the "IHO Secretariat", comprising an elected Secretary-General and two supporting Directors, together with a small staff of 17, at the Organization's headquarters in Monaco.

International Hydrographic Organization

The International Hydrographic Organization (IHO) is the inter-governmental organisation representing hydrography.

A principal aim of the IHO is to ensure that the world’s seas, oceans and navigable waters are properly surveyed and charted. It does this through the setting of international standards, the co-ordination of the endeavours of the world's national hydrographic offices, and through its capacity building programme.
The IHO enjoys observer status at the United Nations where it is the recognised competent authority on hydrographic surveying and nautical charting. When referring to hydrography and nautical charting in Conventions and similar Instruments, it is the IHO standards and specifications that are normally used.

During the 19th century, many maritime nations established hydrographic offices to provide means for improving the navigation of naval and merchant vessels by providing nautical publications, nautical charts, and other navigational services. There were substantial differences in hydrographic procedures charts, and publications. In 1889, an International Maritime Conference was held at Washington, D.C., and it was proposed to establish a "permanent international commission." Similar proposals were made at the sessions of the International Congress of Navigation held at Saint Petersburg in 1908 and the International Maritime Conference held at Saint Petersburg in 1912.

In 1919 the hydrographers of Great Britain and France cooperated in taking the necessary steps to convene an international conference of hydrographers. London was selected as the most suitable place for this conference, and on 24 July 1919, the First International Conference opened, attended by the hydrographers of 24 nations. The object of the conference was "To consider the advisability of all maritime nations adopting similar methods in preparation, construction, and production of their charts and all hydrographic publications; of rendering the results in the most convenient form to enable them to be readily used; of instituting a prompt system of mutual exchange of hydrographic information between all countries; and of providing an opportunity to consultations and discussions to be carried out on hydrographic subjects generally by the hydrographic experts of the world." This is still the major purpose of the IHO.

As a result of the Conference, a permanent organization was formed and statutes for its operations were prepared. The IHB, now the IHO, began its activities in 1921 with 18 nations as members. The Principality of Monaco was selected as the seat of the organization as a result of the offer of Albert I, Prince of Monaco to provide suitable accommodation for the Bureau in the principality. This organization firstly was composed by 89 members, but two of them were suspended because they couldn't pay their fees. Indeed, thirteen Member States had failed to pay their contributions to the organization for 2017 during the calendar year.

The IHO develops hydrographic and nautical charting standards. These standards are subsequently adopted and used by its 89 (as of June 2018) member countries and others in their surveys, nautical charts, and publications. The almost universal use of the IHO standards means that the products and services provided by the world's national hydrographic and oceanographic offices are consistent and recognisable by all seafarers and for other users. Much has been done in the field of standardisation since the Bureau (now the IHO) was founded.

The IHO has encouraged the formation of Regional Hydrographic Commissions (RHCs). Each RHC coordinates the national surveying and charting activities of countries within each region and acts as a forum to address other matters of common hydrographic interest. The 15 RHCs plus the IHO Hydrographic Commission on Antarctica (HCA) effectively cover the world.

The IHO, in partnership with the Intergovernmental Oceanographic Commission (IOC), directs the General Bathymetric Chart of the Oceans programme.

Main achievements of this organization:

1) The exploration of the seabed and movements of the sea.

2) Standardization of maritime measurements, hydrographic terminology, marine cartographic products and geographical information systems for navigation. Great progress has been made concerning standardization of electronic charts

3) High efficiency of the rapid dissemination of information on safety at sea

4) Training of hydrographers and nautical cartographers.

Most IHO publications, including the standards, guidelines and associated documents such as the "International Hydrographic Review", "International Hydrographic Bulletin", the "Hydrographic Dictionary" and the "Year Book" are available to the general public free of charge from the IHO website.

The IHO publishes the international standards related to charting and hydrography, including S-57, "IHO Transfer Standard for Digital Hydrographic Data", the encoding standard that is used primarily for electronic navigational charts. In 2010 the IHO introduced a new, contemporary hydrographic geospatial standard for modelling marine data and information, known as S-100. S-100 and any dependent product specifications are underpinned by an on-line registry accessible via the IHO website. S-100 is aligned with the ISO 19100 series of geographic standards, thereby making it fully compatible with contemporary geospatial data standards. Because S-100 is based on ISO 19100, it can be used by other data providers for their maritime-related (non-hydrographic) data and information. Various data and information providers from both the government and private sector are now using S-100 as part of the implementation of the e-Navigation concept that has been endorsed by the UN International Maritime Organization.

The IHO maintains a programme of the meetings of its Council, committees and working groups around the world. The meetings and the meetings of other related International Organisations are promulgated in the calendar on the IHO website.

Establishment of the Chart Specifications Committee and International Charts. Great improvements have taken place in the following topics:The following countries are members of the IHO:


How large is Montague Island?

Montague Island lies in the Gulf of Alaska at the entrance to Prince William Sound, Alaska. The island has a land area of 790.88 km² (305.36 sq mi), making it the 26th largest island in the United States. As of the 2000 census, Montague did not have a permanent resident population, making it at that time the largest uninhabited island in the United States. Since then, the 2010 abandonment of the Coast Guard station on Attu Island in the Aleutian Islands, which at 344.7 square miles is larger than Montague Island, causes Attu to claim that title. Montague Island is well known among sport fishing out of the Seward port as it is referred to as 'The Land of the Giants'. In 2007 it produced a 350 lb halibut and many boats full of fish over 100 lbs. Montague Island was named by Captain James Cook in honor of John Montagu, 4th Earl of Sandwich, one of his greatest supporters.

Montague Island (Alaska)

The island's coastal ecology has been subject to 'unprecedented amounts of ocean trash' transported by wind and currents from Japan's March 2011 tsunami, according to the Center for Alaskan Coastal Studies, in May 2012. A large scale clean-up began on 22 May 2012, funded by The Marine Conservation Alliance Foundation.

Montague Island is a continental island contained within the Montague Island Nature Reserve, a protected nature reserve that is located offshore from the South Coast region of New South Wales, in eastern Australia. The nearest town located onshore from the reserve and island is, situated approximately to the northwest.

Montague Island (Australia)

Montague Island is the second largest island off the New South Wales east coast other than Lord Howe Island. It has been classified by the National Trust as a Landscape Conservation Area for its scenic, scientific and historical values. The Montague Island Light buildings are entered on the Register of the National Estate because of the architectural quality of the tower and residences.

The island was first sighted by Europeans in 1770 by James Cook and named Cape Dromedary, then identified as an island and named by the master of the Second Fleet convict transport "Surprize" after George Montagu-Dunk, 2nd Earl of Halifax.

Montague Island is a popular tourist destination, known for its lighthouse, wildlife, most especially little penguins ("Eudyptula minor"), and recreational activities; managed by the NSW National Parks & Wildlife Service (NPWS). Public access to the island is restricted to guided tours conducted by the NPWS in association with private operators.

A lighthouse is maintained on the island by the Australian Maritime Safety Authority. The lighthouse was designed by James Barnet and built in 1881. It was automated in 1986 and demanned in 1987. The lighthouse is tall and the light is above sea level with a nominal range of and a geographic range of. The original Fresnel lens was removed in 1986 and is now on display at the Narooma Lighthouse Museum.

The next lighthouse to the north is the Burrewarra Point lighthouse. Amateur radio expeditions to the island were organised in 2010 and 2011.

Forty nine species of fauna have been recorded on the island by the New South Wales National Parks and Wildlife Service.

The island is home to a large colony of little penguins on the island. As the island has no foxes or feral cats, the penguins have no predators other than other seabirds and seals. With the restoration of native habitat and the provision of penguin breeding boxes, penguin numbers have increased, and there are now approximately 12,000 on the island. The female usually lays two eggs, and during a good year, both chicks will survive. The birds come ashore at dusk after feeding at sea, and visitors to the island can watch the birds from a platform near the jetty.

Crested terns, "Sterna bergii," have brilliant white feathers covering the body while the head is completely black.

Shearwaters, also known as mutton birds, nest on the island. Species recorded are:

The northern tip of the island is the seasonal home to a seal bachelor colony. Due to the site's remoteness, it is only possible for visitors to see them from a boat.

The majority of the seals are Australian fur seals, ("Arctocephalus pusillus doriferus"), New Zealand fur seals ("Arctocephalus forsteri"), subantarctic fur seals ("Arctocephalus tropicalis") and Australian sea lions ("Neophoca cinerea") have also been observed.

Kikuyu grass is a major weed on the island. Originally introduced in the early 19th century to help feed the animals kept by the lighthouse keepers and their families, it has spread to cover most of the south island. To control it, NPWS officers poison a section, then burn it, before replanting with help from volunteers. In the less accessible areas of the northern and eastern parts, an aerial spraying program is used to manage the kikuyu where it infests shearwater breeding sites. The kikuyu is a barrier for the shearwaters and penguins who cannot penetrate it to move or to burrow. Various native species are used to replant areas after the kikuyu grass has been controlled.


How many ribs do humans have?

Ribs are classed as flat bones which usually have a protective role in the body. Humans have 24 ribs, in 12 pairs. All are attached at the back to the thoracic vertebrae, and are numbered from 1–12 according to the vertebrae they attach to. The first rib is attached to thoracic vertebra 1 (T1). At the front of the body most of the ribs are joined by costal cartilages to the sternum. The ribs connect to the vertebrae with two joints, the costovertebral joints.

Rib

In vertebrate anatomy, ribs () are the long curved bones which form the rib cage, part of the axial skeleton. In most tetrapods, ribs surround the chest, enabling the lungs to expand and thus facilitate breathing by expanding the chest cavity. They serve to protect the lungs, heart, and other internal organs of the thorax. In some animals, especially snakes, ribs may provide support and protection for the entire body.

The parts of a rib include the head, neck, body (or "shaft"), tubercle, and angle.

The head of the rib lies next to a vertebra. The ribs connect to the vertebrae with two costovertebral joints, one on the head and one on the neck. The head of the rib has a superior and an inferior articulating region, separated by a crest. These articulate with the superior and inferior costal facets on the connecting vertebrae. The crest gives attachment to the intra-articulate ligament that joins the rib to the vertebra of the same number, at the intervertebral disc. Another ligament, the radiate ligament joins the head of the rib to the both the body of the upper vertebra and to the body of the lower vertebra. The smaller middle part of the ligament connects to the intervertebral disc. This plane joint is known as the articulation of the head of the rib.

The other costovertebral joint is that between the tubercle on the neck and the transverse process of the joining thoracic vertebra of the same rib number, and this is known as the costotransverse joint. The superior costotransverse ligament attaches from the non-articular facet of the tubercle to the transverse process of the vertebra.

The neck of the rib is a flattened part that extends laterally from the head. The neck is about 3 cm long. Its anterior surface is flat and smooth, whilst its posterior is perforated by numerous foramina and its surface rough, to give attachment to the ligament of the neck. Its upper border presents a rough crest ("crista colli costae") for the attachment of the anterior costotransverse ligament; its lower border is rounded.

A tubercle of rib on the posterior surface of the neck of the rib, has two facets (surfaces) one articulating and one non-articulating. The articular facet, is small and oval and is the lower and more medial of the two, and connects to the transverse costal facet on the thoracic vertebra of the same rib number. The transverse costal facet is on the end of the transverse process of the lower of the two vertebrae to which the head is connected. The non-articular portion is a rough elevation and affords attachment to the ligament of the tubercle. The tubercle is much more prominent in the upper ribs than in the lower ribs.

The first seven sets of ribs, known as "true ribs", are attached to the sternum by the costal cartilages. The first rib is unique and harder to distinguish than other ribs. It is a short, flat, C-shaped bone. The vertebral attachment can be found just below the neck at the first thoracic vertebra, and the majority of this bone can be found above the level of the clavicle. Ribs 2 through 7 have a more traditional appearance and become longer and less curved as they progress downwards. The following five sets are known as "false ribs", three of these sharing a common cartilaginous connection to the sternum, while the last two (eleventh and twelfth ribs) are termed floating ribs. They are attached to the vertebrae only, and not to the sternum or cartilage coming off of the sternum.

In general, human ribs increase in length from ribs 1 through 7 and decrease in length again through rib 12. Along with this change in size, the ribs become progressively oblique (slanted) from ribs 1 through 9, then less slanted through rib 12.

The rib cage is separated from the lower abdomen by the thoracic diaphragm which controls breathing. When the diaphragm contracts, the thoracic cavity is expanded, reducing intra-thoracic pressure and drawing air into the lungs. This happens through one of two actions (or a mix of the two): when the lower ribs the diaphragm connects to are stabilized by muscles and the central tendon is mobile, when the muscle contracts the central tendon is drawn down, compressing the cavity underneath and expanding the thoracic cavity downward. When the central tendon is stabilized and the lower ribs are mobile, a contraction of the diaphragm elevates the ribs, which works in conjunction with other muscles to expand the thoracic indent upward.

Early in the developing embryo, somites form and soon subdivide into three mesodermal components – the myotome, dermatome, and the sclerotome. The vertebrae and ribs develop from the sclerotomes.

During the fourth week (fertilization age) "costal processes" have formed on the vertebral bodies. These processes are small, lateral protrusions of mesenchyme that develop in association with the vertebral arches. During the fifth week the costal processes on the thoracic vertebrae become longer to form the ribs. In the sixth week, the costovertebral joints begin to develop and separate the ribs from the vertebrae. The first seven pairs of ribs, the true ribs join at the front to the sternal bars. By the fetal stage the sternal bars have completely fused.

The ribs begin as cartilage that later ossifies – a process called endochondral ossification. Primary ossification centers are located near the angle of each rib, and ossification continues in the direction away from the head and neck. During adolescence secondary ossification centers are formed in the tubercles and heads of the ribs.

In fish, there are often two sets of ribs attached to the vertebral column. One set, the dorsal ribs, are found in the dividing septum between the upper and lower parts of the main muscle segments, projecting roughly sideways from the vertebral column. The second set, the ventral ribs arise from the vertebral column just below the dorsal ribs, and enclose the lower body, often joining at the tips. Not all species possess both types of rib, with the dorsal ribs being most commonly absent. Sharks, for example, have no dorsal ribs, and only very short ventral ribs, while lampreys have no ribs at all. In some teleosts, there may be additional rib-like bones within the muscle mass.

Tetrapods, however, only ever have a single set of ribs which are probably homologous with the dorsal ribs of fishes. In the early tetrapods, every vertebra bore a pair of ribs, although those on the thoracic vertebrae are typically the longest. The sacral ribs were stout and short, since they formed part of the pelvis, connecting the backbone to the hip bones.

In most subsequent forms, many of these early ribs have been lost, and in living amphibians and reptiles, there is great variation in rib structure and number. For example, turtles have only eight pairs of ribs, which are developed into a bony or cartilaginous carapace and plastron, while snakes have numerous ribs running along the full length of their trunk. Frogs typically have no ribs, aside from a sacral pair, which form part of the pelvis.

In birds, ribs are present as distinct bones only on the thoracic region, although small fused ribs are present on the cervical vertebrae. The thoracic ribs of birds possess a wide projection to the rear; this uncinate process is an attachment for the shoulder muscles.
Usually dogs have 26 ribs.
Mammals usually also only have distinct ribs on the thoracic vertebra, although fixed cervical ribs are also present in monotremes. In marsupials and placental mammals, the cervical and lumbar ribs are found only as tiny remnants fused to the vertebrae, where they are referred to as transverse processes. In general, the structure and number of the true ribs in humans is similar to that in other mammals. Unlike reptiles, caudal ribs are never found in mammals.

Ribs as food are widely used from many animals. The ribs are the less meaty part of the meat chop and they are often cooked as part of a slab; five or more is known as a "rack", as in a rack of lamb. Short ribs are ribs of beef either served singly or several as a "plate". A rib steak from beef is a popular choice used in many cuisines. Pork ribs, including spare ribs are popular in European and Asian cuisine.

The rib cage is the arrangement of ribs attached to the vertebral column and sternum in the thorax of most vertebrates, that encloses and protects the heart and lungs. In humans, the rib cage, also known as the thoracic cage, is a bony and cartilaginous structure which surrounds the thoracic cavity and supports the shoulder girdle to form the core part of the human skeleton. A typical human rib cage consists of 24 ribs in 12 pairs, the sternum and xiphoid process, the costal cartilages, and the 12 thoracic vertebrae.

Rib cage

Together with the skin and associated fascia and muscles, the rib cage makes up the thoracic wall and provides attachments for the muscles of the neck, thorax, upper abdomen, and back.

The rib cage has a major function in the respiratory system.

Ribs are described based on their location and connection with the sternum. All ribs are attached behind to the thoracic vertebrae and are numbered accordingly one to twelve. Ribs that articulate directly with the sternum are called "true ribs", whereas those that connect indirectly via cartilage are termed "false ribs". Floating ribs (eleven and twelve) are not attached to the sternum at all.

The terms "true ribs" and "false ribs" describe rib pairs that are directly or indirectly attached to the sternum. The first seven rib pairs known as the "fixed" or vertebrosternal ribs are the "true ribs" () as they connect directly to the sternum; the next five pairs (eighth to twelfth) are the "false ribs" (), or vertebrochondral ribs as they connect indirectly to the sternum via the costal cartilages of the ribs above them. Their elasticity allows rib cage movement for respiratory activity.

The phrase "floating rib" () refers to the two lowermost, the eleventh and twelfth rib pairs; so-called because they are attached only to the vertebrae–and not to the sternum or cartilage of the sternum. These ribs are relatively small and delicate, and include a cartilaginous tip.

The spaces between the ribs are known as intercostal spaces; they contain the intercostal muscles, and neurovascular bundles containing the nerves, arteries, and veins.

Each rib consists of a head, neck, and a shaft. All ribs are attached posteriorly to the thoracic vertebrae. They are numbered to match the vertebra they attach to – one to twelve, from top (T1) to bottom. The head of the rib is the end part closest to the vertebrae with which it articulates. It is marked by a kidney-shaped articular surface which is divided by a horizontal crest into two articulating regions. The upper region articulates with the inferior costal facet on the vertebra above, and the larger region articulates with the superior costal facet on the vertebra with the same number. The transverse process of a thoracic vertebra also articulates at the transverse costal facet with the tubercle of the rib of the same number. The crest gives attachment to the intra-articular ligament.

The neck of the rib is the flattened part that extends laterally from the head. The neck is about 3 cm long. Its anterior surface is flat and smooth, whilst its posterior is perforated by numerous foramina and its surface rough, to give attachment to the ligament of the neck. Its upper border presents a rough crest ("crista colli costae") for the attachment of the anterior costotransverse ligament; its lower border is rounded.

On the posterior surface at the neck, is an eminence—the tubercle that consists of an articular and a non-articular portion. The articular portion is the lower and more medial of the two and presents a small, oval surface for articulation with the transverse costal facet on the end of the transverse process of the lower of the two vertebrae to which the head is connected. The non-articular portion is a rough elevation and affords attachment to the ligament of the tubercle. The tubercle is much more prominent in the upper ribs than in the lower ribs.

The angle of a rib (costal angle) may both refer to the bending part of it, and a prominent line in this area, a little in front of the tubercle. This line is directed downward and laterally; this gives attachment to a tendon of the iliocostalis muscle. At this point, the rib is bent in two directions, and at the same time twisted on its long axis.

The distance between the angle and the tubercle is progressively greater from the second to the tenth ribs. The area between the angle and the tubercle is rounded, rough, and irregular, and serves for the attachment of the longissimus dorsi muscle.

The first rib (the topmost one) is the most curved and usually the shortest of all the ribs; it is broad and flat, its surfaces looking upward and downward, and its borders inward and outward.

The "head" is small and rounded, and possesses only a single articular facet, for articulation with the body of the first thoracic vertebra. The "neck" is narrow and rounded. The "tubercle", thick and prominent, is placed on the outer border. It bears a small facet for articulation with the transverse costal facet on the transverse process of T1. There is no "angle", but at the tubercle, the rib is slightly bent, with the convexity upward, so that the head of the bone is directed downward. The upper surface of the body is marked by two shallow grooves, separated from each other by a slight ridge prolonged internally into a tubercle, the scalene tubercle, for the attachment of the anterior scalene; the "anterior groove" transmits the subclavian vein, the "posterior "the subclavian artery and the lowest trunk of the brachial plexus. Behind the posterior groove is a rough area for the attachment of the medial scalene. The "under surface" is smooth and without a costal groove. The "outer border" is convex, thick, and rounded, and at its posterior part gives attachment to the first digitation of the serratus anterior. The "inner border" is concave, thin, and sharp, and marked about its center by the scalene tubercle. The "anterior extremity" is larger and thicker than that of any of the other ribs.

The second rib is the second uppermost rib in humans or second most frontal in animals that walk on four limbs. In humans, the second rib is defined as a true rib since it connects with the sternum through the intervention of the costal cartilage anteriorly (at the front). Posteriorly, the second rib is connected with the vertebral column by the second thoracic vertebra. The second rib is much longer than the first rib, but has a very similar curvature. The non-articular portion of the tubercle is occasionally only feebly marked. The angle is slight and situated close to the tubercle. The body is not twisted so that both ends touch any plane surface upon which it may be laid; but there is a bend, with its convexity upward, similar to, though smaller than that found in the first rib. The body is not flattened horizontally like that of the first rib. Its external surface is convex, and looks upward and a little outward; near the middle of it is a rough eminence for the origin of the lower part of the first and the whole of the second digitation of the serratus anterior; behind and above this is attached the posterior scalene. The internal surface, smooth, and concave, is directed downward and a little inward: on its posterior part there is a short costal groove between the ridge of the internal surface of the rib and the inferior border. It protects the intercostal space containing the intercostal veins, intercostal arteries, and intercostal nerves.

The ninth rib has a frontal part at the same level as the first lumbar vertebra. This level is called the transpyloric plane, since the pylorus is also at this level.

The tenth rib attaches directly to the body of vertebra T10 instead of between vertebrae like the second through ninth ribs. Due to this direct attachment, vertebra T10 has a complete costal facet on its body.
The eleventh and twelfth ribs, the floating ribs, have a single articular facet on the head, which is of rather large size. They have no necks or tubercles, and are pointed at their anterior ends. The eleventh has a slight angle and a shallow costal groove, whereas the twelfth does not. The twelfth rib is much shorter than the eleventh rib, and its head is inclined slightly downward.

The sternum is a long, flat bone that forms the front of the rib cage. The cartilages of the top seven ribs (the "true ribs") join with the sternum at the sternocostal joints. The costal cartilage of the second rib articulates with the sternum at the sternal angle making it easy to locate.

The transversus thoracis muscle is innervated by one of the intercostal nerves and superiorly attaches at the posterior surface of the lower sternum. Its inferior attachment is the internal surface of costal cartilages two through six and works to depress the ribs.

Expansion of the rib cage in males is caused by the effects of testosterone during puberty. Thus, males generally have broad shoulders and expanded chests, allowing them to inhale more air to supply their muscles with oxygen.
Variations in the number of ribs occur. About 1 in 200-500 people have an additional cervical rib, and there is a female predominance. Intrathoracic supernumerary ribs are extremely rare. The rib remnant of the 7th cervical vertebra on one or both sides is occasionally replaced by a free extra rib called a cervical rib, which can mechanically interfere with the nerves (brachial plexus) going to the arm.

In several ethnic groups, most significantly the Japanese, the tenth rib is sometimes a floating rib, as it lacks a cartilaginous connection to the seventh rib.

The human rib cage is a component of the human respiratory system. It encloses the thoracic cavity, which contains the lungs. An inhalation is accomplished when the muscular diaphragm, at the floor of the thoracic cavity, contracts and flattens, while the contraction of intercostal muscles lift the rib cage up and out.

Expansion of the thoracic cavity is driven in three planes; the vertical, the anteroposterior and the transverse. The vertical plane is extended by the help of the diaphragm contracting and the abdominal muscles relaxing to accommodate the downward pressure that is supplied to the abdominal viscera by the diaphragm contracting. A greater extension can be achieved by the diaphragm itself moving down, rather than simply the domes flattening. The second plane is the anteroposterior and this is expanded by a movement known as the 'pump handle.' The downward sloping nature of the upper ribs are as such because they enable this to occur. When the external intercostal muscles contract and lift the ribs, the upper ribs are able also to push the sternum up and out. This movement increases the anteroposterior diameter of the thoracic cavity, and hence aids breathing further. The third, transverse, plane is primarily expanded by the lower ribs (some say it is the 7th to 10th ribs in particular), with the diaphragm's central tendon acting as a fixed point. When the diaphragm contracts, the ribs are able to evert and produce what is known as the bucket handle movement, facilitated by gliding at the costovertebral joints. In this way, the transverse diameter is expanded and the lungs can fill.

The circumference of the normal adult human rib cage expands by 3 to 5 cm during inhalation.

Rib fractures are the most common injury to the rib cage. These most frequently affect the middle ribs. When several adjacent ribs incur two or more fractures each, this can result in a flail chest which is a life-threatening condition.

A dislocated rib can be painful and can be caused simply by coughing, or for example by trauma or lifting heavy weights.

One or more costal cartilages can become inflamed – a condition known as costochondritis; the resulting pain is similar to that of a heart attack.

Abnormalities of the rib cage include pectus excavatum ("sunken chest") and pectus carinatum ("pigeon chest"). A bifid rib is a bifurcated rib, split towards the sternal end, and usually just affecting one of the ribs of a pair. It is a congenital defect affecting about 1.2% of the population. It is often without symptoms though respiratory difficulties and other problems can arise.

Rib removal is the surgical removal of one or more ribs for therapeutic or cosmetic reasons. Rib resection is the removal of part of a rib.

Their position can be permanently altered by a form of body modification called tightlacing, which uses a corset to compress and move the ribs.

The ribs, particularly their sternal ends, are used as a way of estimating age in forensic pathology, due to their progressive ossification.

The number of ribs as 24 (12 pairs) was noted by the Flemish anatomist Vesalius in his key work of anatomy "De humani corporis fabrica" in 1543, setting off a wave of controversy, as it was traditionally assumed from the Biblical story of Adam and Eve that men's ribs would number one fewer than women's.

In herpetology, costal grooves refer to lateral indents along the integument of salamanders. The grooves run between the axilla to the groin. Each groove overlies the myotomal septa to mark the position of the internal rib.

Birds and reptiles have bony uncinate processes on their ribs that project caudally from the vertical section of each rib. These serve to attach sacral muscles and also aid in allowing greater inspiration. Crocodiles have cartilaginous uncinate processes.


When was the first lobotomy performed?

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.) 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. 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.

Lobotomy

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. 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. This was 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.

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", although the awarding of the prize has been subject to controversy.

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 alone and proportionally more in the United Kingdom. The majority of lobotomies were performed on women; a 1951 study of American hospitals found nearly 60% of lobotomy patients were women; data shows 74% of lobotomies in Ontario from 1948–1952 were performed on women. From the 1950s onward lobotomy began to be abandoned, first in the Soviet Union and Europe. The term is derived from "lobe" and "cut, slice".
The purpose of the operation was to reduce the symptoms of mental disorder, 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. Activity was replaced by inertia, and people were left emotionally blunted and restricted in their intellectual range.

The consequences of the operation have been described as "mixed". 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. A few people managed to return to responsible work, while at the other extreme people were left with severe and disabling impairments. 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. On average, there was a mortality rate of approximately 5 percent during the 1940s.

The lobotomy procedure could have severe negative effects on a patient's personality and ability to function independently. Lobotomy patients often show a marked reduction in initiative and inhibition. They may also exhibit difficulty putting themselves in the position of others because of decreased cognition and detachment from society.

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.

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 couldn't remember Freeman's name and endlessly poured coffee from an empty pot. When her parents had difficulty dealing with her behaviour, Freeman advised a system of rewards (ice-cream) and punishment (smacks).

In the early 20th century, the number of patients residing in mental hospitals increased significantly while little in the way of effective medical treatment was available. 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. The new "heroic" physical therapies devised during this experimental era, including malarial therapy for general paresis of the insane (1917), deep sleep therapy (1920), insulin shock therapy (1933), cardiazol shock therapy (1934), and electroconvulsive therapy (1938), 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. 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.

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." For Roy Porter, once the doyen of medical history, 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. 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 if desperate remedy for categories of patients who were otherwise regarded as hopeless. Today, lobotomy has become a disparaged procedure, a byword for medical barbarism and an exemplary instance of the medical trampling of patients' rights.

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. 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. Burckhardt's hypothesis was that by deliberately creating lesions in regions of the brain identified as association centers a transformation in behavior might ensue. 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. He reasoned, however, that removing material from either of the sensory or motor zones could give rise to "grave functional disturbance". 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.

Intending to ameliorate symptoms in those with violent and intractable conditions rather than effect a cure, Burckhardt began operating on patients in December 1888, but both his surgical methods and instruments were crude and the results of the procedure were mixed at best. 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. Complications included motor weakness, epilepsy, sensory aphasia and "word deafness". Claiming a success rate of 50 percent, 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.

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. 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.
"We have quoted this data to show not only how groundless but also how dangerous these operations were. We are unable to explain how their author, holder of a degree in medicine, could bring himself to carry them out ..."

The authors neglected to mention, however, that in 1910 Puusepp himself had performed surgery on the brains of three mentally ill patients, sectioning the cortex between the frontal and parietal lobes. 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. By 1937, Puusepp, despite his earlier criticism of Burckhardt, was increasingly persuaded that psychosurgery could be a valid medical intervention for the mentally disturbed. 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.

Leucotomy was first undertaken in 1935 under the direction of the Portuguese neurologist (and inventor of the term "psychosurgery") António Egas Moniz. First developing an interest in psychiatric conditions and their somatic treatment in the early 1930s, Moniz apparently conceived a new opportunity for recognition in the development of a surgical intervention on the brain as a treatment for mental illness.

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. 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. 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. At the 1935 Congress, with Moniz in attendance, Fulton and Jacobsen presented two chimpanzees, named Becky and Lucy who had had frontal lobectomies and subsequent changes in behaviour and intellectual function. 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 defecatingif, because of their poor performance in a set of experimental tasks, they were not rewarded. 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". 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.
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. 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. 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. 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. 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.

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. 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. 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. 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. Cases were reported where mental symptoms were alleviated following the surgical removal of diseased or damaged brain tissue. 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. 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. 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. This work, while influential, was not without its critics due to deficiencies in experimental design.

The first bilateral lobectomy of a human subject was performed by the American neurosurgeon Walter Dandy in 1930. The neurologist Richard Brickner reported on this case in 1932, 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. Brickner concluded from this evidence that "the frontal lobes are not 'centers' for the intellect". 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. 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 as part of its deliberations, "a remarkable symposium ... on the functions of the frontal lobes." 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". This parallel symposium contained numerous papers by neurologists, neurosurgeons and psychologists; amongst these was one by Brickner, which impressed Moniz greatly, that again detailed the case of "Patient A". 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. 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.

Nor was Moniz the only medical practitioner in the 1930s to have contemplated procedures directly targeting the frontal lobes. 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. 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. 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". 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. 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. In Romania, Ody's procedure was adopted by Dimitri Bagdasar and Constantinesco working out of the Central Hospital in Bucharest. 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".

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, in essence he simply interpreted this new neurological research in terms of the old psychological theory of associationism. 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." As Moniz wrote in 1936:
[The] mental troubles must have ... a relation with the formation of cellulo-connective groupings, which become more or less fixed. The cellular bodies may remain altogether normal, their cylinders will not have any anatomical alterations; but their multiple liaisons, very variable in normal people, may have arrangements more or less fixed, which will have a relation with persistent ideas and deliria in certain morbid psychic states.

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," thus removing their fixed pathological brain circuits. Moniz believed the brain would functionally adapt to such injury. 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.

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. 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. 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. The intention was to remove some of the long fibres that connected the frontal lobes to other major brain centres. 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" so as to destroy the connecting fibres, or association tracts, and create what Moniz termed a "frontal barrier". 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. 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. For the ninth patient they introduced a surgical instrument called a leucotome; this was a cannula that was in length and in diameter. It had a retractable wire loop at one end that, when rotated, produced a diameter circular lesion in the white matter of the frontal lobe. 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.

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. 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. Patients were normally operated on the day they arrived at Moniz's clinic and returned within ten days to the Miguel Bombarda Mental Hospital. A perfunctory post-operative follow-up assessment took place anywhere from one to ten weeks following surgery. 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". Moniz asserted that these effects were transitory and, 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.

Moniz rapidly disseminated his results through articles in the medical press and a monograph in 1936. Initially, however, the medical community appeared hostile to the new procedure. 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. Sobral Cid, who had supplied Moniz with the first set of patients for leucotomy from his own hospital in Lisbon, attended the meeting where he denounced frontal lobe surgery, declaring that the patients who had been returned to his care post-operatively were "diminished" and had suffered a "degradation of personality". 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." 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. 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. 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.

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, only six operations had been undertaken before 1942. 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.

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. 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. 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. The major centre for leucotomy in Italy was the Racconigi Hospital, where the experienced neurosurgeon Ludvig Puusepp provided a guiding hand. Under the medical directorship of Emilio Rizzatti, the medical personnel at this hospital had completed at least 200 leucotomies by 1939. Reports from clinicians based at other Italian institutions detailed significantly smaller numbers of leucotomy operations.

Experimental modifications of Moniz's operation were introduced with little delay by Italian medical practitioners. Most notably, in 1937 Amarro Fiamberti, the medical director of a psychiatric institution in Varese, first devised the transorbital procedure whereby the frontal lobes were accessed through the eye sockets. 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. 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. Fiamberti's innovation of Moniz's method would later prove inspirational for Walter Freeman's development of transorbital lobotomy.

The first prefrontal leucotomy in the United States was performed at the George Washington University Hospital on 14 September 1936 by the neuropsychiatrist Walter Freeman and his friend and colleague, the neurosurgeon, James W. Watts. 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. 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". 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. 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. 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. 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". 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.

Upon receipt of Moniz's monograph, Freeman reviewed it anonymously for the "Archives of Neurology and Psychiatry". Praising the text as one whose "importance can scarcely be overestimated", 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. 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.

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".

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.

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 from his own kitchen and began testing the idea on grapefruit 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 fifteen degrees toward the interhemispherical fissure. The orbitoclast was malleted five centimeters (2 in) into the frontal lobe, and then pivoted forty 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 two centimeters ( in) into the brain, before being pivoted around twenty-eight 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.

In the United States, approximately 40,000 people were lobotomized. In England, 17,000 lobotomies were performed, and the three Nordic countries of Finland, Norway, and Sweden had a combined figure of approximately 9,300 lobotomies. Scandinavian hospitals lobotomized 2.5 times as many people per capita as hospitals in the US. Sweden lobotomized at least 4,500 people between 1944 and 1966, mainly women. This figure includes young children. In Norway, there were 2,005 known lobotomies. In Denmark, there were 4,500 known lobotomies. 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 and Germany soon followed suit. By the late 1970s, the practice of lobotomy had generally ceased, although it continued as late as the 1980s in France..

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." In 1948 Norbert Wiener, the author of "", 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."

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." The USSR officially banned the procedure in 1950 on the initiative of Gilyarovsky. 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." By the 1970s, numerous countries had banned the procedure as had several US states.

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.

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.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 forming a negative public sentiment towards the procedure.

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