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History of Neurosurgery for Mental Disorder

This information is from David Christmas' thesis, the full version of which is available on the site.

Preface

The convention regarding terminology has been one such that early (i.e. before stereotactic methods) references to psychiatric surgery adopt the contemporary title of the time, i.e. ‘psychosurgery’. Later procedures such as cingulotomy and capsulotomy are referred to as ‘NMD’ to reflect the change both in technique and thinking that accompanied these advances.

Traditionally, the history of Neurosurgery for Mental Disorder (NMD) begins with trepanation and at some point crosses paths with the story of Phineas Gage. Both are worthy of a mention in the preface. We should note that the history of NMD is not a smooth continuum of progress, but instead is simply one of recognisable steps.

Trepanation is not the starting point because it initiated a gradual evolution of surgical activity culminating in modern neurosurgery, but because we have clear archaeological evidence of such a human endeavour occurring early on in society and it give us an intriguing, and time-locatable point with which to begin the story. The two practices were guided by very different belief systems and medical contexts, and it would be foolish to link such early ‘surgical’ practices with those that emerged in the 19th and 20th Centuries.

The inclusion of Phineas Gage is more problematic. There is little to suggest that he influenced the development of psychosurgery to any degree yet his story refuses to go away. Reasons for this are discussed later in Section 3.3, but perhaps his oddly morbid tale simply appeals to us all.

A Prehistory of NMD

Trepanation (a.k.a. trephination), the deliberate creation of holes in a person’s skull, has been practised in various cultures for thousands of years. The trephined skull of a man in his fifties was discovered in France in 1996. Carbon dating revealed the skull to date from approximately 5100 B.C. Furthermore, the skull showed evidence of healing, suggesting that the man survived the procedure (Alt, Jeunesse, Buitrago-Tellez, et al, 1997). The practice was probably widespread throughout early human societies, and there is evidence of such procedures in parts of North Africa, Europe, Asia, and South America. Trephining knives have been discovered in excavated Inca settlements. Trepanation was frequently used to treat ‘spirit’ or ‘demonic’ possession, which was probably a primitive ‘diagnosis’ for many forms of mental illness, epilepsy, headaches, and other neurological conditions.

Trepanation (in various forms) has continued throughout the last two millennia. Such an intervention was being recommended for mood disorders in the 12th Century. Ruggio Frugardi, a physician from the Hippocratii School of Medicine at Salerno, Italy wrote that, “For mania and melancholy the skin at the top of the head should be incised in a cruciate fashion and the skull perforated to allow matter to escape” (Cited in O'Callaghan & Carroll, 1982, p. 4). Trepanation continues to be performed today by a small number of people, most of who believe that it can improve “brain pulsations” and hence overall well-being. The belief that brain pulsations have some impact upon health dates back to the work of Claudius Galen (c. AD 129 – c. AD 216) and despite there not being any scientific support for such beliefs, many modern devotees report positive health benefits (For example, see Henderson, 2000).

References

Alt, K. W., Jeunesse, C., Buitrago-Tellez, C. H., et al (1997) Evidence for stone age cranial surgery. Nature, 387, 360.
Henderson, B. (2000). Trepanation. BMEzine.com. Website. Last updated: Not Stated. Accessed: 16 April, 2006. Available at: http://www.bmezine.com/news/people/A10101/trepan/index.html
O'Callaghan, M. A. J. & Carroll, D. (1982) Psychosurgery: A Scientific Analysis. Lancaster: MTP Press.


The Story of Phineas Gage

On 13 September, 1848, Phineas Gage, a fit 25-year-old railway-worker from Vermont was packing an explosive charge into a blasting hole. The tamping iron he was using to compress the charge struck rock instead of sand and it ignited the explosive. The resulting explosion drove the iron bar, weighing over 6kg, and 3 ft 7in in length, through Gage’s skull. The bar entered his skull under the left zygomatic arch, passing through the sphenoidal bone, entering the cranium, before passing out through the top of his head (Harlow, 1848). Computerised reassessment of his injuries would suggest that the bar damaged the medial and lateral orbito-frontal, and dorsolateral prefrontal regions of the left frontal lobe (Ratiu, Talos, Haker, et al, 2004). The only observable physical injury that Gage was left with was the loss of his sight in his left eye.

Prior to the injury, Gage was described as having a “well balanced mind . . . a shrewd, smart businessman, very energetic and persistent in executing all his plans of operation”. Twenty years after the accident, in 1868, the local GP John Harlow that attended to his injury previously described Gage’s personality as “radically changed, so decidedly that his friends and acquaintances said ‘he was no longer Gage’” (Harlow, 1868). Gage lived for another 12 years after the accident, and whilst some of the reports about his excess drinking, slovenliness, and disinhibited behaviour are probably over exaggerations and untruths inspired by 20th Century reports of lobotomy patients (Macmillan, 2000), Gage’s post-injury level of functioning was almost definitely reduced. In 1852 Gage went to South America, driving coaches and tending to horses in Chile until 1860. As his health failed he returned to the USA, living in San Francisco, but he never regained his health and after a series of fits, he died on 21 May 1861 (Harlow, 1868).

Interestingly, despite the relative infamy of Phineas Gage’s injury today, there is little evidence to suggest that it influenced any of the early practitioners of psychosurgery (MacMillan, 2002). Gage was not mentioned by Egas Moniz or Walter Freeman during their early presentations and there is nothing to suggest that Gage’s story influenced neurosurgical technique or prompted greater understanding of neuroanatomy. Early neurosurgeons would have been acutely aware of reports of frontal lobe injury or removal due to tumours, and the frontal lobe syndrome was largely described by Brickner (1936), Feuchtwanger (1923), and others. Freeman and Watts, in their 1942 book Psychosurgery, did mention Gage’s injury in some detail but made no suggestion that it was influential, merely of interest (Freeman & Watts, 1942, p. 43-45). The second edition of the book did not contain reference to Gage, suggesting that his influence had dimmed.

Perhaps the significance of Gage lies in his importance to those who were determined to forward the cause of cerebral localisation towards the end of the 19th Century. David Ferrier, a proponent of localisation, used the case in his 1878 lectures on the subject (Neylan, 1999). The story of Gage also illustrated the relationship between damage to the frontal areas of the brain and personality changes. His injury continues to be discussed in the medical literature to this day (For example: Mataro, Jurado, Garcia-Sanchez, et al, 2001; Neylan, 1999; Ratiu, Talos, Haker, et al, 2004).

References

Brickner, R. M. (1936) Bilateral frontal lobectomy: follow-up report of a case. Archives of Neurology and Psychiatry, 41, 580-585.
Feuchtwanger, E. (1923) Die Funktion des Stirnhirns: Ihre Pathologie und Psychologie. Berlin: Springer.
Freeman, W. & Watts, J. (1942) Psychosurgery. Springfield, IL: Charles C. Thomas.
Harlow, J. M. (1848) Passage of an iron rod through the head. Boston Medical and Surgical Journal, 39, 389-393.
---- (1868) Recovery after severe injury to the head. Publications of the Massachusetts Medical Society, 2, 327-347.
Macmillan, M. (2000) Restoring Phineas Gage: A 150th Retrospective. Journal of the History of the Neurosciences, 9, 46-66.
MacMillan, M. (2002) Gage and Surgery for the Psyche. In An Odd Kind of Fame: Stories of Phineas Gage, pp. 229-253. Cambridge, MA: The MIT Press.
Mataro, M., Jurado, M. A., Garcia-Sanchez, C., et al (2001) Long-term effects of bilateral frontal brain lesion: 60 years after injury with an iron bar. Archives of Neurology, 58, 1139-1142.
Neylan, T. C. (1999) Frontal Lobe Function: Mr. Phineas Gage’s Famous Injury. Journal of Neuropsychiaty and Clinical Neurosciences, 11, 281-283.
Ratiu, P., Talos, I. F., Haker, S., et al (2004) The tale of Phineas Gage, digitally remastered. Journal of Neurotrauma, 21, 637-643.


The Nineteenth Century: Gottleib Burckhardt

The first report of what we would recognise as ‘psychosurgery’ was made by Gottleib Burckhardt, a Swiss psychiatrist, in 1891 (Burckhardt, 1891). In a paper of 85 pages which included detailed case histories, he reported on six patients, described as “demented” and “aggressive” that underwent ‘temporal topectomy’ in the Prefarger Asylum in Switzerland, commencing on the 29 December 1888. His subjects were deluded, hallucinated, and frequently violent, and probably suffered from schizophrenia (Berrios, 1997). His aim was to sever the nerve fibres connecting the frontal lobes and the rest of the brain. His results were mixed: one patient developed epilepsy and died five days postoperatively; a further patient developed epilepsy; and one patient suffered permanent motor weakness. One patient improved; two patients were reported as being quieter; and the other two patients showed no change. He presented his findings at the Berlin International Medical Congress in 1889, but his actions met with a mixture of quiet disregard and open ridicule. Despite previously publishing a book on the physiological basis of mental illness, he never wrote further on the subject.

The debate about surgical approaches to insanity continued, but the consensus view among most psychiatrists was that such interventions could not be justified. One of the most vocal critics was the US psychiatrist, Abraham Brill, who despite publishing criticisms of neurosurgical treatments, was forced to accept that some patients may benefit when no other treatment had succeeded.

The poor outcomes from neurosurgery for most patients with schizophrenia undoubtedly contributed to the scepticism among the medical community. Another factor in the resistance to psychosurgery was probably the development of psychoanalysis by Sigmund Freud in the last decade of the 19th Century. His ideas and writings greatly influenced practice throughout Europe on both the aetiology and treatment of most mental disorders, and it could be argued that the biological approach to mental illness of the last half of the 19th Century was only resurrected in the latter half of the 20th Century.

Despite a reluctance to employ surgical interventions for mental disorder at the end of the 19th Century, intracranial surgery for tumours, epileptogenic foci, and brain injuries (often as a result of the First World War) continued, building the surgical base from which people like Egas Moniz and Walter Freeman would step.

References

Berrios, G. E. (1997) The origins of psychosurgery: Shaw, Burckhardt and Moniz. History of Psychiatry, 8, 61-81.
Burckhardt, G. (1891) Ueber Rindenexcisionen, als Beitrag zur operativen Therapie der Psychosen. Allgemeine Zeitschrift für Psychiatrie, 47, 463-548.


The 20th Century

Jacobsen and Fulton

In the years following the First World War, the idea that specific brain areas were responsible for particular mental functions and aspects of mental illness was undergoing a renaissance. In 1935, Carlyle Jacobsen and John Fulton ablated the prefrontal cortex in two chimpanzees called Becky and Lucy (Jacobsen, Wolfe & Jackson, 1935). Jacobsen used the term “experimental neurosis” to describe Becky’s frustration and anger at her mistakes and failure to achieve a reward during experiments. Lucy was less agitated at her errors, appearing more ‘laid back’ under experimental conditions. After cortical ablation, Becky became more passive and did not show the same responses to failure. However, Lucy displayed much more agitated and aggressive responses during the tests.

The traditional history of psychosurgery would accord that it was Fulton and Jacobsen’s presentation at the Second World Conference of Neurology in London which inspired the Portuguese neurologist Egas Moniz, to develop similar procedures in humans. Indeed, it is relatively certain that Moniz asked the question whether surgical ablation of the frontal lobes could treat anxiety states in humans, but it seems that Fulton, ever the cautious scientist, was cautious about such an extrapolation of his findings. However, it is difficult to see how contrasting responses to the same procedure in only two animals could be the sole justification for extending the procedure to humans. Indeed, Moniz subsequently reported that he had been considering such interventions prior to Fulton and Jacobsen’s reports. It is more likely that Moniz was more influenced by Brickner and Penfield’s presentations at the same all-day conference (also attended by Walter Freeman) when Brickner gave a detailed description of his famous case, Joe A., reporting that his psychic functions were affected quantitatively rather than qualitatively [1]. MacMillan argues that this lead Moniz to conclude that frontal lobe damage had potentially non-significant, and transitory, effects on the individual (MacMillan, 2002).

Egas Moniz

Whatever the true inspiration for experiments in humans, at the end of 1935 Moniz teamed up with Almeida Lima, a neurosurgeon (who had trained under Hugh Cairns, England’s leading neurosurgeon) who agreed to perform the procedures under the direction of Moniz. After practising on a cadaver, they went on to treat 20 patients, seventy percent of who came from the Manicome Bombarda asylum. The first operation, lasting thirty minutes, was performed by Almeida Lima with the assistance of Ruy de Lacerda on 12 November 1935 at the Neurology Service of the Santa Marta Hospital. Although Moniz’s paper (1936) includes a note of thanks to Sobral Cid, the director of the asylum, Cid was apparently less than enthusiastic about Moniz’s activities. Whilst the first four patients had been selected by Cid, all the postoperative assessments of the patients were performed by a young psychiatrist called Barahona Fernandes, and Cid refused to provide any more cases. The patients had been institutionalised with a range of psychiatric illnesses characterised by severe anxiety, obsessional behaviour, and irrational fears. Thirty percent of the patients came from "other sources", and his cases were probably selected because of availability rather than other reasons (Valenstein, 1986, p. 105). A number of cases had schizophrenia. Subsequent analysis of Moniz’s results by Berrios (1997) reveals that three factors predicted a better outcome: older age; female sex; and affective (rather than non-affective) psychosis.

They started by injecting alcohol to cause the desired lesions, but this tended to track along the injection tracts causing extraneous damage, and after the seventh patient they switched to using a leucotome to cut the fibres connecting subcortical areas in the brain and the frontal lobes. The leucotome was a thin, cylindrical device with a retractable wire which allowed 'cores' of tissue to be created in the white matter. They initially created six lesions bilaterally, but would create additional lesions during later procedures if the patient did not respond.

Moniz’s patients were probably suffering from a mixture of depression, schizophrenia, or panic disorder. Although there were no objective data collected other than case reports, he reported that: 35% had “clinical recovery”; 35% enjoyed “ameliorations”; and 30% showed no improvement (Moniz, 1936). Moniz reported that, “none of the patients became worse after the intervention” and boldly stated that, “No deaths. The intervention is harmless.” They presented their results in Paris on 3 March 1936 and published their first paper shortly afterwards. So keen was Moniz to get to publication that the follow-up period for most patients was less than two months and for four of the ‘cures’ the last observation was less than eleven days after the operation.

Moniz was the first person to use the term ‘psychosurgery’ in 1936 (Moniz & Lima, 1936), and he went on to be jointly awarded the 1949 Nobel Prize for Physiology and Medicine for his work in establishing leucotomy for psychosis. It is likely that Moniz’s previous work (the development of cerebral angiography) contributed to the award, and along with Moniz’s desire for recognition, this may explain why Moniz’s tentative experiments received more attention than Burckhardt’s. Moniz had been nominated by a Brazilian delegation at the First International Congress of Psychosurgery in Lisbon, and the nomination letter was written by António Flores, a renowned neurologist at the University of Lisbon. Incidentally, it was before Flores that Moniz had been awarded the professorship of neurology at the University of Lisbon in 1911. With regard to the Nobel Prize, Gosta Rylander, the Swedish neurosurgeon, was on the selection panel and was one of those who signed the award (Valenstein, 1986, p. 225). It was not the first time that Moniz had been nominated for the Nobel Prize. In 1928, less than six months after the first cerebral angiogram had been performed, the Nobel Committee received two nomination letters from Moniz’s colleagues. He was nominated once more in 1933 for his work in cerebral angiography, again by colleagues from the University of Lisbon (Valenstein, 1986, p. 77).

Moniz had started his career in politics, rather than surgery. He had been christened António Caetano de Abreu Freire Egas and had added the name Moniz in honour of Egas Moniz de Ribadouro, a Portuguese patriot who had helped to defend Portugal from the Muslim invasion of the Iberian Peninsula in the 12th Century. Prior to his surgical career Moniz had served as a minister to Spain and was a signatory to the Treaty of Versailles. Later in his career, after a political shift in Portugal to a more right-wing government, Moniz ceased his psychosurgical activity and devoted his time again to cerebral angiography. Eventually, Moniz was shot and injured by a former psychiatric patient in 1939, and although many have claimed that this patient had undergone leucotomy under Moniz, this has not been substantiated. He ended his days incapacitated with gout, an illness that had affected him for most of his life.


Freeman and Watts

In July 1936 – only four months after Moniz started performing his leucotomies – a US neurologist named Walter Jackson Freeman had published a review of Moniz’s work (Freeman, 1936). He discussed such reports with a neurosurgical colleague, James Watts and they ordered a number of Moniz’s leucotomes from Moniz’s instrument-maker in France. After practising the procedure on cadavers in the mortuary they modified Moniz’s technique slightly (adopting a lateral rather than a superior approach), and started treating patients with depression, using a procedure of their own called bilateral frontal leucotomy. It is reported that when Freeman and Watts performed their lobotomies in the USA, Watts operated with the leucotome whilst Freeman gave ‘directions’ from the head end of the bed (Slovick, 2004). Freeman’s knowledge of neuroanatomy was probably unparalleled by most neurosurgeons, but his lack of surgical privileges prevented him from performing the procedure himself. However, in 1937 whilst Watts was unwell he went ahead with a lobotomy, causing a surgeon at George Washington University to complain.

At the Southern Medical Association conference in Baltimore in November 1936 Freeman and Watts presented their results of the first six cases. Freeman chose to refer to their procedure as ‘lobotomy’, both to reflect a more accurate term for the lesion but arguably also to distinguish his technique from Moniz’s procedure. Such a semantic change would also allow him to retain ‘ownership’ of the term when he and Watts went on to further develop the procedure.

In the late 1930s and early 1940s, Freeman and Watts’ results with chronic schizophrenic patients appeared poor, with many patients relapsing. This led Freeman to adopt the view that lobotomy should be made more readily available to other patient groups. One of the perceived problems with the standard frontal lobotomy was that it required a surgical team, and in 1945, inspired by the work of Italian Amarro Fiamberti who had published a report in 1937, he adopted a transorbital approach. Such a route to the brain was not new. A. M. Doglotti had used the route for ventricular puncture and Maurice Ducosté had used a transorbital technique for introducing malaria inoculations into the brain (Ducosté, 1932). Fiamberti had used the approach in approximately 100 patients using alcohol or formalin to create lesions in the frontal lobes before the outbreak of World War II diverted his attentions elsewhere.

Freeman searched for the perfect tool with which to perform such a procedure and is reported to have eventually come across an ice-pick in his kitchen drawer. Indeed, his original tool had the name of the ‘Uline Ice Company’ engraved on it. With a few modifications (including strengthening the tool), the ‘ice-pick lobotomy’ (a.k.a. transorbital lobotomy) was born. The procedure involved inserting an instrument under the eyelids, through the roof of the orbit, and into the fronto-orbital cortex. A quick sweeping motion cut the fronto-thalamic tracts. It was essentially a non-sterile procedure, could be performed with minimal anaesthesia (often two electroconvulsive treatments were used), and required a minimal team.

The first transorbital lobotomy took place in January 1946 and the first 10 cases were performed in Freeman’s office in the subsequent two months. Typically, patients were allowed home with a relative in a taxi after an hour or two, reportedly with little more than two black eyes and some disorientation. Watts disapproved of the procedure from the outset, arguing that ‘brain surgery should not take place as an office procedure’, and he eventually moved out of their shared offices in Washington. Watts intervened to prevent Freeman from performing transorbital lobotomy at George Washington University and Freeman sought permission to perform transorbital lobotomy under ECT anaesthesia (and was successful) at two other hospitals in Washington D. C. Following Watts’ separation from Freeman at this time, Freeman took on a new neurosurgical partner, Jonathan Williams, who was less surgically conservative than Watts. However, Watts and Freeman did not sever their partnership completely and Watts went on to perform 28 transorbital lobotomies with Freeman between 1949 and 1956, albeit in a neurosurgical operating theatre.

Walter Freeman was undoubtedly a gifted neurologist who was devoted to the treatment of mental illness. Like Moniz, he was politically astute and desired recognition. He was very aware of the power of the media to further his cause, and has even been described as a ‘showman’ at times. He exhibited at every American Medical Association conference from 1937-1946, reportedly using a clacker and shouting like a “carnival barker” to draw crowds (El-Hai, 2005, p.123). One frequent criticism of Freeman is that he was cavalier in his approach and there are certainly episodes which do nothing to silence his critics. In the early 1940s, before the use of muscle relaxants during ECT, Freeman treated a private patient with ECT in his offices. His secretary, who usually helped, was unavailable and the patient’s husband was too physically frail to assist. Alone, Freeman proceeded to give ECT but the patient’s seizure broke both of her legs. Freeman gave her morphine before leaving to see patients at the hospital and when he returned he found the patient and her husband angry and litiginous. Freeman eventually settled out of court (El-Hai, 2005, p.133).

Freeman also infamously performed a transorbital lobotomy in a motel room, after the patient had failed to attend for numerous appointments. The patient had been apprehended by police after causing a disturbance and Freeman collected his surgical tools and drove to the motel, where the patient underwent lobotomy after the police restrained him whilst Freeman used ECT to sedate him.

Freeman was cavalier but he was undoubtedly committed, and through his efforts lobotomy entered the public and professional consciousness. Famous people who underwent prefrontal lobotomy include Rosemary Kennedy, the eldest sister of John F Kennedy who was operated on by Freeman and Watts in 1941, at the age of 25. Unfortunately, the operation was unsuccessful, and she lived the remainder of her years in institutional care, inert and with limited speech. Freeman is also widely reported to have operated on the actress Frances Farmer, and whilst it is still claimed in the popular media that she underwent the procedure (Toomey & Young, 2006), there are no clear records to support this assertion and she and her family have persistently denied that she had a lobotomy (Tate, 2003). Despite such incorrect claims about lobotomy’s alleged “victims”, it has nevertheless entered into the public’s perceived history of psychosurgery [2].


Psychosurgery spreads

Whatever the truth behind the initial inspiration of the lobotomy, the fact that it rapidly became such a widespread treatment for schizophrenia and other mental disorders is remarkable. James Watts was originally a student of John Fulton and by the end of the 1930s Fulton was a prominent figure in American psychiatry. Watts engaged in regular correspondence with Fulton, who met up with Watts and interviewed some of the early lobotomy patients. Convinced of the potential value of the procedure, Fulton spread the word among his network of influential colleagues and once Fulton was a public proponent of lobotomy, sceptics such as the Harvard psychiatrist Harry Solomon were won over. In particular, it is argued that Fulton’s support gave the procedure a neurophysiological legitimacy (Pressman, 1998).

It is interesting to acknowledge that a relatively small number of psychiatrists and neurosurgeons were responsible for spreading lobotomy across the globe. International travel in the 1930s and 1940s is insufficient to explain the widespread uptake. Moniz was a political man who was unlikely to have missed an opportunity for self-publicity. Walter Freeman, driven by his desire to achieve as much as his grandfather W. W. Keen, demonstrated his talent for ‘drawing a crowd’ at most of the conferences he attended. Together, they managed to put lobotomy in most of the mental hospitals in the USA in the 1940s. In 1939 Freeman went to a conference in Copenhagen, and although many Scandinavian psychiatrists were shocked, within 2 years the first lobotomy was being performed in Norway with Ørnulv Ødegård, the director of Gaustad Hospital in Oslo, at the helm.

The fact that Ødegård led with such enthusiasm resulted in a board of inquiry being set up by the Ministry of Health in Norway in 1992 to investigate claims of falsifications over the lobotomy cases. In 1996, the Norwegian Health Department agreed to pay compensation (approx. £10,000) to patients who had undergone lobotomy in Norway (Goldbeck-Wood, 1996). In an attempt to explain the use of lobotomy in Norway, the report (Utredning om lobotomy, 1992: 11) stated that:

The attitude of trendsetting individuals may be decisive for a development, especially in a non-homogenous society like the Norwegian one. The attitude of chief psychiatrist Ørnulv Ødegård can offer an explanation of why the use of lobotomy reached such an extent in Norway. (Cited in: Tranøy & Blomberg, 2005)

Norway was not alone, however. Within five years of Moniz’s first reports of prefrontal leucotomy, the procedure was being performed, outside the USA, in: Brazil (by Pimenta); in France (by Ferdière); in Italy (by Ventura, Ody, Rizzatti, and Sai); in Romania (by Bagdasar and Constantinesco); and the UK (by Hutton and McGregor, amongst others) (Hutton, Fleming & Fox, 1941).

Psychosurgery in a socio-economic context

The neurosurgical techniques employed by Freeman, Watts, and others were, unsurprisingly, crude and inconsistent. The use of external skull landmarks was unreliable and resulted in wide variation in the plane of section from case to case. Whilst the surgeon thought he was cutting brain tissue, often he was merely moving the brain laterally with the leucotome (Swayze, 1995). Despite the surgical problems (which were probably recognised at the time but not widely reported) the lack of effective treatments for chronically hospitalised and psychotic patients meant that the potential benefit of the surgery for selected patients was more compelling than the apparent risks of the procedure. Menninger (1948) illustrates some of the challenges in the public healthcare system with some statistics:

  • In the USA in 1946, 46% of all hospital beds were filled with psychiatric patients.
  • In 1943, there was an annual net increase of 33,000 in the hospital population, with 100,000 new admissions to state hospitals.
  • In 1946, the number of admissions had increased to 271,209. If the minimum standards set down by the American Psychiatric Association were to be met then the cost of inpatient treatment would be $500-700 million. The actual amount spent in 1945 was $165,743,122.

Already by 1946 state hospitals were overcrowded by 17.5%. Surveys at the time revealed that the ratio of patients to doctors in the mid-1940s was at least 250:1 in one-third of the state hospitals (Pressman, 1998, p.151). The survival of a state mental hospital was dependent on three factors: the number of admissions; the rate of discharge; and the number of beds available. Funding for new beds was seldom available; admissions were continuously rising; and so the only factor that the hospital could control was the rate of patient discharge. Treatments were limited and the potential crisis in hospital care undoubtedly led many to seriously consider any treatment which may help to help patients out of hospital.

Further, long-term patients in many public psychiatric hospitals in the first quarter of the 20th Century had an alarmingly high mortality rate, often from tuberculosis. Between the years of 1950 and 1964, more people died in United States ‘mental institutions’ than died in the Revolutionary War, the War of 1812, the Mexican War, the Civil War, the Spanish-American War, World War I, World War II, the Korean War, Vietnam, and the Persian Gulf War combined. In the twenty-five years between 1965 and 1990 the total number of inpatient deaths is estimated at over one million individuals (O'Meara, 2001).

Meanwhile, in the UK, the chances of discharge from mental hospital in 1949 was dependent on duration spent in hospital, and ranged from 7% (2-3 years in hospital) to 0.5% (25-30 years in hospital) (Robin, 1958). The early reports of positive and often dramatic outcomes in patients for whom no treatment was previously available resulted in an optimism that is easy now to criticise. Many proponents of psychosurgery were probably blinded to adverse effects and poor outcomes, despite it being known that frontal lobe damage or removal could cause changes in behaviour (Ackerly, 1935). The poorer outcomes reported in schizophrenia within five years of the first leucotomy (Freeman & Watts, 1945) did not deter psychiatrists and surgeons sufficiently to abandon the procedure for this group. Edward Strecker’s 1942 paper reported that out of five patients with chronic schizophrenia who underwent lobotomy, two were able to be discharged and three were improved (Strecker, Palmer & Grant, 1942). This paper, which was likely to have been widely-read at the time, is cited as having revitalised the role of lobotomy in chronic psychosis (Tierney, 2000).

Psychiatry in a social context

Prior to the 1920s, psychiatry as a medical specialty did not exist. Instead, patients with mental health problems would be treated by primary care physicians, neurologists, and physicians who were working in large public health asylums. Treatments were largely ad hoc, often improvised, and not influenced by any particular model or theory which underpinned the specialty.

In the early 1920s, psychiatry in the USA began to coalesce under a single banner, primarily because of the influence of one man, Adolf Meyer (1866-1950). Indeed, he reclaimed the term ‘psychiatry’ (which had become synonymous with asylum-based medicine) and sold this new specialty to a new generation of doctors. It can be argued that Meyer’s reforms would not have had such wide-reaching effects if it had not been for the First World War.

Struggling to deal with ‘war neurosis’ on an enormous scale, the USA needed new models of delivering psychiatric care to large numbers of people. The successes of the physicians on the front lines, in treating the mental health problems that arose out of the stresses of combat, convinced many that things could be done for sufferers of mental disorder and also illustrated the fact that mental ill health could arise in anyone if there was sufficient stress. The Great War also served to unite the private neurologist and public health asylum worker in the need to both screen out those unfit for military service because of vulnerabilities to neurosis, and also to return those suffering from the psychiatric consequences of combat to useful roles in society. Some may argue that the image of the psychiatrist as an agent of authority and social control was born out of this period. In 1926 William Healy, the chair of an American Psychiatric Association panel on the role of psychiatry in society, announced that:

…it is exactly the psychiatrist’s proper business to take over the problems of mental adjustments that are so immediately and overwhelmingly involved in the problems of personality, of family and other social maladjustments, of misconduct, of vocational dissatisfactions, of educational misfittings in primary or secondary school or college.” (Cited in Pressman, 1998, pp 28-29)



1. Joe A. was a 39-year-old stockbroker who underwent bilateral frontal lobe resection to treat a large glioma. After the procedure, despite having no motor or sensory deficits, his personality and social judgement was clearly impaired, and was unable to plan for the future. Despite being able pre-operatively, post-operatively he was unable to work, having to rely on his family for care.

2. It was William Arnold who first suggested that Frances Farmer underwent a lobotomy in his 1978 book 'Shadowland', which was a fictionalised biography of Farmer. The 1982 film 'Frances' helped to perpetuate the claim. Interestingly, the film-makers created a fictional character 'Harry York' in order to claim that the film was based on original material, and not William Arnold's book.

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Ducosté, M. (1932) L'Impaludation cérébrale. Bulletin de l'Académie de Médecine, Paris, 107, 516-518.
El-Hai, J. (2005) The lobotomist: a maverick medical genius and his tragic quest to rid the world of mental illness. Hoboken, NJ: John Wiley & Sons.
Freeman, W. (1936) Review of 'Tentatives opératoires dans le traitement de certaines psychoses'. Archives of Neurology and Psychiatry, 36, 1413.
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Hutton, E. L., Fleming, G. W. T. H. & Fox, F. E. (1941) Early results of prefrontal leucotomy. Lancet, 238, 3-7.
Jacobsen, C. F., Wolfe, J. B. & Jackson, T. A. (1935) Experimental analysis of functions of frontal association areas in primates. Journal of Nervous and Mental Disease, 82, 1-14.
MacMillan, M. (2002) Gage and Surgery for the Psyche. In An Odd Kind of Fame: Stories of Phineas Gage, pp. 229-253. Cambridge, MA: The MIT Press.
Menninger, W. C. (1948) Facts and statistics of significance for psychiatry. Bulletin of the Menninger Clinic, 12, 1-25.
Moniz, E. (1936) Essai d'un traitement chirurgical de certaines psychoses. Bulletin de l'Académie de Médecine, 115, 385-392.
Moniz, E. & Lima, A. (1936) Premiers essais de psychochirurgie - Technique et résultats. Lisboa Médica, 13, 152.
O'Meara, K. P. (2001). Forgotten Dead of St. Elizabeths. Insight Magazine, 6 August 2001, p.
Pressman, J. D. (1998) Last Resort. Psychosurgery and the Limits of Medicine. New York, NY: Cambridge University Press.
Robin, A. A. (1958) A controlled study of the effects of lobotomy. Journal of Neurology, Neurosurgery and Psychiatry, 21, 262-269.
Slovick, L. (2004). The Walter Freeman/ James Watts Collection. The George Washington University. Website. Last updated: Friday, 12-Aug-2005. Accessed: 12 November, 2005. Available at: http://www.gwu.edu/gelman/archives/collections/freeman_watts.html
Strecker, E. A., Palmer, H. D. & Grant, F. C. (1942) A Study of Frontal Lobotomy. Neurosurgical and Psychiatric Features and Results in 22 Cases with a Detailed Report on 5 Chronic Schizophrenics. American Journal of Psychiatry, 98, 524-530.
Swayze, V. W., 2nd (1995) Frontal leukotomy and related psychosurgical procedures in the era before antipsychotics (1935-1954): a historical overview. American Journal of Psychiatry, 152, 505-515.
Tate, C. (2003). Farmer, Frances (1913-1970) -- Part Two. HistoryLink.org - the Online Encyclopedia of Washington State History. Website. Last updated: January 17, 2003. Accessed: 19 February, 2006. Available at: http://www.historylink.org/essays/output.cfm?file_id=5059
Tierney, A. J. (2000) Egas Moniz and the Origins of Psychosurgery: A Review Commemorating the 50th Anniversary of Moniz's Nobel Prize. Journal of the History of the Neurosciences, 9, 22-36.
Toomey, C. & Young, S. (2006). Mental Cruelty. Sunday Times Magazine, 19 February 2006, p. 48-57
Tranøy, J. & Blomberg, W. (2005) Lobotomy in Norwegian psychiatry. History of Psychiatry, 16, 107-110.
Valenstein, E. S. (1986) Great and Desperate Cures. New York, NY: Basic Books.


Psychosurgery in Europe

Spurred on by excessively optimistic publications about the benefits of lobotomy, and driven by the pressures upon the public mental health system by the psychiatric casualties of World War II, psychiatrists and neurosurgeons in the USA and Europe emphatically embraced the new treatments that were available to them. Sweden, Norway, and Denmark together performed two-and-a-half times as many lobotomies per capita as the USA (Tranøy, 1996), and after the USA (with 40,000 lobotomies) and Great Britain (with 17,000), Scandinavia was the third most active region (with 9,500) in terms of absolute numbers.

Psychosurgery in Sweden

In 1939, Gösta Rylander proposed that psychosurgery should be performed in Sweden, and its psychosurgery programme has been active for the last 60 years. It is claimed by Tranøy (1996) that without the influence of Walter Freeman lobotomy might never have been adopted. Freeman visited Copenhagen in August 1939 and lectured on lobotomy. His book Psychosurgery was published in 1942. In Denmark, there was initial resistance to the new treatment but the early reports emerging from the USA and Great Britain were simply too compelling.

The first lobotomy in Scandinavia was performed at Gaustad Mental Hospital, Oslo in 1941. The practice was led by Ørnulv Ødegård, the director of Gaustad Mental Hospital, who had studied under Adolf Meyer in the USA and he had retained many contacts there. It is estimated that 2500 patients underwent lobotomy in Norway, frequently in mental hospitals rather than neurosurgical centres as a consequence of the geography (Tranøy & Blomberg, 2005). Norway was a little unusual in that it embraced transorbital lobotomy, and its psychosurgery programme had high mortality rates with almost 30% of patients dying shortly after surgery (Tranøy, 1996). Psychosurgery was last performed in Norway in the mid 1970s and in Denmark in 1981.

The Swedish lobotomy programme performed approximately 4,500 operations between 1944 and 1966, with 28% of all operations being performed in two hospitals; Umedalen, and Sidsjön State Mental Hospital. At Umedalen, women made up approximately 63% of all cases, and 63% of all deaths, which averaged out at a mortality of 7.4% between 1947 and 1955, but peaked at 17% in 1949. Of 101 women operated on between 1947 and 1949, only 14% were eventually sent home, and only 3% were able to work (Ögren & Sandlund, 2005).

Eastern Europe

Some countries, particular in Eastern Europe, were opposed to psychosurgery and the USSR announced a ban at the World Federation for Mental Health in Vienna in 1953. Arguing that it turned “an insane person into an idiot” Russian psychiatrists concluded that “lobotomy is an anti-physiological method that makes the patient an intellectual invalid” (Laurence, 1953). Another oft-cited reason for the ban was that it was considered ‘anti-Pavlovian’ and therefore anathema in the USSR at the time.

Psychosurgery in the UK

As stated above, Great Britain was second only to the USA in the total number of psychosurgical procedures performed. The rapid adoption of leucotomy in the UK during the 1940s is shown below in Figure 1.

Leucotomies by Year

Figure 1 : Leucotomies performed by year 1942-1954. From data by Tooth and Newton (1961)

In the 12 years between 1942 and 1954, there were 10,365 leucotomy procedures performed in England and Wales (Tooth & Newton, 1961). This was a questionnaire survey and is likely to have missed as many as 300 procedures per year. The diagnostic breakdown is given below in Table 1. The number of leucotomies by indication, during 1948-1954 is shown below in Figure 2. Whilst the procedure appeared to be in decline for both schizophrenia and affective disorders by 1954, it was increasing for the ‘Other’ category.

Table 1 :  Diagnostic Breakdown of Leucotomies performed, 1942-1954 (Tooth & Newton, 1961)

 

Diagnosis

Total

Schizophrenia

6,591

Affective

2,637

Other

1,137

 

10,365

 

Leucotomies by Indication 1948-1954

Figure 2: Number of Leucotomies performed in the UK, 1948-1954. From data by Tooth and Newton (1961)

The numbers of procedures performed in the USA is difficult to estimate with accuracy, but a survey of all state hospitals reported that at least 18,600 operations had been performed by 1951 (Kramer, 1954).  Assuming an equal yearly distribution and that these figures do not include procedures before Freeman and Watts (1938), this equates to 1,430 procedures per year in the USA. Elliot Valenstein estimates that approximately 40,000 ‘earlier’ procedures were carried out in the USA (Valenstein, 1973, p. 55).

These numbers should be viewed in context. Clozapine, an atypical antipsychotic drug is licensed for the treatment of refractory schizophrenia (Joint Formulary Committee, 2005). Over the fifteen years from 1990 to 2005, 41,500 patients were treated with clozapine (Annan, 2005), and the rate of adoption of this new treatment is shown in Figure 3. This suggests that ablative neurosurgery was being used in both the UK and USA within the same order of magnitude as the most effective current treatment for treatment-refractory schizophrenia today.

Patients enrolled on Clozapine

 

Figure 3 : New patients enrolled on Clozapine 1990-2005. From data provided by Novartis.

References

Annan, L. (2005). Numbers of Patients on Clozapine in UK (Personal Communication).
Joint Formulary Committee (2005) British National Formulary 49. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
Kramer, M. (1954) The 1951 survey of the use of psychosurgery. In Third Research Conference on Psychosurgery: Public Health Service Publication 221 (eds F. A. Mettler & W. Overholser). Washington, DC: US Government Printing Office.
Laurence, W. L. (1953). Lobotomy Banned in Soviet as Cruel. New York Times, 22 August 1953, p. 13
Ögren, K. & Sandlund, M. (2005) Psychosurgery in Sweden 1944-1964. Journal of the History of the Neurosciences, 14, 353-367.
Tooth, J. C. & Newton, M. P. (1961) Leucotomy in England and Wales 1942-1954. Reports on public health and medical subjects. London: Ministry of Health.
Tranøy, J. (1996) Lobotomy in Scandinavian Psychiatry. The Journal of Mind and Behavior, 17, 1-20.
Tranøy, J. & Blomberg, W. (2005) Lobotomy in Norwegian psychiatry. History of Psychiatry, 16, 107-110.
Valenstein, E. (1973) Brain Control: A Critical Examination of Brain Stimulation and Psychosurgery. New York: Wiley.


The Decline of Lobotomy

Introduction of drug treatments for schizophrenia

The widespread introduction of chlorpromazine in 1954 was associated with reduced rates of psychosurgery across the globe, and gave State Hospital staff a valuable new treatment for psychotic and agitated patients (See Figure 5). In New York State, in 1956 there were more discharges from hospital than the previous year, despite a greater number of admissions. The rate of readmission was reduced as well (Brill & Patton, 1957).

It is estimated that over 2 million people in the USA received chlorpromazine in the first year after its release (Feldman & Goodrich, 2001), and for the first time, there was an alternative to insulin coma, electroconvulsive therapy, and psychosurgery. Ironically, the effects of chlorpromazine on many patients were described in terms of reduced property destruction, improved behaviour, and satisfaction of relatives. Much of the structure that existed to assess the response to chlorpromazine in the state hospitals had been developed from, or had evolved from, experiences with psychosurgery (Pressman, 1998, p. 422). For example, the Inpatient Multidimensional Psychiatric Scale (IMPS), developed by Lorr in the early 1960s was used to assess symptom improvement in the NIMH collaborative study of Chlorpromazine (Guttmacher, 1964). The scale itself was developed to assess responses to psychosurgery a number of years previously.
Despite hopes, chlorpromazine was not perfect, and adverse effects were recognised within the first year or so (Cohen, 1956). Some patients who did not respond to the new medication still progressed to lobotomy as a treatment of last resort.

Public attitudes towards psychosurgery

During the 1950s, public antipathy to psychosurgery led to mounting socio-political pressure on psychiatrists and neurosurgeons to stop performing such procedures. The general public and a large, vocal proportion of the medical profession were vehemently opposed to such procedures. It is generally accepted that popular opinion led to a decline in psychosurgery but this is likely to be an oversimplification. In a review of magazine and newspaper articles from 1935 to 1960, Diefenbach et al (1999) found that from 1935 to 1944 articles were generally positive in their reporting of psychosurgery, often excessively so. However, from 1945-1954 reporting became more balanced and authors debated the risks associated with such procedures, which were being widely performed. In 1949, Egas Moniz received the Nobel Prize for Medicine for the development of leucotomy for psychosis. During this period the press became increasingly negative, beginning to criticise an apparent eagerness to perform surgery without key questions about safety and efficacy being asked.

Whilst much of the opposition to psychosurgery was critical of an absence of research detailing key outcomes, and the changes in personality and higher cognitive functions, many of the arguments took a rather ‘principled’ approach, accusing psychosurgery of irreversibly removing such attributes as “personal sovereignty” and “personal freedom” (Breggin, 1980). To better understand the opposition to psychosurgery that was developing, it is important to take into account a number of other factors (Sections 3.7.3 and 3.7.4).

Diagnostic Uncertainty

During the period when psychosurgery was in its heyday many of the patients who were in psychiatric institutions would probably have been unlikely to warrant admission to hospital in the UK today. Many patients who underwent psychosurgery weren’t even inpatients (Bernstein, Callahan & Jaranson, 1975). Furthermore, diagnosis was an inexact (and corruptible) science as David Rosenhan’s famous experiment, “On being sane in insane places” demonstrated (Rosenhan, 1973). During the 1970s, there were significant cross-national differences in the rates of diagnosis of schizophrenia. In the USA (New York) the rate of diagnosis was 65% whilst the rate in London was 34%, despite similar rates of admission and the fact that both countries were using the same classification system, ICD-8 (Cooper, Kendall, Gurland, et al, 1972). In the USA, many patients with mania, for example, would be diagnosed as schizophrenic and Gurland and colleagues went on to comment that, “New York hospital staffs tend to give a diagnosis of schizophrenia to the major proportion of every kind of patient group” (Gurland, Fleiss, Cooper, et al, 1970). The authors of the report also stated that, “there is a tendency in New York for most patients, other than those with organic or addictive states, to be regarded as schizophrenics regardless of their symptoms” (Cooper, Kendall, Gurland, et al, 1972). This is undoubtedly a rather damming assessment of the robustness of a diagnosis of schizophrenia in the USA. It is a reasonable conclusion, therefore, that:

  1. A significant number of patients who underwent psychosurgery in the 1960s and 1970s probably did not have schizophrenia as we would recognise it now. A diagnosis of schizophrenia was a poor prognostic indicator following psychosurgery in the UK, but less so in the USA. This may have reflected the inclusion of other diagnoses (with a greater likelihood of good outcome) within the ‘schizophrenic’ category in the USA. The poor outcomes reported in the popular press and in various medical journals will reflect the effects of leucotomy on a heterogenous group of patients. Many patients received leucotomy because of a lack of response to other treatments, but the possibility of incorrect diagnosis is not mentioned as a cause of non-response in early reports of psychosurgical techniques. It is a noticeable point among most of the early literature on psychosurgery that the diagnosis was vague at best. Performing a retrospective diagnosis from early published reports is virtually impossible due to the lack of information given.
  2. Reports of a diminution of personality, drive, and other higher-order functions are easier to understand if we assume that many subjects reported in the literature would have not had indications that we recognise now as appropriate for neurosurgical intervention. Indeed, it is likely that in the absence of chronic depression or OCD, the operation was performed on what we would recognise now as ‘normal brain’.
  3. Due to uncertainties in the diagnosis, the rates of improvement in an individual’s condition would have been unpredictable and it would not have been safe to assume that an individual would have had an unremitting course. Rates of improvement following hospitalisation for schizophrenia ranged from 5% recovered (paranoid) to 20% recovered (catatonic) to 10% much improved (paranoid) to 21% much improved (simple) (Cheney & Drewry Jr., 1938). Other studies have found that in those cases with less than 6 months duration of illness, 34.5% were improved at 5-10 year follow-up (Rupp & Fletcher, 1940). Romano and Ebaugh (1938) found that 23% were improved although only one patient fulfilled criteria for remission/ recovery without defect.

Theories of psychiatric illness

By the end of the 19th Century, biological psychiatrists had explored the brain and nervous system in great detail but had failed to connect abnormal brain structure or function with psychiatric illness, with the only exception being neurosyphilis. Carl Wernicke (who was convinced that psychiatric disorders were caused by disturbances of the associative system) and Jean-Martin Charcot (who believed that hysteria was caused by traumatic experiences in those individuals with “degenerate” brains) had both been unsuccessful in their attempts to discover demonstrable abnormalities in the brains of their psychiatric patients. At the same time, Sigmund Freud was developing his ideas about the causes of mental illness. Freud was first read in the USA in the late 19th Century and first visited the USA in 1909. It wasn’t long before his ideas were becoming popular and the American psychoanalytical movement sprang up within a few years of his visit to the USA. State hospitals were typically large, depressing buildings overflowing with patients for whom there was little treatment, and therapeutic nihilism among staff was undoubtedly widespread. The prospect of being able to take the practice of psychiatry to private offices in the community was appealing to many US psychiatrists, and the potentially lucrative nature of private psychoanalysis would have been attractive

References

Bernstein, I. C., Callahan, W. A. & Jaranson, J. M. (1975) Lobotomy in Private Practice. Archives of General Psychiatry, 32, 1041-1047.
Breggin, P. R. (1980) Brain Disabling Therapies. In The Psychosurgery Debate: A Model for Policy Makers in Mental Health (ed E. Valenstein), pp. 467-492. San Francisco: WH Freeman and Co.
Brill, H. & Patton, R. E. (1957) Analysis of 1955-1956 Population Fall in New York State Mental Hospitals in First Year of Large-Scale Use of Tranquillizing Drugs. American Journal of Psychiatry, 114, 509-517.
Cheney, C. O. & Drewry Jr., P. H. (1938) Results of Non-Specific Treatment in Dementia Præcox. American Journal of Psychiatry, 95, 203-217.
Cohen, I. M. (1956) Complications of Chlorpromazine Therapy. American Journal of Psychiatry, 113, 115-121.
Cooper, J. E., Kendall, R. E., Gurland, B. J., et al (1972) Psychiatric Diagnosis in New York and London (Maudsley Monograph 20). London: Oxford University Press.
Diefenbach, G. J., Diefenbach, D., Baumeister, A., et al (1999) Portrayal of lobotomy in the popular press: 1935-1960. Journal of the History of the Neurosciences, 8, 60-69.
Feldman, R. P. & Goodrich, J. T. (2001) Psychosurgery: a historical overview. Neurosurgery, 48, 647-657.
Gurland, B. J., Fleiss, J. L., Cooper, J. E., et al (1970) Cross-national study of diagnosis of mental disorders: hospital diagnoses and hospital patients in New York and London. Comprehensive Psychiatry, 11, 18-25.
Guttmacher, M. S. (1964) Phenothiazine Treatment in Acute Schizophrenia; Effectiveness: the National Institute of Mental Health Psychopharmacology Service Center Collaborative Study Group. Archives of General Psychiatry, 10, 246-261.
Pressman, J. D. (1998) Last Resort. Psychosurgery and the Limits of Medicine. New York, NY: Cambridge University Press.
Romano, J. & Ebaugh, F. G. (1938) Prognosis in Schizophrenia: A Preliminary Report. American Journal of Psychiatry, 95, 583-596.
Rosenhan, D. L. (1973) On Being Sane in Insane Places. Science, 179, 250-258.
Rupp, C. & Fletcher, E. K. (1940) A Five to Ten Year Follow-Up Study of 641 Schizophrenic Cases. American Journal of Psychiatry, 96, 877-888


A Renaissance (of sorts)

In the 1960s and 1970s there was a modest revival in interest in psychosurgery, partly as a result of developments in stereotactic technique that moved surgical intervention away from the freehand procedures exemplified by the work of Freeman and Watts. This ‘second wave’ of psychosurgery was undoubtedly not of the scale of the 1950s. A review of psychosurgical activity in the USA by Elliot Valenstein, commissioned by The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1977) was able to estimate that the number of procedures performed annually in the USA in the early 1970s to be 414. Corresponding estimates were 200-250 for the UK and 83 for Australia. It is interesting to note that four surgeons were responsible for 48% of the activity reported in 1973. A questionnaire survey of psychosurgery centres in the USA, inquiring about activity from 1971-1973 revealed that 195 neurosurgeons had performed 1,039 procedures for psychiatric conditions during those three years, supporting Valenstein’s estimate to be reasonably accurate (Donnelly, 1978).

The total number of NMD procedures in the UK from 1979-1995 is given in Figure 1. Although the rate of NMD was clearly decreasing by the late 1970s it is apparent that the introduction of the Mental Health Act 1983 may have had an effect on activity, and helped to keep procedures at a constant level.

NMD procedures in UK by year 1979-95 annotated
Figure 1 : Total number of NMD procedures in the UK (1979-95). From data by Freeman (1997).

 

In the 'third wave' of neurosurgery for mental disorder, stereotactic procedures took over from earlier interventions. Important landmarks in this development include:

  • 1962 - Foltz and White: the first open Anterior Cingulotomy.
  • 1964 - Geoffrey Knight: develops the subcaudate tractotomy - an extensive lesion of orbitofrontal cortex and frontostriatal thalamic tracts by focal irradiation
  • 1968 - Lars Leksell develops the Gamma Knife – a stereotactic method for creating lesions by targeted irradiation without the need for cranial burr holes
  • 1972 - Lars Leksell: performs the thermal Anterior Capsulotomy as a focal method of disconnecting ventral and medial frontal cortex from subcortical and limbic structures.
  • 1973 - Desmond Kelly and Alan Richardson– Limbic Leucotomy.

Although four procedures were in common use in the past (Anterior capsulotomy, anterior cingulotomy, limbic leucotomy, and subcaudate tractotomy), only the first two are still used in the UK and Europe. The last UK centre offering subcaudate tractotomy - the Geoffrey Knight Centre in London - closed down a number of years ago.

References

Donnelly, J. (1978) The incidence of psychosurgery in the United States, 1971--1973. American Journal of Psychiatry, 135, 1476-1480.
Freeman, C. (1997) Neurosurgery for mental disorder in the UK. Psychiatric Bulletin, 21, 67-69.
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1977) Report and Recommendations - Psychosurgery. Washington: U.S. Department of Health, Education, and Welfare.


Definitions of Neurosurgery for Mental Disorder

A universally-recognised definition of ‘psychosurgery’, and more latterly Neurosurgery for Mental Disorder, has been elusive. Interestingly, definitions used in the last thirty years or so have mirrored contemporary thinking on the aetiology of mental disease. One of the first generally acceptable definitions of psychosurgery was provided by Professor Alan Stone in the Massachusetts Task Force Report on psychosurgery (published in 1975):

…any procedure which, by direct or indirect access to the brain, removes or destroys or interrupts the continuity of the brain tissue that is histologically normal (i.e. tissue that is normal as seen under a microscope, though its physiological functions for properties might obviously be abnormal) for the  purpose of altering behaviour or treating a psychiatric illness.” (Cited in O'Callaghan & Carroll, 1982, page xi)

This definition specifically excluded procedures for intractable pain and epilepsy, adding that such conditions “are clearly demonstrable.” Around the same time (1976) the World Health Organisation defined psychosurgery as “…the selective surgical removal or destruction…of neural pathways…with a view to influencing behaviour”.

A similar description, two years earlier, was:

“selective destruction of areas of the brain for the primary purpose of altering thoughts, emotional  reactions, personality characteristics of social response patterns” (Chorover, 1974).

These definitions contain within them the implicit assumption that psychosurgery’s primary purpose was the modification of behaviour by a destructive surgical procedure. It is important to emphasise that such concepts do not reflect modern conceptualisations of the potential role for neurosurgery in the management of severe mental disorder. Moving away from surgically altering behaviour, the Canadian Psychiatric Association defined ‘psychosurgery’ as:

..brain surgery performed on (i) normal tissues of an individual who does not suffer from physical  disease, for the purpose of changing or controlling the emotions or behaviour of such an individual, or on (ii) diseased brain tissue of an individual, if the primary objective of the performance of such  surgery is to control, change, or affect any emotional or behavioural disturbance in such an individual.” (Earp, 1979)

A more contemporary definition has been offered by the UK Royal College of Psychiatrists (2000), who defined NMD as:

“A surgical procedure for the destruction of brain tissue for the purposes of alleviating specific mental disorders carried out by a stereotactic or other method capable of making an accurate placement of the lesion”.

This definition focuses on symptom relief being the primary goal of surgery and also reflects the notion that mental disorders have their origins in specific neural substrates of the brain. Further, it makes no assumptions about the functional or anatomical normality of the target tissue. Such a definition, incorporating specific anatomical lesions, is the one in general use today in the UK when referring to NMD, and is the one used in this study.

References

Chorover, S. L. (1974) Behavioral Surgery. Science, 184, 669-670.
Earp, J. D. (1979) Psychosurgery. The position of the Canadian Psychiatric Association. Canadian Journal of Psychiatry, 24, 353-365.
Freeman, C., Crossley, D. & Eccleston, D. (2000) Neurosurgery for mental disorder.  Report from the Neurosurgery Working Group of the Royal College of Psychiatrists. London: Royal College of Psychiatrists.
O'Callaghan, M. A. J. & Carroll, D. (1982) Psychosurgery: A Scientific Analysis. Lancaster: MTP Press.


Psychosurgery under the spotlight

The first major review of neurosurgery was carried out by Tooth and Newton in 1961 (Tooth & Newton, 1961). They reviewed over 10,000 procedures that were carried out between 1942 and 1954. Forty percent had been unwell for at least six years prior to neurosurgery. Eighty percent had a standard (freehand) leucotomy, and only 9% had one of the more modern (stereotactic) surgical techniques. Two thirds had chronic schizophrenia, and these patients had the worst outcome: only 17-20% of the patients had totally recovered.

A review of neurosurgery for psychological disorders in the UK during the period 1974 – 1976 looked at main indications for surgery (Barraclough & Mitchell-Heggs, 1978). Within the three main centres providing functional neurosurgery (accounting for 58% of the total operations), the primary indication for surgery was:

  1. Depression (63%)
  2. ‘Anxiety, tension, and phobic states’ (12%)
  3. Violence (8%)
  4. Obsessive-compulsive disorder (7%)

By 2000, these figures had shifted, and the primary indications for surgery were (Freeman, Crossley & Eccleston, 2000):

  1. Depression (64.7%)
  2. OCD (20.6%)
  3. Bipolar Disorder (11.8%)
  4. Anxiety (2.9%)

Although used for the treatment of aggressive states (Cox & Brown, 1977; Mayangi & Sano, 1979; Schvarcz, 1977), sexual deviation (Dieckmann, Horn & Schneider, 1979), and drug misuse (Balasubramaniam, Kanaka & Ramanujam, 1973) throughout the 1960s and 1970s, today in the Western Hemisphere NMD is not considered a suitable intervention for aggressive, impulsive, antisocial, or hypersexual behaviour. However, it continues to be used for aggression and drug misuse in some parts of the world, including the Far East (Gao, Wang, He, et al, 2003; Kim, Lee & Choi, 2002) and Russia (Medvedev, Anichkov & Polyakov, 2003). As recently as 1996 it was being performed for schizophrenia in Brazil (da Costa, 1997).

References

Balasubramaniam, V., Kanaka, T. S. & Ramanujam, P. B. (1973) Stereotaxic cingulumotomy for drug addiction. Neurology India, 21, 63-66.
Barraclough, B. M. & Mitchell-Heggs, N. A. (1978) Use of neurosurgery for psychological disorder in British Isles during 1974-6. BMJ, 2, 1591-1593.
Cox, A. W. & Brown, M. H. (1977) Results of Multi-target Limbic Surgery in the Treatment of Schizophrenia and Aggressive States. In Neurosurgical Treatment in Psychiatry, Pain and Epilepsy (eds W. H. Sweet, S. Obrador & J. G. Martin-Rodriguez), pp. 469-479. Baltimore: University Park Press.
da Costa, D. A. (1997) The role of psychosurgery in the treatment of selected cases of refractory schizophrenia: a reappraisal. Schizophrenia Research, 28, 223-230.
Dieckmann, G., Horn, H.-J. & Schneider, H. (1979) Long-term Results of Anterior Hypothalamotomy in Sexual Offences. In Modern Concepts in Psychiatric Surgery (eds E. R. Hitchcock, H. T. Ballantine, Jr & B. A. Meyerson), pp. 187-195. New York: Elsevier/ North Holland Biomedical Press.
Freeman, C., Crossley, D. & Eccleston, D. (2000) Neurosurgery for mental disorder.  Report from the Neurosurgery Working Group of the Royal College of Psychiatrists. London: Royal College of Psychiatrists.
Gao, G., Wang, X., He, S., et al (2003) Clinical study for alleviating opiate drug psychological dependence by a method of ablating the nucleus accumbens with stereotactic surgery. Stereotactic and Functional Neurosurgery, 81, 96-104.
Kim, M. C., Lee, T. K. & Choi, C. R. (2002) Review of long-term results of stereotactic psychosurgery. Neurologia Medico-Chirurgica, 42, 365-371.
Mayangi, Y. & Sano, K. (1979) Long-term Follow-up Results of Posteromedial Hypothalamotomy. In Modern Concepts in Psychiatric Surgery (eds E. R. Hitchcock, H. T. Ballantine, Jr & B. A. Meyerson), pp. 197-204. New York: Elsevier/ North Holland Biomedical Press.
Medvedev, S. V., Anichkov, A. D. & Polyakov, Y. I. (2003) Physiological Mechanisms of the Effectiveness of Bilateral Stereotactic Cingulotomy against Strong Psychological Dependence in Drug Addicts. Human Physiology, 29, 492-497.
Schvarcz, J. R. (1977) Results of Stimulation and Destruction of the Posterior Hypothalamus: A Long-term Evaluation. In Neurosurgical Treatment in Psychiatry, Pain and Epilepsy (eds W. H. Sweet, S. Obrador & J. G. Martin-Rodriguez), pp. 429-438. Baltimore: University Park Press.
Tooth, J. C. & Newton, M. P. (1961) Leucotomy in England and Wales 1942-1954. Reports on public health and medical subjects. London: Ministry of Health.


Conclusions

Despite its chequered past, NMD remains a modern treatment for the most unwell and most disabled patients with severe and chronic mental disorders. In the present day there are few who would argue against the claim that the early adoption of ‘psychosurgery’ lacked an evidence base, was driven by a frequently misplaced zeal, and performed on individuals with conditions that would not be indications for surgery now.

However, the evolution of NMD has followed a recognisable path that is shared with many treatments in medicine:

“The practice of lobotomy went through stages of animal experimentation, clinical application, 
social and clinical criticism and modification, indirect scientific contributions, and finally substitution of 
another treatment.” (Kucharski, 1984).

Of all the treatments in psychiatry, the two which have engendered the most emotive discussions in public and the medical profession namely NMD and electroconvulsive therapy (ECT), these are the only two which have emerged out of the first half of the twentieth century and remain in current use, albeit modified from their original form

References

Kucharski, A. (1984) History of frontal lobotomy in the United States, 1935-1955. Neurosurgery, 14, 765-772.

Last Updated on Saturday, 27 July 2013 13:35

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