What is psychosurgery?

Introduction

In the early twentieth century, the treatment of mental disease was limited to psychotherapy for neurotics and long-term care of psychotics in asylums. In the 1930’s, these methods were supplemented by physical approaches using electroconvulsive therapy (ECT), or shock therapy, and brain operations. The operations, psychosurgery, were in vogue from the mid-1930s to the mid- to late 1960s. They became, and still are, hugely controversial, although their use had drastically declined by the last quarter of the twentieth century. Controversy arose because, for its first twenty-five years of existence, crude psychosurgery was too often carried out on inappropriate patients.

ECT developed after the 1935 discovery that schizophrenia
could be treated by convulsions induced through camphor injection. Soon, convulsion production was accomplished by passage of electric current through the brain, as described in 1938 by Italian physicians Ugo Cerletti and Lucio Bini. ECT was most successful in alleviating depression and is still used for that purpose. In contrast, classic psychosurgery by bilateral prefrontal leukotomy (lobotomy) is no longer done because of its bad effects on the physical and mental health of many subjects. These effects included epilepsy and unwanted personality changes such as apathy, passivity, and low emotional responses. It should be remembered, however, that psychosurgery was first planned to quiet chronically tense, delusional, agitated, or violent psychotics.

History and Context of Psychosurgery

Psychosurgery is believed to have originated with the observation by early medical practitioners that severe head injuries could produce extreme changes in behavior patterns. In addition, physicians of the thirteenth to sixteenth centuries reported that sword and knife wounds that penetrated the skull could change normal behavior patterns. Regardless, from the mid-1930s to the mid-1960s, reputable physicians performed psychosurgery on both indigent patients in public institutions and on the wealthy at expensive private hospitals and universities.

Psychosurgery was imperfect and could cause adverse reactions, but it was performed because of the arguments advanced by powerful physician proponents of the method; the imperfect state of knowledge of the brain at the time; the enthusiasm of the popular press, which lauded the method; and many problems at overcrowded mental hospitals. The last reason is thought to have been the most compelling, as asylums for the incurably insane were hellish places. Patients were beaten and choked by attendants; incarcerated in dark, dank padded cells; and subjected to many other indignities. At the same time, little could be done to cure them.

Lobotomy

The two main figures in psychosurgery were António Egas Moniz, the Portuguese neurologist who invented lobotomy, and the well-known American neuropathologist and neuropsychiatrist Walter Freeman, who roamed the world persuading others to carry out the operations. The imperfect state of knowledge of the brain in relation to insanity was expressed in two theories of mental illness. A somatic (organic) theory of insanity proposed it to be of biological origin. In contrast, a functional theory supposed life experiences to cause the problems.

The somatic theory was shaped most by Emil Kraepelin, the foremost authority on psychiatry in the first half of the twentieth century. Kraepelin distinguished twenty types of mental disorder, including dementia praecox (schizophrenia) and manic-depressive (bipolar) disorder. Kraepelin and his colleagues viewed these diseases as genetically determined, and practitioners of psychiatry developed complex physical diagnostic schema that identified people with various types of psychoses. In contrast, Sigmund Freud was the main proponent of the functional theory. Attempts to help mental patients included ECT as well as surgical removal of tonsils, sex organs, and parts of the digestive system. All these methods had widely varied success rates that were often subjective and differed depending on which surgeon used them. By the 1930s, the most widely effective curative procedures were several types of ECT and lobotomy (psychosurgery).

The first lobotomy was carried out on November 12, 1935, at a hospital in Lisbon, Portugal. There, Pedro A. Lima, Egas Moniz’s neurosurgeon collaborator, drilled two holes into the skull of a female mental patient and injected ethyl alcohol directly into the frontal lobes of her brain to destroy nerve cells. After several such operations, the tissue-killing procedure was altered to use an instrument called a leukotome. After its insertion into the brain, the knifelike instrument, designed by Egas Moniz, was rotated like an apple corer to destroy chosen lobe areas.

Egas Moniz—already a famous neurologist—named the procedure prefrontal leukotomy. He won a Nobel Prize in Physiology or Medicine in 1949 for his invention of the procedure. Within a year of his first leukotomy, psychosurgery (another term invented by Egas Moniz) spread through Europe. Justification for its wide use was the absence of any other effective somatic treatment and the emerging concept that the cerebral frontal lobes were the site of intellectual activity and mental problems. The selection of leukotomy target sites was based on two considerations: using the position in the frontal lobes where nerve fibers—not nerve cells—were most concentrated and avoiding damage to large blood vessels. Thus, Egas Moniz targeted the frontal lobe’s centrum ovale, which contains few blood vessels.

After eight operations—50 percent performed on schizophrenics—Egas Moniz and Lima stated that their cure rates were good. Several other psychiatric physicians disagreed strongly. After twenty operations, it became fairly clear that psychosurgery worked best on patients suffering from anxiety and depression, while schizophrenics did not benefit very much. The main effect of the surgery was to calm patients and to make them docile. Retrospectively, it is believed that Egas Moniz’s evidence for serious improvement in many cases was very sketchy. However, many psychiatric and neurological practitioners were impressed, and the stage was set for wide dissemination of psychosurgery.

Lobotomy Procedures

The second great proponent of leukotomy—the physician who renamed it lobotomy and greatly modified the methodology used—was Freeman, professor of neuropathology at George Washington University Medical School in Washington, D.C. In 1936, he tested the procedure on preserved brains from the medical school morgue and repeated Egas Moniz’s efforts. After six lobotomies, Freeman and his associate James W. Watts became optimistic that the method was useful to treat patients exhibiting apprehension, anxiety, insomnia, and nervous tension, while pointing out that it would be impossible to determine whether the procedure had effected the recovery or cure of mental problems until a five-year period had passed.

As Freeman and Watts continued to operate, they noticed problems, including relapses to the original abnormal state, a need for repeated surgery, a lack of ability on the part of patients to resume jobs requiring the use of reason, and death due to postsurgical hemorrhage. This led them to develop a more precise technique, using the landmarks on the skull to identify where to drill entry holes, cannulation to assure that lobe penetration depth was not dangerous to patients, and use of a knifelike spatula to make lobotomy cuts. The extent of surgery also varied, depending on whether the patient involved was suffering from an affective disorder or from schizophrenia. Their method, the “routine Freeman-Watts lobotomy procedure,” became popular throughout the world.

Another method used for prefrontal lobotomy was designed by J. G. Lyerly in 1937. He opened the brain so that psychosurgeons could see exactly what was being done to the frontal lobes. This technique also became popular and was used throughout the United States. Near the same time, in Japan, Mizuho Nakata of Nigata Medical College began to remove from the brain parts of one or both frontal lobes. However, the Freeman-Watts method was most popular as the result of a “do-it-yourself manual” for psychosurgery that they published in 1942. Watts’s book theorized that the brain pathways between cerebral frontal lobes and the thalamus regulate intensity of emotions in ideas, and acceptance of this theory led to better scientific justification of psychosurgery.

Another lobotomy procedure that was fairly widespread was Freeman’s transorbital method, designed not only to correct shortcomings in his routine method but also as an attempt to aid many more schizophrenics. The simple, rapid, but frightening procedure drove a transorbital leukotome (similar in appearance to an ice pick, thus the popularity of the term "ice pick lobotomy" for the procedure) through the eye socket, above the eyeball, and into the frontal lobe. Subjects were rendered unconscious with ECT, and the procedure was done before they woke up. Use of this method gained many converts and, gruesome as it sounds, the method caused less brain damage than other psychosurgery procedures. It was widely used at state hospitals for the insane and was lauded by the press as making previously hopeless cases normal immediately.

Subsequently developed stereotaxic surgical techniques, such as stereotactic cingulatory, enabled psychosurgeons to create much smaller lesions by means of probes inserted into accurately located brain regions, followed by nerve destruction through the use of radioactive implants or by cryogenics. Currently, psychosurgery is claimed to be an effective treatment for patients with intractable depression, anxiety, or obsessional problems and a method that improves the behavior of very aggressive patients. Opponents say that these therapeutic effects can be attained by means of antipsychotic and antidepressant drugs. The consensus is that psychosurgery can play a small part in psychiatric treatment when long-term use of other treatments is unsuccessful and patients are tormented by mental problems.

Mode of Action of Psychosurgery

Collectively, the brain’s limbic system is composed of the hippocampus, amygdala, hippocampal and cingulate gyri, limen insulae, and posterior orbital regions of cerebral frontal lobes. This system, its components linked by nerve pathways, controls emotional expression, seizure activity, and memory storage and recall. Moreover, cerebral lobe limbic system connections from the dorsal convexity of a frontal lobe comprise two pathways running to the cingulate gyrus and hippocampus and the hypothalamus and midbrain. The frontal lobe orbital surface also projects to the septal area of the hypothalamus. The limbic brain architecture therefore yields two neurotransport circuits in a frontolimbic-hypothalamic-midbrain axis. These are a medial frontal, cingulate, hippocampus circuit (MFCHC) and an orbital frontal, temporal, amygdala circuit (OFTAC), which control hypothalamic autonomic and endocrine action. The MFCHC and OFTAC connect in the septa, preoptic area, midbrain, and hypothalamus.

The original Egas Moniz lobotomy divided the frontolimbic structures, and its bad effects were due to the disabling impairment of frontal lobe function. Psychosurgery on the anterior cingulate gyrus and on the thalamofrontal bundle (bimedial leukotomy) divided different parts of the same main circuit. Orbital undercutting severs red nerve tracts running from the posterior orbital cortex to the limbic system. Although psychosurgery is currently an uncommon procedure, when it is performed, the methods used are lower medial quadrant leukotomy, making lesions just before the fourth ventricle; stereotactic-subcaudate-tractotomy, making lesions with rear halves in the subcaudate area; removal of the anterior two inches of the cingulate gyrus; and stereotactic limbic leukotomy, lesioning the lower medial frontal lobe quadrant. These operations cause varied endocrine and autonomic disconnections and are thus chosen to suit the mental condition being treated.

Diagnosis and Treatment

Diagnosis of a need for psychosurgery is based on observation of symptoms supporting abnormal psychological behavior. Examples are extremes of aggression, anxiety, obsession, or compulsiveness, as well as psychoses other than schizophrenia. The exclusion of schizophrenics, except for those having marked anxiety and tension, is based on data supporting poor responses by schizophrenics to lobotomy and other leukotomies. Surveys have shown that good surgical outcomes were obtained in only 18 percent of schizophrenics who underwent lobotomy, as compared with 50 percent of depressives.

Psychosurgery’s unfavorable record between 1935 and 1965, and its postoperative irreversibility, speak to the need for careful study before suggesting such brain surgery. In addition, many members of the medical community believe that the choice of psychosurgery should be based on the long-term nature of symptoms untreatable by other means as well as a severe risk of suicide. In most countries, before psychosurgery is attempted, other methods must be exhausted, such as repeated ECT, prolonged psychoanalysis, and aggressive pharmaceutical treatments with antipsychotic drugs. Some sources suggest, as criteria for choosing psychosurgery, the persistence of symptoms for more than ten years of treatment under conditions where all possible nonsurgical methodology has been exhausted after its aggressive use. Others believe it inhumane to require a decade of illness before allowing the possibility of a cure.

Symptom severity is another hugely important criterion for psychosurgery. Examples of this are the complete inability to work at a job or carry out household chores, as well as long-term and severe endogenous depression. It is also suggested that patients who have strong psychological support from their families and stable environments are the best candidates. Careful assessment of patient symptoms, handicaps, and problems should always be carried out. Formal rating scales, personality assessment via school and work records, and information coming from close relatives or friends are also viewed as crucial.

In most of the world, the use of psychosurgery has declined sharply throughout the late twentieth and early twenty-first centuries and is limited to a very small number of patients not helped by existing chemotherapeutic or psychoanalytical methodology. Only a few countries, such as China and Russia, continue to perform psychosurgery regularly. A wide variety of new techniques have made psychosurgery capable of destroying smaller and smaller targets. In the twenty-first century, the focus of psychosurgery research has also begun to shift from the destruction of brain tissue to the stimulation of said tissue using implanted electrodes. As knowledge of the brain and its functioning increases, it appears possible that modern psychosurgery may yet prove to be useful where other methods fail.

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