Psychosurgery is surgery performed on the brain for the purpose of treating mental illness. Unlike traditional brain surgery, its goal is to change people's behavior. It is undoubtedly the most invasive and controversial form of mental health treatment performed in this century. Its first known use was by the Incas, who “perforated” the skull to relieve mental illness by releasing evil spirits inside the brain.
Between 1936 and 1961 approximately 40,000 to 50,000 people in the United States underwent an early and notorious form of psychosurgery known as prefrontal lobotomy, which involved interrupting some of the connections between the frontal lobes and other parts of the brain. Despite some reported successes, many of the results were harrowing, featuring blunted emotions, pain, stupor, and, in from 1 percent to 4 percent of cases, death.In one study of 134 men who underwent this procedure, 50 percent of the subjects had seizure disorders, 25 percent had severe intellectual disabilities, and only 10 percent had been released from a hospital (Cave 26-29). In his 1888 address Mills (Mills, 1889-1890) commented extensively on two then recent operations as opening “a possible new field for surgical interference in insanity” (228).
Bennett and Gould (1887) and Macewen (1888) attempted to cure or relieve visual psychiatric symptoms by modifications to the angular gyrus. The importance of the cases, Mills observed (1889-1890), was their raising “the question of the propriety of excising cortical areas in insanity” (230). Mills could not know, of course, that Burckhardt was already planning such excisions.However, as with the later operations by Moniz and Freeman, Gage probably played only an insignificant part in the one Burckhardt performed in the frontal area.
Psychosurgery as a treatment for mental illness was started by Egas Moniz in Portugal in 1935, although a Swiss psychiatrist Gottlieb Burckhardt had experimented with surgical removal of part of the temporoparietal region in 1890, causing great outcry (Fennell 98).Having heard of experiments by the leading US physiologist John F. Fulton at Yale University in which the frustration and anger of chimpanzees disappeared completely if their frontal lobes were destroyed, Moniz, himself disabled by gout, trained his junior colleague, Lima, to undertake the procedure and they proceeded to leucotomise eighteen patients in a mental hospital near Lisbon. Moniz gave an enthusiastic account of these experiments in a monograph published in 1936. News of this surfaced in the British medical press via a brief note in a 1938 literature survey in the Journal of Mental Science.
Moniz ‘obtained’ fourteen of the patients from the Manicome Bombarda asylum, and the other six from his own clinic or other asylums. Most of them were deteriorated, many were incapable of consenting to treatment, and some actively resisted. One woman was so disturbed that she pulled out the intravenous needle used to convey the anaesthetic, and after the operation tore at her bandages, screaming, ‘They have tried to kill me twice but I’m still here’ (Fennell 201). Moniz himself claimed that of twenty cases, seven were recovered, seven were improved, and six unchanged.But Valenstein’s careful analysis of the case histories indicates that claims of cure were inflated.
Moniz, who was advancing in years and anxious to publish his results quickly, rushed into print before a proper evaluation could be made. There was an average of four days between the operations in the series, far too soon to evaluate post operative complication.Some of the observations on ‘cure’ were made a mere seven days after the operation, which was to say the least, premature: Moniz presented no evidence indicating that any of the patients was capable of living normally outside the hospital. In the majority of cases the major change was the reduction of agitation and increased ‘calmness.
’ Yet neurologists and psychiatrists commonly described the evidence in Moniz’s monograph as ‘detailed’ and ‘impressive’ (Cave 102). Meanwhile, in the United States in 1945, Freeman had pioneered the transorbital lobotomy, where an ice pick was inserted through the eye socket.This led to a split between Freeman and Watts in 1947, because of the latter’s refusal to accept Freeman carrying out operations in the office. He used an electric convulsion to produce anaesthesia, and ECT just before psychosurgery became a widely adopted procedure because of his assertion that it enhanced the effectiveness of the operation.
Freeman’s rationale for the transorbital lobotomy, which he would maintain into the 1970s, was this.Prefrontal lobotomy required a neurosurgeon, and a large staff to care for patients during the long recovery period. Standard leucotomy was therefore reserved as a treatment of last resort, when shocks and comas failed, and this meant that, in schizophrenia in particular, an illness could become entrenched which could be curable by a speedy surgery. Transorbital lobotomy was viewed by Freeman as being a half-way stage between electroshock and prefrontal lobotomy.
By 1947 psychosurgery was in its heyday and Freeman was its foremost figure below Moniz.He organised the First World Congress of Psychosurgery in Lisbon in 1948, and Moniz received the supreme accolade of the Nobel Prize for Medicine in 1949, an indication of the acceptance and popularity of psychosurgery in mainstream world medicine. Controversy about psychosurgery continued to rage, for two reasons: one was that there was a high death rate, and the other that ‘the indifference’ aimed for in many cases produced serious loss of social functioning. However, Kramer found that between 1936 and 1951 at least 18,608 lobotomies were performed in the US.Between 1945 and 1954, 12,000 leucotomies were performed in England and Wales and reported to the Board of Control (Renfrew 32).
A survey carried out by the Ministry of Health showed that of 10,365 patients who underwent leucotomies between 1942 and 1954, 6,338 were women. Of all patients having the operation, 64 per cent were schizophrenics, 25 per cent were suffering from affective disorder, and 11 per cent had other diagnoses. There were more women than men in all three diagnostic categories, but the difference was far the greatest for patients with affective states (Renfrew 45). What led to the decline of psychosurgery?As Valenstein (1986) says, it would be more pertinent to ask ‘why did it survive so long? ’, given that it was a high risk procedure and results were often not good. When results were poor, surgeons did not give up. With the arrival on the scene of the neuroleptic drugs, of which chlorpromazine (largactil) was the first, psychosurgery was relegated largely to the sidelines, despite the evangelical attempts of Walter Freeman in the US and Sargant and Slater in the UK, which continued well into the 1970s.
By the late 1950s the only physical treatment to survive in widespread use was ECT.The practitioners who gave these heroic treatments had a number of characteristics in common. They were usually struggling against bureaucracy, ignorance, professional jealousy, or over cautious colleagues. Over-punctiliousness about consent was a positive vice when set against the immense benefits to be reaped. In 1947, one of Freeman’s patients who had come from out of town for an operation, became very unruly in a motel. The police would not enter the room without permission, but Freeman went to the motel, and decided that the patient could be calmed with a few bursts of ECT.
The patient’s relatives held him down while these were given, and while the patient was unconscious Freeman performed a transorbital lobotomy. By the early 1970s psychosurgery was undergoing something of a renaissance. Anthony Clare noted, in 1976, that although the theoretical basis of psychosurgery may have appeared simplistic and vague, this did not prevent ‘a veritable plethora of operations from being performed’. At the Brook Hospital, surgeons claimed good results in severely and chronically depressed and obsessional patients from an operation on the frontal lobes involving the implantation of radioactive yttrium rods or pellets.Operations for depression, anxiety and obsessional neurosis were also performed at the Atkinson Morley Hospital in Wimbledon, whilst at the Queen Elizabeth Hospital and Edinburgh Royal Infirmary different operations including temporal lobectomies and amygdalotomies were performed in cases of severe persistent aggression.
Clare found it difficult to judge how fast the operation rate was increasing, but as evidence that it was he cited the fact that the most established psychosurgeon of the day, Geoffrey Knight, presented statistical evidence for over 1,000 of his own cases at the 1970 Second International Conference of psychosurgery.Sargant and Slater remained ardent propagandists of psychosurgery in the 1972 edition of their textbook, Introduction to Physical Treatments in Psychiatry. They continued to argue for its use in treating schizophrenia, even though all studies carried out after 1955 claimed that the effect of the operation on delusions and hallucinations was disappointing. In 1971, during Slater’s editorship of the British Journal of Psychiatry, an article was published by Walter Freeman, again propounding the virtues of early temporal lobectomy because ‘in a dangerous disease such as schizophrenia it may prove safer to operate than to wait’ (Renfrew 89).In July of 1973, the National Association for Mental Health released a statement on psychosurgery.
The statement said that it should not be used except when the patient is in such great emotional stress, due to mental disorder, that he or she, by personal choice, would prefer the operation to living with the existing mental condition. “Because psychosurgery is still, to a large extent, experimental, it is absolutely essential that there be safeguards to protect patients who might otherwise be used as human guinea pigs,” said Mrs. J. Skelly Wright, president of the association.
The association's position was that psychosurgery be regarded as a last resort, to be considered only when all other alternatives have been given adequate trial in the opinion of the patient, the family, and at least two reputable physicians, one of whom should be a psychiatrist. The ethical questions related to psychosurgery derive in part from the technique's irreversibility as well as questions about its efficacy.While usually there is little question of the ethics of removing diseased bodily tissue, such as an infected appendix, or even of excising damaged brain structures, as with tumors or epileptogenic foci, the removal of apparently healthy brain tissue in order to effect a behavioral change has provoked much debate. Questions have been raised whether all less drastic approaches have been thoroughly tested.
After all, testing of alternative approaches is very tedious and time consuming compared to neurosurgery.Concerns have also been voiced about whether psychosurgical procedures have been carried out primarily for the benefit of the patient or those affected by the patient. Caretakers may have great difficulty in controlling the patient, and their task is often much easier following an operation. Alternatively, more radical critics have suggested that the neurosurgeons are crassly experimenting on humans without any concern for them. Still further ethical problems arise when we consider the uncertainty of the outcome and the nature of the clients.
The procedure of informed consent consists of telling patients what will be done to them and informing them of possible outcomes, both positive and negative. Given the inconsistency of the results of psychosurgery, it would be very difficult to adequately inform a prospective patient. Problems arise because many patients are psychotic, with impaired cognitive functions and diminished contact with reality, and they therefore may not readily understand the implications. In extreme cases, decisions have been left to legal guardians, who may or may not be acting in the patient's best interests.Another aspect of informed consent is that it be given without coercion. However, many patients have been psychiatric hospital residents or incarcerated individuals whose prison term may be affected by their decisions, and they cannot be considered free of coercive influences.
Although procedures are still being carried out to a limited degree, they have largely been replaced because of consumer movement opposition, the development of more effective drugs, and improved behavioral therapies. The original psychosurgery procedures underwent many changes over the years.The modern techniques involve exact stereotactic procedures for directing electrodes, which place very small lesions in key areas of the brain. Techniques also include radio frequency waves, use of radioactive elements with a short half-life, and freezing using cryoprobes. On-line video monitors and X-rays are used routinely to carry out the procedures. The best results are reported with patients suffering from severe chronic anxiety, agitated depression with a high risk of suicide, and incapacitating obsessive compulsive disorders.
The procedure is also used for intractable pain (Renfrew 56). Most current practitioners of psychosurgery still do not think the operation helps schizophrenics. New technologies have opened the way to examine former psychosurgery patients and gain new knowledge of their condition. Valenstein describes the case of a woman who had two lobotomies in the 1940s. In 1980 at the National Institutes of Health she was examined with a PET scan.
The test showed that her frontal lobes were large, nonfimctioning areas of dead brain tissue.Previously on the Luria-Nebraska Test to evaluate brain damage she had performed within normal range, with no sign of organic impairment. The PET scan, however, clearly showed the organic damage, which explained such facts as her greatly impaired sense of time. Psychosurgery is used for a number of dysfunctions other than the cotnrol of violent behavior. It has been used to reduce intractable pain as well as self-induced starvation.
Individuals suffering from depression and pathological anxiety have also been treated with surgical procedures.Some individuals oppose all psychosurgical procedures regardless of possible benefits. Included in that ban is the use of psychosurgical procedures to control the not infrequent excruciating pain that comes with terminal cancer. None of the operations described above is one hundred percent successful, but as of now there are no good criteria for deciding which patients will be helped by which operation.
Detailed behavioral analyses and psychological evaluations of all psychosurgical candidates may ultimately permit a more precise identification of the individuals most likely to have their symptoms alleviated.It has recently been suggested, for example, that the tendency to violence toward persons may have a different neurological substrate than the tendency to self-mutiliation or the destruction of objects. In a series of eighteen patients, seven of nine who showed interpersonal hostility were benefited by amygdalectomy, whereas none of nine patients who were either destructive or self-mutilating showed persistent improvement after the operation. Heimburger has also suggested that more detailed analyses need to be made of the electroencephalographic records.Some patients whose EEGs have improved, that is, displayed fewer epileptogenic discharges, have not shown a behavioral improvement, whereas others who have improved behaviorally have shown no changes in their EEG record.
Well-controlled sleep records, with temporal and sphenoidal leads and depth recordings during surgery, may also be useful in finding the type of patient for whom the oepration is potentially successful. It is a far cry from the first crude prefrontal lobotomies, with their massive damage, to the relatively precise amygdalotomy done with the stereotaxic instrument.By comparison, current techniques are highly refined, but they are in need of further refinement. The amygdala is a complex entity that has an influence on a number of behaviors. In animals there is evidence that it is involved in at least three different kinds of aggressive behaviors and that the different nuclei may be involved in either the facilitation or the inhibition of one or more kinds of aggression.
Some of the failures to minimize antisocial behavior through operative techniques may very well be due to the imprecision in electrode location. Thus, a great deal more research is needed to gain this relevant information.
