Psychosurgery

The use of psychosurgery has been traced back to approximately 2000 B.C. using archaeological evidence of skulls with relatively precise holes that seem to have been bored intentionally. It is unclear whether brain matter was directly manipulated in this process called trepanation. Its intended purpose may have been to relieve what was thought to be excess pressure in the skull. Some cultures seem to have performed trepanation in order to allow what they thought were bad spirits to escape.

The first report of surgery on the brain to relieve psychiatric symptoms has been traced to the director of a mental asylum in Switzerland, Gottlieb Burckhardt, who in 1890 removed parts of the cerebral cortex. He performed this procedure on six patients described as highly excitable. The procedure, however, did not seem to lessen the patients' degree of excitability, and in fact seemed to lead to seizures. Burckhardt's procedure met with great opposition and he was forced to stop performing the surgery.

Modern psychosurgery can be traced to the Portuguese physician Egas Moniz (1875-1955) who performed the first prefrontal leukotomy in 1935. Apparently, Moniz had been influenced by a case involving the unintentional damage of a patient's prefrontal areas of the brain in which the patient, although suffering some personality change, continued to function. Moniz also seemed to be influenced by research at Yale reporting that an agitated chimpanzee was greatly calmed after its frontal lobes had been severely damaged.

Moniz's first operation involved drilling two holes in the upper forehead area and injecting absolute alcohol directly into the frontal lobes of the brain. The absolute alcohol acted to destroy the brain tissue it came into contact with. In following operations, Moniz used an instrument called a leukotome, which consists of a narrow rod with a retractable wire loop at one end. Moniz would insert the instrument through the drilled holes, extend the wire loop, and rotate it to destroy brain tissue located in the frontal lobes of the brain. Moniz reported some success in removing some of the patients' more striking psychotic symptoms such as hallucinations and delusions. The accuracy of Moniz's findings and the degree of his success, however, are now questioned. It seems that while it lessened a patient's anxiety and aggression, it often produced marked personality changes and impaired intellectual performance.

The practice of psychosurgery began to receive more attention after Moniz's reports of success, and its study was taken up by a number of researchers, most notably the American physician Walter J. Freeman and neurosurgeon James W. Watts in the late 1930s. These two prominent physicians greatly publicized the prefrontal leukotomy, revised Moniz's initial procedures, and changed the procedure's name to lobotomy.

Around this time, American neurosurgeon J.G. Lyerly developed a procedure that allowed visualization of the brain during surgery. This enabled more precise surgical intervention and seemed to lead to increased use of psychosurgery. Meanwhile, Freeman and Watts continued their research, and the publication of their widely acclaimed book Psychosurgery in 1942 led to increases in psychosurgical procedures worldwide. During the mid-1940s, surgeons developed a number of different psychosurgical techniques intended to improve patient outcome following lobotomy, and the use of psychosurgery increased dramatically.

In the 1950s chlorpromazine and a number of antipsychotic medications were introduced and the number of lobotomies declined rapidly. These drugs not only provided relief from some patients' severe and harmful symptoms, but they were also simple and inexpensive compared to psychosurgery. Moreover, unlike psychosurgery, their effects were apparently reversible. It had become evident over time that lobotomies were not as effective as previously thought, and that, in fact, they often resulted in brain damage.

In order to understand the ease with which psychosurgical procedures were taken up by so many physicians it must be understood that most psychiatrists believed psychotic symptoms would not respond to psychotherapy, and up until the 1950s there were no effective drug treatments for serious mental disorders. Thus, psychosurgery was viewed as having the potential to treat disorders that had been seen as untreatable. Moreover, the treatment of the mentally ill at this time was largely custodial, and the number of severely disturbed individuals in mental health treatment centers was too great to be treated with psychotherapy, which was just beginning to gain acceptance in the 1940s and 1950s. In sum, psychosurgery appealed to many mental health professionals as a potentially effective and economical treatment for patients for whom there seemed to be no effective treatment.