History of psychosurgery
It was first used in modern times by Gottlieb Burckhardt in 1891, but only in a few isolated instances, not becoming more widely used until the 1930s following the work of Portuguese neurologist António Egas Moniz.
[3][5] Moniz's methods were taken up in the United States by the neurological team headed by Walter Freeman and the neurosurgeon James Watts, who, in the words of American psychiatrist Victor Swayze, "did more to promote the use of psychosurgery than anyone else in the world".
José de Matos Sobral Cid, who had initially allowed Moniz to operate on patients from his asylum, became a critic of the procedure.
[8] British psychiatrist William Sargant, on a visit to Washington in 1939, met Freeman and was sufficiently impressed with the results of his operation on three patients to introduce it into the United Kingdom and to remain a lifelong advocate of psychosurgery.
Lyerly at the Florida State Hospital developed a similar operation but reached the brain via larger holes in the forehead and was thus able to see what he was cutting.
[4] In this operation an ice-pick like instrument was inserted through the roof of the orbit (eye socket), driven in with a mallet, and swung to and fro to cut through the white matter.
[5] During the 1940s neurosurgeons devised other methods of psychosurgery in the hope of avoiding the undesirable effects of the standard operation that were becoming increasingly apparent as long-term follow-up studies were conducted.
[5] Two of the techniques still in use today date from this period: Jean Talaraich in France developed the capsulotomy,[5] while at Oxford in England Hugh Cairns performed the first cingulotomies in the late 1940s.
In 1939 Freeman had given a talk at the International Congress in Neurology in Copenhagen and, although initially met with scepticism by Scandinavian psychiatrists, they were soon using psychosurgery on patients, especially those diagnosed as schizophrenic.
In Sweden and Denmark operations were performed in neurosurgical wards; in Norway they were more often carried out by visiting orthopaedic surgeons in psychiatric hospitals.
Essen-Möller also studied the published literature on psychosurgery; he found a mortality rate of about 3.5 per cent, with other patients left in the state of "a surgically induced childhood".
He opined that the personality changes following surgery were of subordinate importance and that the death rate, which he put at one or two per cent by then, was "not worth mentioning".
[11] In the United States in the 1960s up until the early 70s, Harvard Medical School, Neurosurgeon Vernon H. Mark at Boston City Hospital, and his associate, Professor of Psychiatry Dr Frank R. Ervin, carried out research on electroencephalographic recordings on the skull (EEG), cerebral surface, as well as deep structures of the brain.
In Britain in 1964 Geoffrey Knight developed the subcaudate tractotomy, implanting radioactive seeds in the brain to destroy tissue.
In Tulane in the United States, Robert Heath and colleagues in the 1950s began experimenting with deep brain stimulation as a treatment for psychiatric disorders.
[21]: 116 As a result of this controversy, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research held hearings on psychosurgery.
British psychiatrist Maurice Partridge, who conducted a follow-up study of 300 patients who had undergone pre-frontal leucotomy, said that the treatment achieved its effects by "reducing the complexity of psychic life".
The operation left people with a restricted intellectual range; spontaneity, responsiveness, self-awareness and self-control were reduced, and activity was replaced by inertia.
He described one 29-year-old woman as being, following lobotomy, a "smiling, lazy and satisfactory patient with the personality of an oyster" who couldn't remember Freeman's name and endlessly poured coffee from an empty pot.
Psychoanalyst Donald Winnicott wrote to The Lancet in 1943 about the "special objection that is easily felt to the treatment of mental disorder by any method that leaves a permanent physical deficiency or deformity of the brain", even if favourable results could sometimes be shown to follow.
[33] In the 1950s, Winnicott continued to explore the ethics of psychosurgery, arguing that it altered "the seat of the self", "put a premium on the relief of suffering" and created teams of neurosurgeons with vested interests that could affect evaluation of the operation.
[33] By the late 1970s, when modified techniques with less devastating consequences had replaced lobotomies, and the number of operations carried out had dropped considerably, ethical concerns revolved around consent.
A report in 1977 by the US Department of Health, Education and Welfare highlighted the fact that psychosurgery was an irreversible procedure and that the data regarding its effects were unsatisfactory.
Gostin argued that psychosurgery should only be given with the consent of the patient and approval of an independent body comprising a multi-disciplinary legal and lay element.
His proposals were largely incorporated into the Mental Health Act 1983, and led to a significant fall in the use of psychosurgery in England and Wales.
[35] Ethical debate relating to psychosurgery in the twenty-first century still revolves around questions about benefit, risks, consent and the lack of a rationale for the operation.
