Psychosurgery

Psychosurgery is a term for surgeries of the brain or autonomic nervous system involving the severance of neural pathways to effect a change in behaviour, usually to treat or alleviate severe mental illness. The procedures typically considered psychosurgery are now almost universally shunned as inappropriate, due in part to the emergence of less-invasive methods of treatment such as psychiatric medication. Although the term psychosurgery might imply a broad class of treatments, in reality, it is confined to variations on two themes:

History

There is evidence that trephining (or trepanning)—the practice of drilling holes in the skull for pseudomedical reasons—has been in widespread, if infrequent, use since 5000 BCE. This may have been done in an attempt to allow the brain to expand in the case of increased brain fluid pressure, for example, after head injuries. (Several documented cases of healed wounds indicate that such crude surgery could be survived back then.) However, psychosurgery as understood today was not commonly practised until the early 20th century.

Related Topics:
Trephining - Trepanning - 5000 BCE

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The first systematic attempts at human psychosurgery occurred from 1935, when the neurologist Egas Moniz teamed up with the surgeon Almeida Lima at the University of Lisbon to perform a series of prefrontal leucotomies—a procedure severing the connection between the prefrontal cortex and the rest of the brain. This procedure is commonly (and incorrectly) called a "lobotomy", although this name should refer to a whole class of unrelated surgeries (that is, a lobotomy should refer to the removal of a lobe of the brain, not merely the severing of interconnections).

Related Topics:
1935 - Egas Moniz - Almeida Lima - University of Lisbon - Prefrontal cortex - Brain

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Moniz and Lima claimed fair results, especially in the treatment of depression, although about 6% of patients did not survive the operation, and there were often marked and adverse changes in the patients' personality and social functioning. Despite the risks the process was taken up with some enthusiasm, notably in the U.S., as a treatment for previously incurable mental conditions. Moniz received a Nobel Prize in 1949.

Related Topics:
Depression - U.S. - Nobel Prize - 1949

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The initial criteria for treatment were quite steep—only a few conditions of "tortured self-concern" were put forward for treatment. Severe chronic anxiety, depression with risk of suicide and incapacitating obsessive-compulsive disorder were the main symptoms treated. The original leucotomy was a crude operation and the practice was soon developed into a more exact stereotactic procedure where only very small lesions were placed in the brain.

Related Topics:
Depression - Suicide - Obsessive-compulsive disorder - Stereotactic - Brain

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The procedure was popularised in the United States when Walter Freeman invented the "ice pick lobotomy" procedure, which literally used an ice pick and rubber mallet instead of the standard surgical leucotomy. Leaving no visible scars, the ice pick lobotomy was heralded as a great advance in "minimally invasive" surgery, and was eventually done under only local anaesthesia.

Related Topics:
Walter Freeman - Ice pick - Rubber mallet - Leucotomy

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In a minimally invasive procedure, Freeman would hammer the ice pick into the skull just above the tear duct and wiggle it around. Between 1936 through the 1950s, he advocated lobotomies throughout the United States. Such was Freeman's zeal that he began to travel around the nation in his own personal van, which he called his "lobotomobile", demonstrating the procedure in many medical centres. He reputedly even performed a few lobotomies in hotel rooms.

Related Topics:
Tear duct - 1936 - 1950s - United States

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Freeman's advocacy led to great popularity for lobotomy as a general cure for all perceived ills, including misbehaviour in children. Ultimately between 40,000 and 50,000 patients were lobotomised. A follow-up study of almost 10,000 patients claimed 41% were "recovered" or "greatly improved", 28% were "minimally improved", 25% showed "no change", 4% had died, while only 2% were made worse off (Tooth, et al. 1961). Lobotomies gradually became unfashionable with the development of antipsychotics and are no longer performed. The era of lobotomy is now generally regarded as a barbaric episode in psychiatric history.

Related Topics:
Children - Antipsychotic

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It is possible that some patients did benefit from the more precise psychosurgery, but there was a strong division amongst the medical profession as to the viability of the treatment and concern over the irreversible nature of the operation and the extension of the surgery into the treatment of unsuitable cases (drug or alcohol dependence, sexual disorders, etc). Whatever the truth, psychosurgery was offered in only a few centres, and by the 1960s the number of operations was in decline. The signal improvements in psychopharmacology and behaviour therapy gave the opportunity for more effective and less-invasive treatment.

Related Topics:
Psychopharmacology - Behaviour therapy

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