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 Table of Contents  
MEDICAL HISTORY
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 118-120

A brief history of psychosurgery


Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka, India

Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. A T Safeekh
Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_66_19

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  Abstract 


Diagnosis and treatment of psychiatric disorders has changed significantly over years. Our understanding of aetiology of psychiatric disorders has evolved from demonic possession to specific neurobiological mechanism. With the continuous growth in the knowledge of aetiology and advancement in medical technologies, the treatment too has progressed from removal of major parts of brain to targeting specific neurotransmitter and receptor. The present article highlights a brief history of psychosurgery which is currently an uncommon mode of treatment.

Keywords: Egas Moniz, history, psychosurgery


How to cite this article:
Nayak K P, Safeekh A T. A brief history of psychosurgery. Arch Med Health Sci 2019;7:118-20

How to cite this URL:
Nayak K P, Safeekh A T. A brief history of psychosurgery. Arch Med Health Sci [serial online] 2019 [cited 2019 Oct 15];7:118-20. Available from: http://www.amhsjournal.org/text.asp?2019/7/1/118/260023



The treatment of psychiatric disorders has evolved through centuries with a fascinating history and many controversies. History of treatment can be traced to early man in the Stone Age where they burred holes using trephine to the possessed person for the spirits to escape.[1] It has continued over the years, and there are few written records about the same. Perhaps, the first psychosurgical procedure on human brain was conducted by Peruvian Indians in South America over 2000 years ago. They had incised the scalp and applied “tumi” which is a kind of sharp tool used in the central Andes region. Terebra serrata was another instrument used to perforate the cranium by ancient Roman and Greek surgeons.[2] One evidence of excavated skull in 1996 which was C-14 dated back to 5100 BC corroborates the history [Figure 1].[1] A famous oil painting “The extraction of the stone of madness” by H. Bosch and inscriptions by Peter Treveris adds to the evidence [Figure 2].[2]
Figure 1: Photograph of trephinated skull found at Ensisheim burial site in France and dated to 5100 BC (Courtesy of Kurt W Alt; Source: Feldman RP, Goodrich JT. Psychosurgery: A historical Overview. Neurosurgery 2001;48:647-59)

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Figure 2: The Extraction of The Stone of Madness by Hieronymus Bosch. Museo del Prado,Madrid, Spain (Source: Faria MA Jr. Violence, mental illness, and the brain - A brief history of psychosurgery: Part 1 - From trephination to lobotomy. SurgNeurol Int 2013;4:49)

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Most of the research till the early 19th century were based on the observation of the patients who survived the accidents and war. Clinical presentation and the site of injury to the brain were studied and analyzed. A well-known case happens to be of Phineas Gage who was a railroad worker. He had an accidental explosion where a steel rod pierced his left cheek and through the frontal lobe and out from near the sagittal suture. This was published by Harlow in 1848 where he had described Gage's personality following the accident. This laid the groundwork for the future researchers regarding brain injury and behavioral manifestations and the concept of cerebral localization.[3]

Evolution of modern psychosurgical procedure began in 1890 by Swiss surgeon Gottlieb Burckhardt who is considered by some as the father of modern psychosurgery. He had conducted destructive surgical procedure by incision in the frontal lobe on six psychotic patients of whom only one improved. He discontinued his concepts due to strong negative reaction from professionals as well as from society as they all had a dominant view that the brain always needs to be preserved. It was in 1910, Lodovicus Puusepp, an Estonian neurosurgeon, conducted similar surgeries on three patients with mood disorders and had similar negative results, but he concluded in his report that such procedures deserve further research.[4]

Egas Moniz [Figure 3], a neuropsychiatrist, from Portugal in 1935 along with his associate Almeida Lima conducted successful surgeries for the patients with psychiatric illness. He had studied patients over years and concluded that cortical tissues are fixed in patients and removal of such tissues could help in the treatment of illness. He had conducted surgeries at various subcortical levels and had opened skull on either side unlike the earlier surgeons. With this, Moniz was successful in his surgeries and achieved the Nobel Prize for Medicine in 1949.[4]
Figure 3: Dr. Antonio Egas Moniz (1874-1955) (Source: Photo from Nobel Foundation Archive)

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This paved the way to what is prestereotactic era in the history of psychosurgery. There were more lobotomies performed during this period. The surgeries were conducted mostly on patients with personality disorders, and there was no much research evidence about these surgeries.[5]

Other contemporaries like Freeman and Watts from the United States followed similar lobotomies, where they removed parts of the brain through blind incision and burr holes in the cranium. But soon, they developed modification in these surgeries with precision method where they removed predetermined areas in the frontal lobe. One such development includes the approach to the frontal lobe through the transorbital region instead of burr holes.[4] A performance regarding this was staged in American Fine Arts Gallery in SoHo in the 1990s which inspired one of its stage artist Ledes. He learned further from the archives of Dr. Walter Freeman which was maintained at George Washington University. Instead of a documentary, he decided on a fictional story of a lady approaching a doctor for transorbital lobotomy to handle her emotional suffering. This marked the directorial debut of American filmmaker Richard Ledes for the movie “A Hole in One” in 2004.[6]

Another important modification involved using lighted speculum for clear visualization for incision rather than a blind operation. This procedure of open operation was explained by Lyerly in 1937.[4] As the number of surgeries grew, researchers were keen to modify the method which included lobectomy, gyrectomy, topectomy, and cortical undercutting for the relief of symptoms. This also led to the reduction in the total complications. Heinrich Kluver and Dr. Paul Bucy too contributed by performing temporal lobectomies in monkeys and observing the behavioral changes.[7]

All these laid the foundation for the second phase in the history of psychosurgeries where they used stereotactic apparatus for surgeries and were conducted on patients with mood disorders rather than personality disorders. This made it more accurate and less prone to errors. Cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leucotomy were some of the commonly employed stereotactic procedures. There was a drastic reduction in the number of open surgeries performed. The use of chlorpromazine as a treatment option during this period was successful in further reducing the number of surgeries. This was soon followed by the use of other antipsychotics and antidepressant medications. Medications had a significant improvement in symptoms and less complication and were cost-effective.[5]

The third era of psychosurgeries is the current era where the indications for surgeries have been restricted mostly to resistant cases. Ablative surgeries and neuromodulation of subcortical structures with deep brain stimulation are the key procedures that are developed.[8] Advancement in the neuroimaging has also aided for these surgeries to be more precise. The current neurobiological understanding of psychiatric disorders motivates to use psychosurgeries in various disorders such as addiction and eating disorder but should not be used inadvertently.

Many countries do not perform these surgeries due to ethical reasons. No scientific basis for the surgery, irreversibility and the informed consent from the patient for surgery were the concerns. Some were also of the opinion that the indication for surgery was determined by the society which decided the so-called “abnormal” behavior of the patient. Most important is that few believed psychosurgery as a pure experimental procedure and demanded for protection of humans. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research had come up with a Belmont Report which affirms that “the use of psychosurgery for any other procedure other than to provide treatment to individual patients would be inappropriate and should be prohibited.”[9] Hence, a patient needs to be selected carefully and evaluated thoroughly along with the permission from ethical bodies and needs to be operated only in full-fledged institutions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Feldman RP, Goodrich JT. Psychosurgery: A historical overview. Neurosurgery 2001;48:647-57.  Back to cited text no. 1
    
2.
Faria MA Jr. Violence, mental illness, and the brain – A brief history of psychosurgery: Part 1 –from trephination to lobotomy. Surg Neurol Int 2013;4:49.  Back to cited text no. 2
    
3.
Shelley BP. Footprints of phineas gage: Historical beginnings on the origins of brain and behavior and the birth of cerebral localizationism. Arch Med Health Sci 2016;4:280-6.  Back to cited text no. 3
  [Full text]  
4.
Ramsey GV. A short history of psychosurgery. Am J Psychiatry 1952;108:813-6.  Back to cited text no. 4
    
5.
Doshi PK. Neurosurgery for psychiatric disorders. Neurol India 2017;65:777-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Kennedy R. A Filmmaker Inspired by Lobotomy. New York Times; 2004.  Back to cited text no. 6
    
7.
Faria MA Jr. Violence, mental illness, and the brain – A brief history of psychosurgery: Part 2 – From the limbic system and cingulotomy to deep brain stimulation. Surg Neurol Int 2013;4:75.  Back to cited text no. 7
    
8.
Faria MA. Violence, mental illness, and the brain – A brief history of psychosurgery: Part 3 – from deep brain stimulation to amygdalotomy for violent behavior, seizures, and pathological aggression in humans. Surg Neurol Int 2013;4:91.  Back to cited text no. 8
    
9.
The Belmont Report. Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington, DC. United States Government Printing Office: The National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research; 1978. DHEW Publication No. (OS) 78-0012.  Back to cited text no. 9
    


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