Psychosurgery, also called neurosurgery for mental disorder or functional neurosurgery, is surgery in which brain tissue is destroyed with the aim of alleviating the symptoms of mental disorder. 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. The 1940s was the decade when psychosurgery was most popular, largely due to the efforts of American neurologist Walter Freeman; its use has been declining since then. Freeman's particular form of psychosurgery, the lobotomy, was last used in the 1970s, but other forms of psychosurgery, such as the cingulotomy and capsulotomy have survived.

Early history

Trepanning, the practice of drilling holes in the skull, was performed from prehistoric times to the early Middle Ages and then again during the Renaissance. There is speculation that some of these operations were carried out on people who had mental disorders or epilepsy. Trepanation was depicted in prints, woodblocks, and paintings, including the allegorical painting by Hieronymus Bosch, The Extraction of the Stone of Madness, which depicts the extraction of a "brain stone".

In 1891 Gottlieb Burckhardt, the superintendent of a psychiatric hospital in Switzerland, published the results of an operation on the brains of six patients. The operation was a topectomy, in which parts of the frontal, parietal and temporal cortex were excised. Other psychiatrists were not enthusiastic about his work and he abandoned his operations. The Estonian neurosurgeon Ludvig Puusepp also operated on psychiatric patients in St Petersburg in 1910.

1930s

It was the work of the Portuguese neurologist António Egas Moniz in the 1930s that led to a wider use of psychosurgery. Moniz, working with neurosurgeon Pedro Almeida Lima, started operating on patients in late 1935. The first operations involved injections of alcohol into the frontal lobes of patients to destroy white matter; Moniz then devised an instrument he called a leucotome to remove small cores of white matter. He coined the terms leucotomy and psychosurgery. 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". At first they used the same technique as Moniz, but then they devised their own technique which more completely severed the connections between the frontal lobes and deeper structures. They coined the term lobotomy for the operation, and it became known as the standard prefrontal lobotomy or leucotomy of Freeman and Watts.Some countries, such as the United Kingdom, retained the word leucotomy rather than lobotomy Freeman and Watts eventually performed 600 of these standard operations; in the United Kingdom neurosurgeon Wylie McKissock performed over 1,400.

The two foremost promoters of psychosurgery in the 1930s, Moniz in Portugal and Freeman in the US, were both neurologists. Psychiatrists were later found amongst both the supporters and critics of psychosurgery. José de Matos Sobral Cid, who had initially allowed Moniz to operate on patients from his asylum, became a critic of the procedure.ES Valenstein 1986 Great and desperate cures : the rise and decline of psychosurgery and other radical treatments for mental illness. New York : Basic Books Freeman was at first not allowed to operate on patients at the hospital where he was director of laboratories, St. Elizabeth's, Washington, as the superintendent William Alanson White was opposed to the operation. White's successor, Winfred Overholser, cautiously allowed Freeman to operate at the hospital.M Raz 2013 The lobotomy letters: the making of American psychosurgery. University of Rochester Press: 46-48. 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.W Sargant 1967 The unquiet mind: the autobiography of a physician in psychological medicine. London: Heinemann Until Freeman introduced the technique of transorbital lobotomy, psychosurgery required the skills of a surgeon.

The standard lobotomy/leucotomy involved drilling burr holes in the skull on the side of the head and inserting a cutting instrument; it was thus a "closed" operation, with the surgeon unable to see exactly what he was cutting. In 1937 J.G. 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. Some neurosurgeons preferred this "open" technique to Freeman and Watts' closed technique as it was less likely to damage blood vessels; it became the most widely used standard lobotomy/leucotomy in the United States.

1940s

The use of psychosurgery increased during the 1940s, and there was a proliferation of the techniques used for the operation. In 1946 Freeman developed the transorbital lobotomy, based on a technique first reported by Italian psychiatrist Amarro Fiamberti. 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. Freeman used electroconvulsive therapy in the place of a normal anaesthetic and carried out the operation without the aid of a neurosurgeon. This led to a rift with Watts. Freeman performed over 4,000 of these transorbital operations.

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. William Beecher Scoville, of Hartford Hospital and Yale Medical School, developed a method of cortical undercutting. Two of the techniques still in use today date from this period: Jean Talaraich in France developed the capsulotomy, while at Oxford in England Hugh Cairns performed the first cingulotomies in the late 1940s.GJ Fraenkel 1991 Hugh Cairns: first Nuffield Professor of Surgery, University of Oxford. Oxford University Press: 207-08 The 1940s also saw the introduction of the stereotactic frame, which would allow surgeons to find their bearings more accurately when doing closed operations.

Many countries started to use psychosurgery during this decade. 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. Norway was also the only Scandinavian country to use transorbital lobotomy.

In Britain, the first psychosurgical operations were carried out in Bristol in late 1940 and early 1941. By 1947 the Board of Control was able to publish a report entitled Pre-frontal leucotomy in 1,000 cases. Psychosurgery was also introduced into British East Africa. In 1946 twenty prefrontal leucotomies were performed, mostly on African women, in Bulawayo. The next year a further 70 were performed, but the number declined after that.J McCulloch 1995 Colonial psychiatry and "the African mind". Cambridge University Press: 19

In 1949 Moniz shared the Nobel Prize in Physiology or Medicine because of his "discovery of the therapeutic value of leucotomy in certain psychoses". He had already been nominated three times for his work on radiology. A further nomination in 1943, this time by Walter Freeman for psychosurgery, had led to an evaluation of the operation by Erik Essen-Möller, a professor of psychiatry. His report to the Nobel Committee pointed out that Moniz had paid too little attention to the side-effects of psychosurgery and had not done any in-depth observations. 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 also noted the lack of comparison with other treatments and concluded that it was a mutilating treatment with a "negative side yet to be heard", and did not deserve the prize.C-M Stolt 2002 Moniz, lobotomy, and the 1949 Nobel Prize. In E Crawford (ed.) Historical studies in the Nobel Archives: the prizes in science and medicine. Universal Academy Press, Tokyo: 79-93 Moniz received nine nominations in 1949 (five from Lisbon, three from Brazil and one from Copenhagen) and this led to a special report by the neurosurgeon Herbert Olivecrona, who deemed that Moniz's hypothesis "that emotional tension could be eliminated by leucotomy" had been proven. 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". Accordingly, Moniz was awarded the prize.

1950s and 1960s

In spite of the award of the Nobel Prize to Moniz, the popularity of psychosurgery decreased during the 1950s. This has been attributed to "an increased awareness of the negative changes of personality in addition to the introduction of new anti-psychotic medication". In the United States the use of psychosurgery probably peaked at an estimated 5,000 or so operations annually.

In Britain in the mid-1950s, about three-quarters of psychosurgical operations were standard pre-frontal leucotomies. By the end of the decade, some 500 operations were carried out every year. The standard operation was on its way out, but still accounted for about one-fifth of operations.

From 1940 to 1960, Scandinavia used psychosurgery at a rate of about two-and-a-half times the rate of the United States. Gaustad in Norway became a particular centre for psychosurgery in the mid-1950s, with money from the United States.

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. They studied patients with EEG abnormalities and overt seizure disorders associated with uncontrolled aggression and found that many of these patients had abnormalities of the brain causing their temporal lobe epilepsy or psychomotor seizures. Their treatment was stimulation or ablation of the amygdala, unilaterally or bilaterally. Approximately 20 amygdalotomies were performed, with many patients improved but not necessarily cured. This work in psychosurgery became highly controversial and as the debate on psychosurgery heated up in the 70s it was abandoned.

Innovations in surgical techniques continued apace. In Britain in 1964 Geoffrey Knight developed the subcaudate tractotomy, implanting radioactive seeds in the brain to destroy tissue. This was to become the most widely used type of psychosurgery in Britain, until it was abandoned some thirty years later. 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. The Tulane programme would continue until the 1970s.

1970s to the 1980s