AANS Neurosurgeon | Volume 29, Number 1, 2020


Psychosurgery: History’s Trash Heap or Tomorrow’s Promise

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The quest to alter the mind through manipulation of brain anatomy has historically occurred at the intersection of neurosurgery, psychiatry and neuroscience. As a result, the pursuit of a surgical treatment for psychiatric illness has sparked significant advancements in surgery for depression, obsessive-compulsive disorder, eating disorders and pain, despite a fairly rudimentary understanding of the biological basis of the mind. Nevertheless, progress has occurred in fits and starts – sometimes with tragic missteps. For example, neurological physicians created disturbing and controversial treatments for psychiatric illness. One such procedure, the leucotomy/lobotomy, was widely-adopted and the neurologist who developed the procedure even won the Nobel Prize for the treatment of psychiatric illness in 1949. Eventually, however, the unfortunate side effects of the procedure led to its eventual abandonment as a psychiatric therapy.

Leucotomy/Lobotomy Thrived

Egas Moniz performed the first leucotomy in 1936 at a time when psychiatric disease was viewed as a huge social problem without effective treatment options. It was originally performed via two frontal burr holes before being modified into the minimally-invasive icepick “lobotomy”. The charismatic Walter J. Freeman, MD, popularized the procedure in the U.S. The procedure was viciously demonized in books and movies such as the play Suddenly, Last Summer by Tennessee Williams, the novel The Bell Jar by Sylvia Plath, or the film One Flew Over the Cuckoo’s Nest starring Jack Nicholson.

At the time, lobotomy offered a viable and less violent alternative to other treatments for psychiatric ailments practiced at the time, such as:

    • Insulin shock
    • Electroshock
    • Straitjackets
    • Ice baths
    • Restraints

Effective medical treatment with antipsychotics was two decades away and the asylums were full, despite their unspeakable conditions and depraved mistreatment of the committed. Lobotomy, performed as an outpatient procedure in the office, offered an ostensibly simple and promising treatment for curing psychiatric disease, particularly for patients with violent outburst or socially unacceptable behavior. The fact that Dr. Moniz was the 1949 Nobel Laureate in Physiology or Medicine reflected society’s attitude toward mental illness at the time.

The Fall of Lobotomy

Unfortunately, indications were loose and inconsistent outcomes ultimately contributed to negative public and regulatory sentiment against lobotomy. There was also a preponderance of women being subjected to lobotomy. There was limited voluntary informed consent. When there weren’t complications, patients were left with intellectual deterioration and emotional flatness. One of the most prominent failures remains Dr. Freeman’s lobotomy of Rosemary Kennedy, sister of President John F. Kennedy. Kennedy had suffered from a mild developmental delay, which progressed into anxiety and agitation as she aged. Following the procedure, she became severely disabled and was unable to function independently and she was ultimately institutionalized for the remainder of her life.

Lobotomy’s Legacy

The legacy of lobotomies is not all dark. In fact, the procedure garnered considerable headlines, which ultimately led to an explosion of interest in the biology of psychiatric issues. Ultimately, we now think about psychiatric illness the way we think about trauma, brain tumors or epilepsy. Further, Dr. Freeman’s legacy uncovered ethical and social concepts that warranted further examination by neurosurgeons, researchers, administrators and collaborating clinicians. Specifically, it helped highlight aspects of patient safety, informed consent, postoperative care as well as the future portrayal of ‘psychosurgery’.

The successes of deep brain stimulation took hold in the 1960’s with its advances moving like a juggernaut through modern times with significant benefits to society. In the same way as lobotomy (but hopefully with greater safety and quality outcomes) psychosurgery remains the result of the collision between science, psychiatry and the surgical management of the mentally ill. Techniques continue to evolve and have shifted to modulation of neural function without destruction of the tissue to effect the desired changes. While psychosurgery now involves more humane and less invasive means of treating mental disorders, the legacy of the lobotomy continues to provoke ethically and sociologically relevant discussions about the field.


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