A Brief History of Psychosurgery

It is a rather frightening and rather unnerving thought that psychosurgical procedures can be traced back to Neolithic times, roughly 40,000 years ago (2, 6, 7).  Current psychosurgical techniques are by no way in a state of perfection so one can only imagine how crude and often fatal these ancient procedures were.  Modern psychosurgery can better be understood through a more recent historical investigation of the era of neuroscientific inquiries that was going on during the 19th century (2). 

The first indications of skull surgery come from the archeological unearthing of skulls with holes carbon dating back to 1500 BC (2).  Further study of the bone surrounding the hole, evidence of proper healing, and estimation of the individual’s lifespan indicate that the hole was in fact surgical in nature rather than some sort of head wound.  This ancient method is called trepanning and was more than likely used in order to release demons and evil spirits that were thought to be trapped in the skull and were linked with madness and brain disease.  In many cases the reasons for trepanning were completely bogus and purely based on religious and spiritual beliefs and therefore showed no benefit. However, in other sincere medical cases such as strong headaches, brain tumors, intracranial pressure due to hematomas, hydrocephalus, etc., this procedure potentially had some therapeutic effect and is actually a technique that is still being used to this day to relieve intracranial pressure.   This procedure was performed without any sort of anesthetic and took about 30 to 60 minutes to cut through the skull.  If the tool used to make the hole in the skull does not touch the brain itself, the patient had a relatively high chance of survival. 

Jumping forward several thousand years to the early-mid 19th century when Franz Joseph Gall proposed the idea of phrenology, which was the belief that the size and shape of the skull directly reflects the size and shape of the underlying cerebrum and thus variations in character can be correlated with variations in skull conformation (2).  Although his theory was false, he was the first to propose the idea that the brain is the organ of the mind.  After the proposition of phrenology by Gall, other scientists and philosophers also became interested in localization of function in the brain but relied more on scientific evidence, such as lesions and stimulations of animal brains, to base their ideas on.  Some of the key players in the development of localization of function were David Ferrier, Paul Broca, Jean Pierre Flourens, Gustav Fritsch, and Eduard Hitzig.  There were also two key clinical cases that helped to enforce the idea that extensive lesions of certain areas of the brain will cause different effects. 

The first and probably most famous case is that of Phineas Gage, a railroad construction supervisor who survived an accident in which a pole impaled his head going through his left cheek, destroying his eye, through the frontal part of his brain, and back out the right top part of his skull (2).  There were several things that made this accident fascinating.  First of all, he survived the accident without becoming paralyzed.  Second, after several months, drastic changes in his personality were observed.  Before the accident, he was described by his friends as a friendly, calm, caring man whereas after the accident, he became bad mannered, aggressive, foul-mouthed, anti-social to the point where he could no longer hold a job and none of his friends wanted to associate with him anymore.  When Gage died, no formal autopsy was performed so for many years, Gage’s drastic change in character remained a mystery.  His skull, however, was later recovered and studied.  In 1994, two Portuguese neurobiologists, Hanna and Antonio Damasio, used computer imaging techniques to plot the trajectory of this pole through his skull.  They found that the rod mostly damaged the ventromedial region of the frontal lobes.  From other cases of ventromedial frontal lobe lesions and similar changes in behavior, they concluded that this part of the brain’s function is for social behaviors since people with lesions in this area can not perform normal social behaviors.

The second famous case was that of a patient in a mental institution in Paris, France known by the name of “Tan” because this was the only word he was able to say (2).  It was found that he acquired this handicap after a syphilitic lesion of the frontal part of the left hemisphere of his brain.  Paul Broca used “Tan” to study the location of speech in the brain.  He found that the third gyrus of the prefrontal cortex was responsible for speech.  This area of the brain is now known as Broca’s area.

The first case of psychosurgery can be traced to Gottlieb Burckhardt, a Swiss asylum superintendent (6).  In 1890, he removed parts of the cerebral cortex in patients that were described as highly excitable.  The results led to epilepsy, paralysis, the loss of the ability to understand words, and in one case, death.  This procedure was highly controversial and was not to become a popular technique.

However, modern psychosurgery is most accurately traced back to the first lobotomy, performed by Egas Moniz, a Portuguese physician, in 1935 (7).  Moniz was greatly influenced by experimentation at Yale in which it was found that damage to the frontal lobes of an agitated chimpanzee caused a substantial increase in the calmness of the chimp.  He reported that lobotomized patients showed a decrease in agitation, anxiety, or depression.  Moniz’s results were reported to the world in 1936, and although most psychiatrists and psychoanalysts were vehemently against this procedure, others were inspired and excited by this new technique, most notably Walter Freeman and James Watts.  Freeman and Watts almost single handedly spread the technique of lobotomy across America and was considered as a quick fix method, especially since insane asylums were overflowing after World War II.  With the advent of psychotherapeutic drugs and increasing evidence for the horrors and lack of therapeutic effects of lobotomy, the surgery lost popularity, almost becoming completely extinct.

Contemporary psychosurgery techniques are much less invasive and aided by stereotaxic instruments and other brain imaging techniques that can more accurately pinpoint regions of the brain to lesion (6).  Generally in current psychosurgery, radio waves are sent to specific sites that cause small scale damage to brain tissue.  However, psychosurgery remains a controversial technique and seems to come in waves of popularity, losing popularity with the findings of limited benefits and often excruciating and irreversible damage.  Currently, psychosurgery is used as a last resort technique and appears to be beneficial for patients with severe depression with physiological symptoms and obsessive tendencies along with agitation and tension.  Rarely is psychosurgery performed on those with violent tendencies, for there are many ethical issues with treating antisocial people with psychosurgery. 

With increasing research using animal models, I feel that psychosurgery could become more effective than psychotherapeutic drugs.  The issue with drugs is that people are not able to regulate which part of the brain they act on.  The drug may affect only one kind of neurotransmitter but that neurotransmitter may work on several different brain functions.  Extensive research is being performed in order to create drugs that act as “magic bullets”, only working on the maladapted part of the brain, but so far is unsuccessful.  Therefore, psychosurgery could be the answer to this problem since it is the manipulation of only the affected region of the brain.  However, it is very far from perfection and still requires much investigation.

WWW Sources

1) http://scienceweek.com/2005/sw050812-6.htm; History of Medicine: On Lobotomy. ScienceWeek, 2005.
2) http://www.cerebromente.org.br/n02/historia/psicocirg_i.htm; The History of Psychosurgery. Renato M.E. Sabbatini, PhD, 1997.
3) /bb/neuro/neuro01/web1/Goff.html; Brain Busters: The History of Lobotomy and its Application to Neuroscience. Alice Goff, 2000.
4) http://webspace.ship.edu/cgboer/lobotomy.html; A Brief History of Lobotomy. Dr. C. George Boeree, 2001.
5) http://www.pbs.org/wgbh/aso/databank/entries/dh35lo.html; Moniz Develops Lobotomy for Mental Illness 1935. A Science Odyssey: People and Discoveries. PBS website, 1998.
6) http://science.jrank.org/pages/5576/Psychosurgery-History.html; Psychosurgery - History, Contemporary Psychosurgery, Patient Selection, Postoperative Care, Current Status. Science Encyclopedia Vol. 5, 2007.
7) http://health.mongabay.com/surgery/Psychosurgery.html; Psychosurgery. Mongabay.com, 2006.
8) http://www.cchr.org/index.cfm/6631; History of Psychosurgery. Citizens Commission on Human Rights: Investigating and Exposing Psychiatric Human Rights Abuse,