This is the first in an occasional series of posts examining aspects of psychiatric practice which have given shrinks a bad name. As always comments and suggestions are welcome and if you can think of a candidate then let me know.
Anyone who has seen the film ‘One Flew Over the Cuckoo’s Nest’ will remember McMurphy’s fate; having tried to strangle Nurse Ratched and subsequently restrained, he comes back to the ward where Chief Bromden discovers that he has been given a lobotomy. Previously sparky and defiant, he appears subdued and submissive.
Evidence for the use of surgical techniques, such as trepanation of the skull, in people has been found from skulls dating from the middle ages. Famously Phineas Gage underwent a non-surgical lobotomy following an accident during railroad construction. His subsequent personality change played a role in the understanding of the localisation of brain function.
Neurosurgery for psychiatric problems was introduced in modern times by the Portuguese neurologist Egas Moniz and his neurosurgical colleague Almeida Lima, when in 1935 they sought to damage connections to and from the frontal lobes in patients with symptoms of mental disorders. At this time there were no effective therapies for these conditions and the surgery was received positively, Moniz receiving the 1949 Nobel prize for medicine. Moniz’s technique was to drill holes in the skull and inject alcohol into the frontal lobes.
Walter Freeman and James Watts in America modified Moniz’s operative technique and introduced the standard prefrontal leucotomy, which is what we are normally referring to when we say ‘prefrontal lobotomy’. This however required trained neurosurgeons and Freeman was concerned that this restriction would mean that those patients who needed the procedure most, those in asylums, would not be able to access it. As a result he developed the transorbital lobotomy, a terrifying technique whereby a pick like instrument was driven through the thin bone at the top of the eye socket and into the brain at which stage it was blindly manipulated. This procedure could be undertaken anywhere, without surgical training; beforehand the patient was rendered unconscious by electroshock. Dr Freeman was a showman, who would occasionally like to show off in front of an audience of doctors by lobotomizing both sides of a patient at the same time. Dr Freeman alone peformed over 3,000 lobotomies during his career, the results of which, due to its imprecision, were very variable.
Overall between 1936 and 1961 50,000 patients underwent surgery in the United States and about 10,000 in the United Kingdom. No controlled studies were performed and many people who received this treatment did not have a mental health disorder. It is stated that about 20 per cent of patients with schizophrenia and between one-half and two-thirds of patients with affective disorder derived who underwent the procedure derived some benefit. There was a very high mortality (up to 4%), as well as severe abulia and amotivation (up to 4%), personality change (up to 60%), and postoperative epilepsy (up to 15% – all figures for success and side effects are from the Oxford Textbook of Psychiatry). Due to a lack of other effective treatments these were accepted by many psychiatrists as worthwhile risks.
The use of surgery declined rapidly following the introduction of antipsychotic and antidepressant medication during the late 1950s. Since then, neurosurgery has only been used for severe treatment-resistant affective, obsessional, and anxiety disorders. These operations are used only rarely there having been, on average, no more than 20 operations a year in the United Kingdom over the last 20 years.
Dr Elliot Valenstein has written a book called Great and Desperate Cures!: Rise and Decline of Psychosurgery and other Radical Treatments for Mental Illness. (Which I haven’t read either)
Jack El-Hai has written a biography of Walter Freeman. I have read this, and it’s very interesting and detailed. It’s called The Lobotomist: A maverick medical genius and his tragic quest to rid the world of mental illness