History Matter Friday, May 5, 2023
“Psychosurgery”
Can “abnormal” thinking or behavior be found in a discreet anatomical area? The grander question is “Can mental illness be explained as a brain illness?”
Is there even such thing as “the mind”? or “mental illness”? Or is it just neuroanatomy and neurochemistry not yet understood? Is the “mind” simply a secular version of the religious “soul”? Are both mind and soul simply metaphors for science undiscovered like miasma or bad spirits for what was later discovered to be microbes?
If one takes this line of reasoning, it does become troubling that science has moved so far in it’s physiological understanding and treatment of diseases in every organ of the body except the brain— and has been utterly abysmal at understanding, much less treating any mental illnesses! There is neurosyphilis which presented historically as “mental illness” and was later found to be an infection of the brain. But no such success has been found with schizophrenia, bipolar illness, and other psychosis, —not even depression and anxiety for which most medications are no better than talking or exercising.
Early in the maturation of neurological science, much like the maturation of an individual human brain, theories tend to be rather “mechanical” and “concrete”. Surgery is a rather “concrete” way to approach therapy for an illness. Brain surgery for mental illness is called “psychosurgery” and has a history as long as history itself.
Trephination
Trephination is the oldest documented surgery performed by humans. Trephined skulls have been found all over the world from the Old World to Asia to South America, from the Neolithic age to the earliest prehistoric times. Trephination as a “brain surgery” done by “witch doctors” to alter human behavior is undeniable. We not only have multitudes of skulls, but we also have neurosurgical tools (eg. tumi) from pre-Inca culture.
What we do not know was the beliefs of the various cultures who performed trephinations. Did they view trephination as a “brain only” problem based upon an anatomical problem (eg. trephination for an intractable headache)? Or did they view trephination as a soul-mind problem to let out evil spirits that caused people to go “mad” (eg a ritual surgery for demon possession)? Or is this dichotomous material vs immaterial our construct for which they did not make a distinction —in the same way that ‘blood-letting” has been done throughout history? We assume the latter, but we do not really know. Sir William Osler, Father of American Medicine, writes,
“Trephination was done for epilepsy, headaches, and various cerebral diseases believed to be caused by confined demons to whom the hole gave a ready method of escape.”
In ancient Greece and Rome, many various neurosurgical instruments were developed to penetrate the skull. Celsus (25 BC - 50 AD) and Galen (129 AD - 216 AD) used these neurosurgical instruments called, cerebra serrata. Today, we call them “burr holes” or the electric drill used for craniotomy.
Hieronymous Bosch (1488 - 1516) was a Dutch painter with a fascinating art piece called “The Extraction of the Stone of Madness.” The title alone points to the idea that insanity (poor mental health) was connected to surgery on the anatomy of the brain. What is less clear is whether Bosch believed in it or was making satire of the idea? (well known for his dark satire).
The modern era is illustrated by the story of Phineas Gage (1848). Phineas Gage was a 25-year-old man working on a railway line in Vermont. An explosion propelled a tamping iron rod 3 1/2 feet long and weighing 13 pounds through the air; and through the skull of Phineas Gage. It went into his left cheek and up through his left frontal lobe. He lived the rest of his life with an extremely different personality (and carried the 13-pound iron rod everywhere he went, as a cane and companion!)
In the 19th century, anatomical dissection was at its zenith (re-read childbed fever). The first intentional psychosurgery was performed in 1888 in Switzerland by a psychiatrist, Dr. Gottlieb Burckhardt who removed a portion of cerebral cortex (white matter of the brain) that he thought was responsible for the patient’s abnormal behavior. This type of surgery was immediately “shunned” by the medical community.
In 1935, the Second International Neurological Congress was held in London; and many sessions were devoted to “psychosurgery”. An American physiologist, Dr. John Fulton, described a bilateral resection of the pre-frontal cortex of chimpanzees that turned their aggressive and incorrigible behavior into docile animals “devoid of emotion.” He had surgically reduced their “low frustration tolerance.”
Two Portuguese neuroscientists in the audience, Dr. Antonio Moniz (1874 - 1955), the Father of cerebral angiograms, and Dr. Almeida Lima (1903 - 1985) worked together in performing “frontal leukotomies” (removal of white matter) for psychiatric illness in humans. The first modern human psychosurgery was performed in 1935. Dr. Munoz received the Nobel Prize for this work in 1949.
As unimaginable as this seems to us today that only 70 years ago, we awarded a Nobel Prize to a man who took out a piece of brain to cure mental illness (eg. psychosurgery). We must remind ourselves, that there was no drug therapy to even ameliorate symptoms of those with mental health issues (and would not become available for another two decades after the first lobotomy). The history and experience of the insane asylum is one of the most depressing and cruel chapters in the history of medicine- going back to the straight jackets and padded cells of the notorious Bedlam Hospital in 19th century London (from where we get the word, bedlam). The amount of physical and sexual abuse that occurred in asylums and mental institutions is incalculable.
After WWII and The Great Depression, asylums and mental hospitals reached explosive proportions (also in part due to neurosyphilis). There were more that 450 asylums with over 450,000 patients. That averages 9 asylums per state each with 1,000 patients who were hospitalized for 5 years or longer. Today, we have no idea the extent to which asylums were a part of the American landscape. For anyone back then to offer even the idea of hope of therapy was welcomed.
There was an absence of any effective therapies, including Freudian psychotherapy, anti-malarial therapy (1917), deep sleep therapy (1920), insulin shock therapy (1933) and electroconvulsive shock therapy (ECT) (1938) and many more. Neither psychiatrists who took a mental approach nor neurologists who took a neurobiological approach were finding any success.
During that 1935 Second International Neurological Congress meeting, another American was in the audience, a neuropathologist Dr. Walter Freeman (1895 - 1972). In 1936, he collaborated with a neurosurgeon, Dr. James Watts (1904 -1994) and performed the first US prefrontal lobotomy on a Kansas housewife. (my frontal lobe will prevent me from making any comments here). In 1942, he published a case series of 200 patients in whom they performed frontal lobotomies, claiming a 63% success rate. Later, they modified Phineas Gage’s accidental approach, and did it intentionally by developing the 10-minute trans-orbital lobotomy without having to drill through the thick skull. Dr. Freeman, literally took an ice pick and using local anesthesia on a chimpanzee, entered the skull and brain above the eyeball and “pithed” the brain. Dr. Freeman modified the ice pick (slightly) and called it an “orbitoclast”. With local anesthesia and no sterile technique or by using electroshock, he inserted the orbitoclast above the eyeball and entered the base of the skull by “tapping” it forward 7 cm to the frontal lobe and blind sweeping it 15 degrees laterally. He performed over 2500 of these “simple lobotomies” in out patient clinics and at people’s homes; sometimes as many as 25 in one day.
Drs. Freeman and Watts performed a lobotomy in November 1941 on Rosemary Kennedy, sister of John F. Kennedy Jr (later US President). Rosemary had a hypoxic birth injury which left her developmentally delayed. This type of thing was hidden in the 1920’s, especially among a family as prominent as The Kennedy’s. Rosemarie was quite functional but as she got into her early 20s, she became increasingly belligerent with strange outbursts and seizures. Her father, Joseph Kennedy Sr. without the consent of his wife and without the knowledge of her family, had a lobotomy performed for the purpose of making his 23-year-old daughter more docile. Unfortunately, the result was disastrous, and Rosemarie was left completely disabled and without speech. Rosemarie was sent off to a private institution where she had no visitors from anyone in her family for over 20 years, and the family did not even know what had happened and where she was until Joseph Kennedy Sr died of stroke in 1961! Eunice Kennedy Shriver, her sister, perhaps in response to her sister’s plight, began the Special Olympics in the early 1960s. And President Kennedy responded by encouraging many patients that were “institutionalized” in the mental health hospitals to be re-integrated into the communities through community mental health centers.
Ken Kelsey wrote his book, One Flew Over the Cuckoo’s Nest in 1962 and turned it into a movie in 1975 starring Jack Nicholson. This brought public awareness of lobotomy as a treatment for mental illness.
The last frontal lobotomy in the US was done around 1968. But this was not the end of psychosurgery. Between 1991 and 1995, a neurosurgeon named G. Rees Cosgrove performed Magnetic Resonance Image Guided Stereotactic Cingulotomy where dime size holes are burned in the cingulate gyrus which plays a role in human emotional states. This was performed on 34 patients with severe depression, bipolar disorder, obsessive-compulsive disorder and generalized anxiety disorder. Neuromodulation using Deep Brain Stimulation by the use of targeted stereotactic procedures including cingulotomy, capsulotomy, sub-caudate tractotomy, and limbic leukotomy are the progeny of a philosophy that sees mind and behavior as having a discreet organic location. “Lobotomies” at least in philosophy are still being performed.
references
1. FARIA, M, “Violence, mental illness, and the brain—a brief history of psychosurgery: part I— from trephination to lobotomy.” Surg Neuro