A Brief History of Neurosurgery for Mental Disorder

The 20th Century

Jacobsen and Fulton

In the years following the First World War, the idea that specific brain areas were responsible for particular mental functions and aspects of mental illness was undergoing a renaissance. In 1935, Carlyle Jacobsen and John Fulton ablated the prefrontal cortex in two chimpanzees called Becky and Lucy (Jacobsen, Wolfe & Jackson, 1935). Jacobsen used the term “experimental neurosis” to describe Becky’s frustration and anger at her mistakes and failure to achieve a reward during experiments. Lucy was less agitated at her errors, appearing more ‘laid back’ under experimental conditions. After cortical ablation, Becky became more passive and did not show the same responses to failure. However, Lucy displayed much more agitated and aggressive responses during the tests.

The traditional history of psychosurgery would accord that it was Fulton and Jacobsen’s presentation at the Second World Conference of Neurology in London which inspired the Portuguese neurologist Egas Moniz, to develop similar procedures in humans. Indeed, it is relatively certain that Moniz asked the question whether surgical ablation of the frontal lobes could treat anxiety states in humans, but it seems that Fulton, ever the cautious scientist, was cautious about such an extrapolation of his findings. However, it is difficult to see how contrasting responses to the same procedure in only two animals could be the sole justification for extending the procedure to humans. Indeed, Moniz subsequently reported that he had been considering such interventions prior to Fulton and Jacobsen’s reports. It is more likely that Moniz was more influenced by Brickner and Penfield’s presentations at the same all-day conference (also attended by Walter Freeman) when Brickner gave a detailed description of his famous case, Joe A., reporting that his psychic functions were affected quantitatively rather than qualitatively [1]. MacMillan argues that this lead Moniz to conclude that frontal lobe damage had potentially non-significant, and transitory, effects on the individual (MacMillan, 2002).

Egas Moniz

Whatever the true inspiration for experiments in humans, at the end of 1935 Moniz teamed up with Almeida Lima, a neurosurgeon (who had trained under Hugh Cairns, England’s leading neurosurgeon) who agreed to perform the procedures under the direction of Moniz. After practising on a cadaver, they went on to treat 20 patients, seventy percent of who came from the Manicome Bombarda asylum. The first operation, lasting thirty minutes, was performed by Almeida Lima with the assistance of Ruy de Lacerda on 12 November 1935 at the Neurology Service of the Santa Marta Hospital. Although Moniz’s paper (1936) includes a note of thanks to Sobral Cid, the director of the asylum, Cid was apparently less than enthusiastic about Moniz’s activities. Whilst the first four patients had been selected by Cid, all the postoperative assessments of the patients were performed by a young psychiatrist called Barahona Fernandes, and Cid refused to provide any more cases. The patients had been institutionalised with a range of psychiatric illnesses characterised by severe anxiety, obsessional behaviour, and irrational fears. Thirty percent of the patients came from "other sources", and his cases were probably selected because of availability rather than other reasons (Valenstein, 1986, p. 105). A number of cases had schizophrenia. Subsequent analysis of Moniz’s results by Berrios (1997) reveals that three factors predicted a better outcome: older age; female sex; and affective (rather than non-affective) psychosis.

They started by injecting alcohol to cause the desired lesions, but this tended to track along the injection tracts causing extraneous damage, and after the seventh patient they switched to using a leucotome to cut the fibres connecting subcortical areas in the brain and the frontal lobes. The leucotome was a thin, cylindrical device with a retractable wire which allowed 'cores' of tissue to be created in the white matter. They initially created six lesions bilaterally, but would create additional lesions during later procedures if the patient did not respond.

Moniz’s patients were probably suffering from a mixture of depression, schizophrenia, or panic disorder. Although there were no objective data collected other than case reports, he reported that: 35% had “clinical recovery”; 35% enjoyed “ameliorations”; and 30% showed no improvement (Moniz, 1936). Moniz reported that, “none of the patients became worse after the intervention” and boldly stated that, “No deaths. The intervention is harmless.” They presented their results in Paris on 3 March 1936 and published their first paper shortly afterwards. So keen was Moniz to get to publication that the follow-up period for most patients was less than two months and for four of the ‘cures’ the last observation was less than eleven days after the operation.

Moniz was the first person to use the term ‘psychosurgery’ in 1936 (Moniz & Lima, 1936), and he went on to be jointly awarded the 1949 Nobel Prize for Physiology and Medicine for his work in establishing leucotomy for psychosis. It is likely that Moniz’s previous work (the development of cerebral angiography) contributed to the award, and along with Moniz’s desire for recognition, this may explain why Moniz’s tentative experiments received more attention than Burckhardt’s. Moniz had been nominated by a Brazilian delegation at the First International Congress of Psychosurgery in Lisbon, and the nomination letter was written by António Flores, a renowned neurologist at the University of Lisbon. Incidentally, it was before Flores that Moniz had been awarded the professorship of neurology at the University of Lisbon in 1911. With regard to the Nobel Prize, Gosta Rylander, the Swedish neurosurgeon, was on the selection panel and was one of those who signed the award (Valenstein, 1986, p. 225). It was not the first time that Moniz had been nominated for the Nobel Prize. In 1928, less than six months after the first cerebral angiogram had been performed, the Nobel Committee received two nomination letters from Moniz’s colleagues. He was nominated once more in 1933 for his work in cerebral angiography, again by colleagues from the University of Lisbon (Valenstein, 1986, p. 77).

Moniz had started his career in politics, rather than surgery. He had been christened António Caetano de Abreu Freire Egas and had added the name Moniz in honour of Egas Moniz de Ribadouro, a Portuguese patriot who had helped to defend Portugal from the Muslim invasion of the Iberian Peninsula in the 12th Century. Prior to his surgical career Moniz had served as a minister to Spain and was a signatory to the Treaty of Versailles. Later in his career, after a political shift in Portugal to a more right-wing government, Moniz ceased his psychosurgical activity and devoted his time again to cerebral angiography. Eventually, Moniz was shot and injured by a former psychiatric patient in 1939, and although many have claimed that this patient had undergone leucotomy under Moniz, this has not been substantiated. He ended his days incapacitated with gout, an illness that had affected him for most of his life.

Freeman and Watts

In July 1936 – only four months after Moniz started performing his leucotomies – a US neurologist named Walter Jackson Freeman had published a review of Moniz’s work (Freeman, 1936). He discussed such reports with a neurosurgical colleague, James Watts and they ordered a number of Moniz’s leucotomes from Moniz’s instrument-maker in France. After practising the procedure on cadavers in the mortuary they modified Moniz’s technique slightly (adopting a lateral rather than a superior approach), and started treating patients with depression, using a procedure of their own called bilateral frontal leucotomy. It is reported that when Freeman and Watts performed their lobotomies in the USA, Watts operated with the leucotome whilst Freeman gave ‘directions’ from the head end of the bed (Slovick, 2004). Freeman’s knowledge of neuroanatomy was probably unparalleled by most neurosurgeons, but his lack of surgical privileges prevented him from performing the procedure himself. However, in 1937 whilst Watts was unwell he went ahead with a lobotomy, causing a surgeon at George Washington University to complain.

At the Southern Medical Association conference in Baltimore in November 1936 Freeman and Watts presented their results of the first six cases. Freeman chose to refer to their procedure as ‘lobotomy’, both to reflect a more accurate term for the lesion but arguably also to distinguish his technique from Moniz’s procedure. Such a semantic change would also allow him to retain ‘ownership’ of the term when he and Watts went on to further develop the procedure.

In the late 1930s and early 1940s, Freeman and Watts’ results with chronic schizophrenic patients appeared poor, with many patients relapsing. This led Freeman to adopt the view that lobotomy should be made more readily available to other patient groups. One of the perceived problems with the standard frontal lobotomy was that it required a surgical team, and in 1945, inspired by the work of Italian Amarro Fiamberti who had published a report in 1937, he adopted a transorbital approach. Such a route to the brain was not new. A. M. Doglotti had used the route for ventricular puncture and Maurice Ducosté had used a transorbital technique for introducing malaria inoculations into the brain (Ducosté, 1932). Fiamberti had used the approach in approximately 100 patients using alcohol or formalin to create lesions in the frontal lobes before the outbreak of World War II diverted his attentions elsewhere.

Freeman searched for the perfect tool with which to perform such a procedure and is reported to have eventually come across an ice-pick in his kitchen drawer. Indeed, his original tool had the name of the ‘Uline Ice Company’ engraved on it. With a few modifications (including strengthening the tool), the ‘ice-pick lobotomy’ (a.k.a. transorbital lobotomy) was born. The procedure involved inserting an instrument under the eyelids, through the roof of the orbit, and into the fronto-orbital cortex. A quick sweeping motion cut the fronto-thalamic tracts. It was essentially a non-sterile procedure, could be performed with minimal anaesthesia (often two electroconvulsive treatments were used), and required a minimal team.

The first transorbital lobotomy took place in January 1946 and the first 10 cases were performed in Freeman’s office in the subsequent two months. Typically, patients were allowed home with a relative in a taxi after an hour or two, reportedly with little more than two black eyes and some disorientation. Watts disapproved of the procedure from the outset, arguing that ‘brain surgery should not take place as an office procedure’, and he eventually moved out of their shared offices in Washington. Watts intervened to prevent Freeman from performing transorbital lobotomy at George Washington University and Freeman sought permission to perform transorbital lobotomy under ECT anaesthesia (and was successful) at two other hospitals in Washington D. C. Following Watts’ separation from Freeman at this time, Freeman took on a new neurosurgical partner, Jonathan Williams, who was less surgically conservative than Watts. However, Watts and Freeman did not sever their partnership completely and Watts went on to perform 28 transorbital lobotomies with Freeman between 1949 and 1956, albeit in a neurosurgical operating theatre.

Walter Freeman was undoubtedly a gifted neurologist who was devoted to the treatment of mental illness. Like Moniz, he was politically astute and desired recognition. He was very aware of the power of the media to further his cause, and has even been described as a ‘showman’ at times. He exhibited at every American Medical Association conference from 1937-1946, reportedly using a clacker and shouting like a “carnival barker” to draw crowds (El-Hai, 2005, p.123). One frequent criticism of Freeman is that he was cavalier in his approach and there are certainly episodes which do nothing to silence his critics. In the early 1940s, before the use of muscle relaxants during ECT, Freeman treated a private patient with ECT in his offices. His secretary, who usually helped, was unavailable and the patient’s husband was too physically frail to assist. Alone, Freeman proceeded to give ECT but the patient’s seizure broke both of her legs. Freeman gave her morphine before leaving to see patients at the hospital and when he returned he found the patient and her husband angry and litiginous. Freeman eventually settled out of court (El-Hai, 2005, p.133).

Freeman also infamously performed a transorbital lobotomy in a motel room, after the patient had failed to attend for numerous appointments. The patient had been apprehended by police after causing a disturbance and Freeman collected his surgical tools and drove to the motel, where the patient underwent lobotomy after the police restrained him whilst Freeman used ECT to sedate him.

Freeman was cavalier but he was undoubtedly committed, and through his efforts lobotomy entered the public and professional consciousness. Famous people who underwent prefrontal lobotomy include Rosemary Kennedy, the eldest sister of John F Kennedy who was operated on by Freeman and Watts in 1941, at the age of 25. Unfortunately, the operation was unsuccessful, and she lived the remainder of her years in institutional care, inert and with limited speech. Freeman is also widely reported to have operated on the actress Frances Farmer, and whilst it is still claimed in the popular media that she underwent the procedure (Toomey & Young, 2006), there are no clear records to support this assertion and she and her family have persistently denied that she had a lobotomy (Tate, 2003). Despite such incorrect claims about lobotomy’s alleged “victims”, it has nevertheless entered into the public’s perceived history of psychosurgery [2].

Psychosurgery spreads

Whatever the truth behind the initial inspiration of the lobotomy, the fact that it rapidly became such a widespread treatment for schizophrenia and other mental disorders is remarkable. James Watts was originally a student of John Fulton and by the end of the 1930s Fulton was a prominent figure in American psychiatry. Watts engaged in regular correspondence with Fulton, who met up with Watts and interviewed some of the early lobotomy patients. Convinced of the potential value of the procedure, Fulton spread the word among his network of influential colleagues and once Fulton was a public proponent of lobotomy, sceptics such as the Harvard psychiatrist Harry Solomon were won over. In particular, it is argued that Fulton’s support gave the procedure a neurophysiological legitimacy (Pressman, 1998).

It is interesting to acknowledge that a relatively small number of psychiatrists and neurosurgeons were responsible for spreading lobotomy across the globe. International travel in the 1930s and 1940s is insufficient to explain the widespread uptake. Moniz was a political man who was unlikely to have missed an opportunity for self-publicity. Walter Freeman, driven by his desire to achieve as much as his grandfather W. W. Keen, demonstrated his talent for ‘drawing a crowd’ at most of the conferences he attended. Together, they managed to put lobotomy in most of the mental hospitals in the USA in the 1940s. In 1939 Freeman went to a conference in Copenhagen, and although many Scandinavian psychiatrists were shocked, within 2 years the first lobotomy was being performed in Norway with Ørnulv Ødegård, the director of Gaustad Hospital in Oslo, at the helm.

The fact that Ødegård led with such enthusiasm resulted in a board of inquiry being set up by the Ministry of Health in Norway in 1992 to investigate claims of falsifications over the lobotomy cases. In 1996, the Norwegian Health Department agreed to pay compensation (approx. £10,000) to patients who had undergone lobotomy in Norway (Goldbeck-Wood, 1996). In an attempt to explain the use of lobotomy in Norway, the report (Utredning om lobotomy, 1992: 11) stated that:

The attitude of trendsetting individuals may be decisive for a development, especially in a non-homogenous society like the Norwegian one. The attitude of chief psychiatrist Ørnulv Ødegård can offer an explanation of why the use of lobotomy reached such an extent in Norway. (Cited in: Tranøy & Blomberg, 2005)

Norway was not alone, however. Within five years of Moniz’s first reports of prefrontal leucotomy, the procedure was being performed, outside the USA, in: Brazil (by Pimenta); in France (by Ferdière); in Italy (by Ventura, Ody, Rizzatti, and Sai); in Romania (by Bagdasar and Constantinesco); and the UK (by Hutton and McGregor, amongst others) (Hutton, Fleming & Fox, 1941).

Psychosurgery in a socio-economic context

The neurosurgical techniques employed by Freeman, Watts, and others were, unsurprisingly, crude and inconsistent. The use of external skull landmarks was unreliable and resulted in wide variation in the plane of section from case to case. Whilst the surgeon thought he was cutting brain tissue, often he was merely moving the brain laterally with the leucotome (Swayze, 1995). Despite the surgical problems (which were probably recognised at the time but not widely reported) the lack of effective treatments for chronically hospitalised and psychotic patients meant that the potential benefit of the surgery for selected patients was more compelling than the apparent risks of the procedure. Menninger (1948) illustrates some of the challenges in the public healthcare system with some statistics:

• In the USA in 1946, 46% of all hospital beds were filled with psychiatric patients.
• In 1943, there was an annual net increase of 33,000 in the hospital population, with 100,000 new admissions to state hospitals.
• In 1946, the number of admissions had increased to 271,209. If the minimum standards set down by the American Psychiatric Association were to be met then the cost of inpatient treatment would be $500-700 million. The actual amount spent in 1945 was $165,743,122.

Already by 1946 state hospitals were overcrowded by 17.5%. Surveys at the time revealed that the ratio of patients to doctors in the mid-1940s was at least 250:1 in one-third of the state hospitals (Pressman, 1998, p.151). The survival of a state mental hospital was dependent on three factors: the number of admissions; the rate of discharge; and the number of beds available. Funding for new beds was seldom available; admissions were continuously rising; and so the only factor that the hospital could control was the rate of patient discharge. Treatments were limited and the potential crisis in hospital care undoubtedly led many to seriously consider any treatment which may help to help patients out of hospital.

Further, long-term patients in many public psychiatric hospitals in the first quarter of the 20th Century had an alarmingly high mortality rate, often from tuberculosis. Between the years of 1950 and 1964, more people died in United States ‘mental institutions’ than died in the Revolutionary War, the War of 1812, the Mexican War, the Civil War, the Spanish-American War, World War I, World War II, the Korean War, Vietnam, and the Persian Gulf War combined. In the twenty-five years between 1965 and 1990 the total number of inpatient deaths is estimated at over one million individuals (O'Meara, 2001).

Meanwhile, in the UK, the chances of discharge from mental hospital in 1949 was dependent on duration spent in hospital, and ranged from 7% (2-3 years in hospital) to 0.5% (25-30 years in hospital) (Robin, 1958). The early reports of positive and often dramatic outcomes in patients for whom no treatment was previously available resulted in an optimism that is easy now to criticise. Many proponents of psychosurgery were probably blinded to adverse effects and poor outcomes, despite it being known that frontal lobe damage or removal could cause changes in behaviour (Ackerly, 1935). The poorer outcomes reported in schizophrenia within five years of the first leucotomy (Freeman & Watts, 1945) did not deter psychiatrists and surgeons sufficiently to abandon the procedure for this group. Edward Strecker’s 1942 paper reported that out of five patients with chronic schizophrenia who underwent lobotomy, two were able to be discharged and three were improved (Strecker, Palmer & Grant, 1942). This paper, which was likely to have been widely-read at the time, is cited as having revitalised the role of lobotomy in chronic psychosis (Tierney, 2000).

Psychiatry in a social context

Prior to the 1920s, psychiatry as a medical specialty did not exist. Instead, patients with mental health problems would be treated by primary care physicians, neurologists, and physicians who were working in large public health asylums. Treatments were largely ad hoc, often improvised, and not influenced by any particular model or theory which underpinned the specialty.

In the early 1920s, psychiatry in the USA began to coalesce under a single banner, primarily because of the influence of one man, Adolf Meyer (1866-1950). Indeed, he reclaimed the term ‘psychiatry’ (which had become synonymous with asylum-based medicine) and sold this new specialty to a new generation of doctors. It can be argued that Meyer’s reforms would not have had such wide-reaching effects if it had not been for the First World War.

Struggling to deal with ‘war neurosis’ on an enormous scale, the USA needed new models of delivering psychiatric care to large numbers of people. The successes of the physicians on the front lines, in treating the mental health problems that arose out of the stresses of combat, convinced many that things could be done for sufferers of mental disorder and also illustrated the fact that mental ill health could arise in anyone if there was sufficient stress. The Great War also served to unite the private neurologist and public health asylum worker in the need to both screen out those unfit for military service because of vulnerabilities to neurosis, and also to return those suffering from the psychiatric consequences of combat to useful roles in society. Some may argue that the image of the psychiatrist as an agent of authority and social control was born out of this period. In 1926 William Healy, the chair of an American Psychiatric Association panel on the role of psychiatry in society, announced that:

“…it is exactly the psychiatrist’s proper business to take over the problems of mental adjustments that are so immediately and overwhelmingly involved in the problems of personality, of family and other social maladjustments, of misconduct, of vocational dissatisfactions, of educational misfittings in primary or secondary school or college.” (Cited in Pressman, 1998, pp 28-29)

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