In an article published in 1993, Professor of Neurosurgery B L Lichterman divides the history of psychosurgery in Russia into three periods:

The first period starts at the turn of the century under the initiative of Bekhterev. His pupil and one of the fathers of Russian neurosurgery Puusepp performed leucotomy-like cuttings of frontal association fibers in manic-depressive cases and psychic equivalents of epileptics as early as 1906-1910. The second period includes the time from the late 1930ies till the late 1940ies. The classical leucotomy of Moniz and Lima, with some modifications, was used for treatment of schizophrenia and severe pain. In 1950 psychosurgery was prohibited by the special order of the Minister of Health of the USSR for ideological reasons. The third period starts in the early 1980ies with the acceptance of modern stereotactic techniques for treatment of intractable pain and obsessive-compulsive disorders. (On the history of psychosurgery in Russia, Acta Neurochirugie [Wien], 1993, vol 125: 1-4)

In 1998 doctors in Russia found a new indication for psychosurgery - drug addiction. Actually, it wasn’t a completely new indication - stereotactic cingulotomy (the operation used in Russia) has been used in India as a treatment for addiction and in the UK (and presumably in other countries) a small number of addicts have been operated on, although not in recent years. Over a four-year period doctors at the Institute of the Human Brain in St Petersburg, under the leadership of
the Institute’s director, Sviatoslav Medvedev, operated on 348 heroin addicts aged between 17 and 35. The results were published in the Journal of Human Physiology (S V Medvedev, A D Anichkov, and Yu I Polyakov, 2003, Physiological mechanisms of the effectiveness of bilateral stereotactic cingulotomy against strong psychological dependence in drug addicts, Human Physiology, vol 29, 492-97). The authors describe a consent procedure that sounds similar to that used in the UK, with the “elimination commission” taking the place of the Mental Health Act Commission panel (although there is no indication that the Russian commission was independent):

The duration of drug addiction varied from 2 to 15 years. All of the patients claimed that they were repeatedly treated in licensed medical institutions by noninvasive methods, but without results….

All patients that turned to the Institute of the Human Brain were examined by an elimination commission, which ascertained the strong wish of a patient to get out of drug dependence and determined the presence of an obsessive-compulsive component in the structure of psychological dependence, the absence of contraindications for the stereotactic surgery, and the presence of real prospects for social rehabilitation after the treatment. If there were any doubts that these conditions were met, the patient was denied hospitalization. The elimination commission explained to the patients the essence and details of the surgery, as well as possible alternatives and complications, which, in principle, are possible in the case of surgery. If the patient was accepted and agreed to the surgery, the clinic and the patient signed a contract containing exhaustive information on the condition of treatment and possible complications. This contract served as the patient’s informed consent to the surgery.

The authors claimed good results, with over half of the patients who were followed up for more than two years remaining completely drug free, and most of the rest showing some improvement. Only 14 per cent were unchanged. Postoperative complications were rare, occuring in 1.4 per cent of patients, and the authors also reported a general improvement in the patients’ mental state.

We observed improvements in attention and emotional state, an increase in motivation, and compensatory and adaptive changes in personality structure.

In 1999 the Observer newspaper in the UK published an article entitled “Russian addicts cured by surgery: removing part of the brain under local anaesthetic is a revolutionary cure that seems to work”, which in its enthusiasm for the procedure is reminiscent of newspaper and magazine articles from the very early days of psychosurgery. The article reported Dr Medvedev’s claims of an eighty per cent success rate and spoke to a grateful patient who said:”The day I had this operation, I was born again. I’d recommend anyone addicted to heroin to have it. Otherwise, I would have died”. Dr Medvedev is quoted as saying: “We take out a cubic millimetre from one hemisphere and another cubic millimetre from the other hemisphere and that stops the addiction”, which is strange since bilateral cingulotomies usually destroy about 2,000 times this amount of brain.

However, trouble was in store for the Institute of the Human Brain. In 2002 a patient who was not cured of his heroin addiction and suffered a postoperative wound infection and headaches sued the doctors and won. He was awarded damages to cover the cost of the operation, about 8,700 dollars, and the Institute of the Human Brain was told to stop doing the operations. The case was covered in an article in the Guardian newspaper entitled “Russia bans brain surgery on addicts”. The “revolutionary cure” has now become a “controversial brain operation”.

The Institute of the Human Brain appealed against the authorities’ ban on the operation. From their website it is not clear whether psychosurgery for drug addiction, or other diagnoses, is still carried out. They have this to say about it:

Valuable contribution to practice was made through application of the theoretical concepts into most up-to-date line of medicine — psychosurgery. Institute of the Human Brain. On the basis of formulated and developed common theory of stereotactics targeting and to ensure this work, the first Russian computerized stereotactic system POANIK, produced now in series, as well as the cryosurgical device using the solid dioxide carbon were developed (A. D. Anichkov). Using stereotactic system POANIK, the most effective modern method of obsessive-compulsive syndrome treatment of patients with drug addiction was worked out (A. D. Anichkov, Y. I. Polyakov).

In the USA and the UK patients have won lawsuits against doctors who performed psychosurgery on them (one case that I know of in each country), but, unlike in Russia, it has not led to attempts to call a halt to the operations.

The Mexican artist Manuel Gonzalez Serrano (1917-1960) spent the last few years of his life in a State Asylum in San Pedro del Monte. He underwent a psychosurgical operation and died of a heart attack shortly afterwards, at the age of 43.
Paintings by Manuel Gonzalez Serrano can be seen at the Andres Blaisten virtual museum.

Mexico still has a psychosurgery programme. This newspaper article, for example, describes the case of a 21 year old patient who was operated on for anorexia.

The National Library of Medicine in Bethesda, Maryland, has several films and videos relating to psychosurgery, including:

Author(s): Freeman, Walter, 1895-1972.; Watts, James W (James Winston), 1904-; Pennsylvania State College. Psychological Cinema Register.; George Washington University. Dept. of Neurology. Title(s): Prefrontal lobotomy in the treatment of mental disorders [motion picture] / from the Psychological Cinema Register of the Pennsylvania State College ; from the Department of Neurology, George Washington University ; by Walter Freeman and James W. Watts. Publisher: State College, Pa. : The Register, [1942] Description: Answer print : 1 film reel of 1 (438 ft.) : sd., col. ; 16 mm. Language: English Summary: This film describes and demonstrates a prefrontal lobotomy, an operative procedure employed in mental disorders resistive to other methods of treatment. Procedure consists of cutting the white matter in each frontal lobe in the plane of the coronal suture. This passes just anterior to the frontal horn of the ventricle and interrupts the anterior thalamic radiation. This film includes a written description of the procedure, review of landmarks on the skull and frontal lobe ona demonstration skull and brain, operation on a live patient, and X-rays taken after the operation. Filmed with cooperation of George Washington University.
MeSH: Frontal Lobe/surgery*
Psychosurgery/methods*
Publication Type(s): Instruction
Notes: Date is production date.
Last inspected: Answer print: 1981. Condition complete; warped.
Last inspected: Videoreel: Apr. 1987. Condition complete; good.
Received: (date unknown) as a donation from Psychological Cinema Register of Pennsylvania State University.
Country of Producing Entity: United States.
Credits: Photography by Guild Photographers.
NLM ID: 8800490A [Motion picture, Videorecording]

Author(s): Bennett, Abram Elting, 1898-; Bishop Clarkson Memorial Hospital (Omaha, Neb.). Psychiatric Dept.; Pennsylvania State College. Psychological Cinema Register. Title(s): Prefrontal lobotomy in chronic schizophrenia [motion picture] / from the Psychiatric Department of the Bishop Clarkson Memorial Hospital. Publisher: [State Colleege, Pa. : Psychological Cinema Register of the Pennsylvania State College, c1944. Description: Master positive : 1 film reel of 1 (488 ft.) : si., b&w ; 16 mm. Language: English Summary: This film shows the recovery that can be made by prefrontal lobotomy in chronic psychotics. Four patients are shown before and after operation. Patients include one 25 year old aggressive female, one 22 year old aggressive male, one female who had been catatonic for five years, and one 26 year old Ph. D. who had catatonic lapses in the last three years. All patients appeared calmer and more sociable after operation. Only the 5 year catatonic female had to continue hospitalization after the lobotomy, although she had improved greatly. Filmed at the Bishop Clarkson Memorial Hospital, Omaha, Nebraska. Donated film is B-wind.
MeSH: Frontal Lobe/surgery*
Psychosurgery*
Schizophrenia/surgery*
Publication Type(s): Case Reports
Instruction
Notes: Copyright: 1944, Psychological Cinema Register of the Pennsylvania State College.
Live.
Last inspected: Apr. 1986. Condition complete; good.
Country of Producing Entity: United States.
Credits: A.E. Bennett.
Received: (date unknown); donation; from Psychological Cinema Register of Pennsylvania State University.
NLM ID: 8601165A [Motion picture, Videorecording]

The library at West Virginia University has a film about transorbital lobotomy

Title: Transorbital lobotomy
Library: Downtown Library, Media Services
Call Number: MEDIA DV1033 AV LIB
Subject: Frontal lobotomy., , Catatonia.,
Abstract: Part one outlines the process of transorbital lobotomy. Demonstrates the scientific reasoning and after effects of surgery. Includes actual surgical footage of a female patient. Part two shows a 19-year-old male catatonic before and after treatment by transorbital lobotomy and insulin shock. Anxious, delusional, hallucinated before treatment, patient largely lost symptoms after therapy, although still considered odd, found employment as musician and salesman. Operation and recovery shown in still photography. Gross dissection of frontal lobes after death, 11 months post-operatively, concludes presentation.

There is a fascinating article in the Sunday London Times written by Christine Toomey and Steven Young. It features Psychosurgery.org member Derek Hutchinson and mentions the Shaw family and even has a quote from me. Here’s an excerpt:

Mental cruelty

The lobotomy is deemed one of the worst crimes in medical history. But a modern form of it is still practised in Britain - and may soon be performed without the patient’s consent. By Christine Toomey and Steven Young

The flashbacks come late at night. First comes the recollection of intense physical pain, as if the bones in his arms are being snapped like twigs. Then he hears the voice of the neurosurgeon applying an electric current to metal pins implanted in the tissue of his brain. “How do you feel, Derek?” the surgeon Arthur E Wall asks, while peering into Derek Hutchinson’s eyes to see if his pupils have yet dilated with fear.

When Hutchinson swears at the surgeon, Wall administers another electric shock to nerve centres located in the hypothalamus at the centre of his patient’s brain. At this, Hutchinson’s pupils dilate and he screams: “You’re going to kill me, you bastard!” Hutchinson’s medical records, written by Wall over 30 years ago, confirm that his patient “felt funny - as if he was dying”. But as he screamed, Hutchinson recalls Wall leaning in close to his face and leering: “And I thought you were a bit of a tough guy.”

His next recollection is of Wall giving orders for surgical implements to be passed. Hutchinson feels the metal pins inserted through nylon balls lodged in cavities bored into the front of his skull being replaced by thicker electrodes he says felt like “broom handles”. “After that I started, I start to feel warm all over and quickly feel as if I have fallen into a vat of molten metal, as if I am, quite literally, frying,” says Hutchinson, tellingly confusing tenses as he describes the brain surgery he underwent in 1974 yet still relives up to a dozen times a day and in frequent nightmares.

Throughout the surgery, Hutchinson was kept conscious; his head held in a brace, his hands and feet strapped to the operating table. Hutchinson, a 27-year-old father of three at the time of the operation, says he had not given his written consent to the operation being performed; neither had his wife - his next of kin. Instead his mother, an alcoholic, had been visited at home, in the late evening, after she had been drinking, and had been asked to sign the form. “My mother thought doctors were gods,” Hutchinson says. “She’d have signed anything they asked.”

More

Here is an interesting article in New York’s Newsday which discusses the murals found in the now abandoned Kings Park Psychiatric Hospital. To the right of the story there is a link that allows you to view all the murals.

Australian Louise Crockett was awarded four and a half million Australian dollars (about 3 million US dollars) in 2002 when she successfully sued the doctors who failed to promptly diagnose and treat a brain infection following psychosurgery. The case did not involve the doctors who carried out the operation. Her award was the largest ever paid by the Tasmanian State. It took nearly twenty years for the case to be settled.

Louise became depressed following the birth of her second daughter, who was diagnosed with a heart condition. Although surgery for her daughter’s heart condition was successful, Louise continued to feel depressed. She went to see a psychiatrist and was given tranquillisers and antidepressants. Then she was admitted to hospital and given electroconvulsive treatment. Then her psychiatrist recommended psychosurgery and the operation was carried out in May 1983 at the Alfred Hospital, Melbourne, New South Wales, just over two years after Louise’s first consultation with a psychiatrist.

The operation was pronounced a success (her nursing notes recorded comments such as “quite cheerful”, “very cheerful” and “talkative”) and Louise was discharged after six days and returned to her home in Tasmania. But two days later the wound started to swell and Louise began to behave oddly and was taken to her local hospital.

It was a delay in diagnosing and treating a brain abscess that led, in the judge’s opinion, to Louise’s respiratory arrest and subsequent brain damage. She was left with movement difficulties, memory loss, and personality problems. Her husband left her.

The award included 700,000 Australian dollars (about 500,000 US dollars) for loss of earnings. I think perhaps Justice Underwood was being optimistic in believing that, following psychosurgery, Louise would have been able eventually to take up “some paid employment involving accounting or the like”.

The judgement can be read here.

The January 2006 issue of the studentBMJ (British Medical Journal) includes an article entitled The white cut: Egas Moniz, lobotomy, and the Nobel prize, written by medical student Seye Abimbola.

In 1949 the Nobel prize was awarded to Egas Moniz, the neurologist who carried out the first lobotomy, a procedure that caused severe physical and psychological impairment. Seye Abimbola investigates the ongoing debate.
The closest most medical students get to learning about lobotomy is during their psychiatry or possibly neurosurgery rotations, although there is more chance for those who do an elective in medical history. However, the story of Egas Moniz and lobotomy exemplifies some of the important events and contemporary issues of social relevance in the history of medicine.

At the end of a well-researched (several quotes from psychosurgery.org) article, Abimbola concludes:

I don’t think it makes sense to withdraw a prize awarded over half a century ago. It would be good if the World Health Organization could dedicate a day to remember the tragedy of lobotomy. And following the example of Norway, which has awarded compensation to all surviving lobotomy patients,4 nothing stops the Swedish Academy from recognising the negative impact of lobotomy on the lives of thousands of patients and their families around the world. My suspicion is that prefrontal lobotomy was just an excuse to award Moniz the deserved prize for cranial angiography he repeatedly missed in 1928 and 1933.

In anterior cingulotomy, one of the most commonly used psychosurgical operations nowadays (used in recent years in for example the USA, Canada, Scotland, South Korea, Russia, France, Poland, and Australia), the aim is to “produce lesions of approximately 1×1x2 cm within the anterior cingulate cortex of each hemisphere (ie total lesion volume = ~ 4cc)”

(A magnetic resonance imaging study of regional cortical volumes following stereo tactic anterior cingulotomy, S L Rauch et al. CNS Spectrums 2001 6(3) 214-222)

On Friday June 25 2004 Professor Rees Cosgrove M.D., Associate Professor of Surgery (Neurosurgery), Harvard Medical School, and Attending Neurosurgeon, Massachusetts General Hospital, addressed the President’s Council on Bioethics on the subject of psychosurgery. (Professor Rees Cosgrove carries out the psychosurgical operations done at the MGH.)

The modern era of psychosurgery was begun by this man, Egas Moniz, who is a very celebrated and famous Portuguese neurologist who experimented by injecting alcohol into the frontal lobes of 20 institutionalized psychiatric patients and thought that 16 of the 20 were favorably improved.

Moniz, or rather his neurosurgeon colleague, Dr Almeida Lima, didn’t inject alcohol into the frontal lobes of all 20 patients; he injected ten with alcohol but ten were operated on with a leucotome. One was subjected to both procedures. Moniz thought that 14, not 16, of the 20 were improved (but that might be a transcription error - Professor Rees Cosgrove gets it right on the MGH /Harvard Medical School Neurosurgical website.)

But, more importantly, were Moniz’ original twenty psychosurgery patients really institutionalised? In fact, only 9 of the 20 had been in the local mental hospital, the Bombarda Asylum, for over a year. Five had been there for six months or less and six had never been in the asylum but had consulted Moniz at his clinic.

The first seven patients had spent between two and eight-and-a-half years in the Bombarda Asylum before they underwent surgery. They were all still in the asylum at follow-up after surgery (the maximum follow-up period was two months).

Patients Eight and Nine also came from the asylum but had been there for just five months and one month respectively. Both were still in the asylum at follow-up, although one of them had been given permission to return home.

Patient Ten had never been in a mental hospital. She consulted Moniz at his clinic, the Santa Marta, and was diagnosed as suffering from an anxiety neurosis.

Patient Eleven had never been in an institution either, having been taken to the Santa Marta in an excited state on 26 December 1935, he was diagnosed as schizophrenic and operated on a week later.

Patient Twelve was diagnosed as suffering from a “cardiac neurosis”. She had never been in a mental hospital.

Patient Thirteen had never been in a mental hospital but was brought to the Santa Marta Clinic by her son who said she had been excited for three months. She was operated on immediately and again a couple of weeks later.

Patient Fourteen had been in the Santa Bombarda Asylum for two years.

Patient Fifteen had never been in a mental hospital.

Patients Sixteen, Seventeen and Eighteen came from the Santa Barbara Asylum (one of them via prison), but had been there a year or less.

Patient Nineteen, suffering from depression and anxiety, had never been in a mental hospital. Her family had heard about the operation and brought her into the Santa Marta Clinic.

Patient Twenty had been admitted to the Bombarda Asylum six weeks before she was operated on.

Professor Rees Cosgrove repeats the claim on the MGH/Harvard Medical School Neurosurgical website:

Moniz reported that 14 of 20 severely ill, institutionalized patients showed “worthwhile” improvement after operation and coined the phrase “psychosurgery” to describe his interventions. ( Moniz, 1937) At that time, few satisfactory treatment options existed and the asylums for the insane were overflowing with the chronic mentally ill. Therefore, despite the lack of objective data and long term follow-up, an enthusiastic response was obtained from the medical community. This response resulted in Moniz receiving the 1949 Nobel Prize in Medicine and Physiology.

Here, Professor Rees Cosgrove makes the usual apologies for the early psychosurgeons: the mental institutions were overflowing and few treatments existed. But only one of the nine patients who had been in hospital for over a year was able to return home following surgery. He was suffering from depression and had been in the Bombarda Asylum for two years. Although he was allowed to go home, he was described at follow-up as lacking in initiative and confused about his age, time and money. Three patients, two suffering from mania and one from depression, who had been in hospital for only a brief period before surgery, were able to go home. None of the seven schizophrenics got to leave hospital, and only two were described as improved.

In fact, Moniz’ results were very typical of what was to follow. Psychosurgery was never going to empty the mental hospitals. Long-term patients who could leave the hospital following surgery were few and far between; those who could work and live independently were even fewer and further between. The majority of cures were obtained with the least ill patients - people who were suffering from anxiety and depression and sometimes hadn’t been ill for very long. Even Moniz, in the 1937 article cited by Professor Rees Cosgrove, admits that “Deteriorated patients obtain slight or no benefit from the treatment”.

Professor Rees Cosgrove opened his address to the President’s Council of Bioethics with the following words:

What I would like to do briefly this morning is give a very short historical perspective because I think that’s paramount to understanding some of the moral and ethical issues that are involved with surgery for psychiatric illness;

For precisely this reason, it is important not to misrepresent the past.

Psychosurgery is still carried out on one or two people a year in Australia. In 2002 the Radio National programme “All in the Mind” featured a discussion about psychosurgery. Taking part were Melbourne, Victoria, neurosurgeon Professor Jeffrey Rosenfeld; and former Chair of the Victoria Psychosurgery Review Board Beth Wilson.

Jeffrey Rosenfeld stresses the differences between lobotomy and modern operations, while Beth Wilson defends the early practitioners of psychosurgery.

Beth Wilson: They saw the incredible suffering of people, particularly in the southern States of America, Negro soldiers who were languishing, not able to go home, hideously ill, very little treatment. The treatments comprised straightjackets, seclusion, insulin shock and electric shock treatment, that was it.

There is a mention of Dr Harry Bailey, who was prominent in psychosurgery in Australia in the 1970s. The operation he favoured for his patients was the anterior cingulotomy, which is still used, for example, at Massachusetts General Hospital in the US and at Ninewells Hospital, Dundee, Scotland. Harry Bailey committed suicide in 1985 rather than face an enquiry into his practice at Chelmsford private hospital, where he used Deep Sleep Treatment and ECT.

The number of lobotomies, or leucotomies, fell dramatically after the 1950s, as drugs became available, especially for schizophrenia. But as recently as the 1970s, in Australia we faced our own controversies surrounding psychosurgery. In 1974, an ABC-TV ‘Four Corners’ investigation into the procedures being used, in part re-ignited public concern. And at the centre of the debate was one Dr Harry Bailey of Chelmsford and ‘Deep Sleep’ therapy notoriety.

Presenter: In Australia, habitual thieves, sex offenders, drug addicts, and people with chronic obsessional behaviour, have undergone psychosurgery by a team of doctors in Sydney’s Macquarie Street.

The team, headed by psychiatrist Dr Harry Bailey, has carried out more than 150 brain operations over the past seven years. They include, among others, Case 1: a 26-year-old housewife with a germ mania who washed her hands at 3 to 5 minute intervals and used one cake of soap a day. Case 2: a 42-year-old accountant, who after sexual intercourse with his girlfriend, would compulsively exhibit himself to a girl on the street 10 minutes later. Case 3: an 18-year-old nurse, suicidal, two overdose attempts, who stated, ‘My last two years have been hell. I only want to die. The voices are screaming at me.’

The programme also contained extracts from Janet Frame’s book, an Angel at My Table (1984) in which she describes how she was saved from a leucotomy at the last moment when the medical superintendent of the hospital saw in a newspaper that one of her books had won a literary award. Janet Frame went on to be nominated several times for the Nobel Prize in literature, demonstrating that the outlook for patients considered for psychosurgery in those days was not, contrary to what the defenders of lobotomy say today, necessarily so bleak.

Reader: My mother had been persuaded to sign permission for me to undergo a leucotomy. I know she would not have done so had not the experts wielded heavily weighted arguments. The experts, who over the years, as my history was accumulating, had not spoken to me at one time for longer than 10 or 15 minutes, and in total time, over 8 years, for about 80 minutes; who had administered no tests, not even a physical test of EEG, or X-rays, apart from a chest X-ray whenever there was a new case of tuberculosis, a disease prevalent in the mental hospitals then. I listened, trying to avoid the swamping wave of horror, when Dr Burt, a likeable, overworked young doctor who had scarcely spoken to me except to say ‘Good Morning, how are you?’, and not wait for a reply as he would whisk through the ward, found time to explain that I would be having a leucotomy operation, that it would be good for me, that, following it, I would be out of hospital in no time.

I listened also with a feeling that my erasure was being completed, when the ward sister, suddenly interested that something was about to be done with, and to me, painted her picture of how I would be when it was all over. ‘We had one patient who was here for years until she had a leucotomy, and now she’s selling hats in a hat shop. I saw her just the other day, selling hats, as normal as anyone. Wouldn’t you like to be normal?’

Everyone felt that it was better for me to be normal, and not have fancy intellectual notions about being a writer.

My friend Nola, who unfortunately had not won a prize, whose name did not appear in the newspaper, had her leucotomy, and was returned to the hospital where, among the group known as ‘the leucotomies’, some attempt was made to continue with personal attention, the process of being made normal, or at least, being changed. The leucotomies were talked to, taken for walks, prettied with make-up and floral scarves covering their shaven heads. They were silent, docile, and their faces pale with damp skin. They were being ‘retrained’ to fit in to the everyday world, always described as ‘outside’, ‘the world outside’.

In the whirlwind of work, and the shortage of staff, and the too-slow process of retraining, the leucotomies one by one became the casualties of withdrawn attention and interest; the false spring turned once again to winter.

Read a transcript of the programme here