Some of the big names of psychosurgery in the USA and Belgium are out in force in the October issue of the journal Neurosurgery. Neurosurgeons Ali Rezai (Cleveland Clinic), Bart Nuttin (Catholic University of Leuven), Chris Heller and Michael Apuzzo (University of Southern California), and Arun Amar and Charles Lui (Yale University) are joined by psychiatrist Benjamin Greenberg (Butler Hospital/Brown University) and medical ethicist Joseph Fins (Cornell University) to write an editorial and two articles.
I haven’t read the articles yet, but the abstract of one, “Surgery of the mind and mood: a mosaic of issues in time and evolution” by the Yale and University of Southern California authors, sounds worrying enough:

“The prevalence and economic burden of neuropsychiatric disease are enormous. The surgical treatment of these psychiatric disorders, although potentially valuable, remains one of the most controversial subjects in medicine, as its concept and potential reality raises thorny issues of moral, ethical, and socioeconomic consequence.
This article traces the roots of concept and surgical efforts in this turbulent area from prehistory to the 21st century. The details of the late 19th and 20th century evolution of approaches to the problem of intractable psychiatric diseases with scrutiny of the persona and contributions of the key individuals Gottlieb Burckhardt, John Fulton, Egas Moniz, Walter Freeman, James Watts, and William Scoville are presented as a foundation for the later, more logically refined approaches of Lars Leksell, Peter Lindstrom, Geoffrey Knight, Jean Talaraich, and Desmond Kelly. These refinements, characterized by progressive minimalism and founded on a better comprehension of underlying pathways of normal function and disease states, have been further explored with recent advances in imaging, which have allowed the emergence of less invasive and technology driven non-ablative surgical directives toward these problematical disorders of mind and mood.
The application of therapies based on imaging comprehension of pathway and relay abnormalities, along with explorations of the notion of surgical minimalism, promise to serve as an impetus for revival of an active surgical effort in this key global health and socioeconomic problem.
Eventual coupling of cellular and molecular biology and nanotechnology with surgical enterprise is on the horizon.”

Today’s cover story at the The Tyee is “The new lobotomy?”, an article by Canadian journalist Danielle Egan. The article takes a much more interesting and critical look at DBS (deep brain stimulation) than most articles on the subject do.

“Eights months ago, surgeons drilled two holes into the skull of a wide-awake Vancouver man and inserted spaghetti-sized electrical wires down through the two sides of his frontal lobes. They left behind a remote control brain pacemaker, which regularly shocks his brain with three volts of electricity, 24 hours a day, seven days a week, powered by a battery pack that sits on his neck. The device is meant to treat his severe depression. It’s part of a controversial clinical trial of a procedure called deep brain stimulation (DBS) that’s jointly run by UBC and VGH, and being partly funded by B.C. health care.

As part of the trial, which is co-sponsored by a Texas-based medical device manufacturer, researchers will also implant five other British Columbia patients through a multi-centre trial also happening in Toronto and Montreal. DBS is also being tested at centres all over the globe, as a treatment for obsessive-compulsive disorder, anxiety, eating disorders, addictions and even violent behaviour. But emerging data on this new technology is raising questions about the effectiveness of the procedure, the link between health care and profits, and the ethics of quick-fix psychological treatments….

It’s the same physiological rationale used to describe lobotomies and their modern counterparts, known as psychiatric neurosurgeries, which are said to be making a comeback at select centres round the globe, including a UBC program started in 2000. DBS is being held up as a good alternative to psychiatric neurosurgeries, because it doesn’t involve permanently destroying pieces of the brain, and because the device can be turned off.” (more…)

In his book about Henry Cotton (Madhouse: A Tragic Tale of Megalomania and Modern Medicine)Professor of Sociology and Science Studies Andrew Scull muses on the trust we place in psychiatrists:

“As members of a healing profession that likes to trace its lineage back at least as far as classical Greece and the fabled Hippocrates, physicians pronounce themselves the guardians of our physical welfare - and, in the case of that subordinate branch once called by the derisive term of “mad-doctors” and now preferring to own to the title “psychiatrist”, our mental welfare as well. Like all of those who make the most well-founded and broadly socially accepted claim to the title of professional, medical men (and these days medical women) operate in an arena where the ordinary disciplines of the marketplace seem to fail, or to perform poorly. As lay people, we lack access to their specialized knowledge and expertise, even though the content of their cognitive world may be quite literally of life and death importance to us. In a poor position to second guess their expert judgments or even, in many instances, to grasp the foundations on which their diagnoses and prescriptions are based, and ill-equipped to assess the quality of the care we are about to receive, we are perforce at their mercy. Elaborate social rituals persuade us to grant these strangers our trust, and reassure us that they are motivated, not by the self-interest of the marketplace - the hidden hand that allegedly guides so much of civil society - but by a higher ethical standard, a genuine concern for our well-being and survival and a willingness to subordinate their interests to ours. And so it sometimes proves.
And sometimes not.” (Madhouse: A Tragic Tale of Megalomania and Modern Medicine.Yale University Press, page 276)

The author has this to say about psychosurgery: “Lobotomy, in my judgment, even by the standards of the 1940s ought ultimately to be seen as indefensible, as a number of informed and perspicacious critics argued at the time. But a proper examination of that issue is a debate place and another time.” (page 285)

I hopefully asked Professor Scull if he was thinking of writing a book about the history of psychosurgery but sadly it is not on his list of things to do in the immediate future.

Wylie McKissock’s patients came from all walks of life, from doctors and nurses to rag and bone men and domestic servants. They ran the gamut of psychiatric diagnoses from schizophrenia and affective psychosis to neurosis and personality disorder. (A few had no psychiatric diagnosis and were operated on for the relief of pain or tinnitus.) Some had been incarcerated for years, some had never been in a mental hospital. In age they ranged from teens to seventies.
Many were – one way or another – casualties of war: a veteran of the Normandy campaign, physically and mentally injured in the front line; an elderly woman bombed out of her home who found it difficult to settle in a new area; a nursing sister who broke down under the stress of trying to protect her patients from enemy bombardment; a widow unable to cope when her son was posted overseas; a blind man who became obsessive about switching off lights after being prosecuted for contravening blackout regulations; a prostitute who was arrested and certified after being found sleeping on War Department land.
Some patients, especially those with a diagnosis of schizophrenia or mental deficiency, were leucotomised in the hope not so much of a cure and return to life outside an institution, but in an attempt to render them less of a management problem within the institution. “The patient who showed great improvement” wrote Dr Cook of Bexley Hospital, Kent, where by 1943 McKissock had leucotomised 13 violent schizophrenic patients (one died), “was a typical example of the use of leucotomy in chronic schizophrenia. The patient was by far the most violent, animal-like catatonic whom even the most senior nurses in the hospital could remember, and after twelve years of “unapproachableness” she had for over a year been up and about, playing the piano, knitting and doing embroidery. She was still as mentally ill as she ever was, but the nursing relief was very great and she was much happier”.
But psychiatrists at St Lawrence’s Hospital, Caterham, were less impressed with the results on their mental defectives and decided to put an end to the visits of McKissock and his assistant McColl after 5 of 43 leucotomy patients (nearly all under the age of forty) died and others suffered mental deterioration or epilepsy.
It was this particular use of leucotomy – to control the behaviour of institutionalised patients – that was curtailed by the discovery of new drugs in the 1950s. McKissock himself noticed that by 1958 there had been “a marked diminution in the number of deteriorated schizophrenics offered for surgery although a number of dangerous or disturbed patients are still referred and can often be adequately sedated by a standard prefrontal operation”, but he doesn’t appear to have made the connection with the introduction of major tranquillisers. In fact, he generally showed little interest in psychiatry or indeed in the fate of his own psychiatric patients.
Women outnumbered men by three to two amongst those leucotomised by McKissock and, although they were found in all diagnostic categories, they especially dominated the depressed group. Many had unhappy marriages and a few appreciative words from their husband post-leucotomy could catapult them into the recovered category (“he rather likes the severe frontal lobe deficit syndrome” or “Barbara is undoubtedly a much pleasanter companion to live with”). Their misfortune was to fall into the hands of psychiatrists before the advent not of a new drug but of a means of escape via easier divorce and more financial independence for women