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Psychosurgery—Old and New

Psychosurgery—Old and New

Despite its wretched history, psychosurgery is back with a new name—neurosurgery for mental disorders—and with renewed confidence in its benefits.1 Two technologies are now available that produce small lesions in the brain: stereotactic microablation and gamma knife radiation (no burr holes necessary). Concomitant functional imaging allows for precision targeting that makes these procedures state of the art, but it is possible that deep brain stimulation (DBS), which has shown early promise in clinical trials and is an exciting research tool, may replace ablative procedures that destroy brain cells. Both new stereotactic neurosurgery and old psychosurgery were the focus of recent mass media reports.

A carefully documented front-page story in the Wall Street Journal described an "outbreak" of stereotactic neurosurgery in China.2 The news story contrasted the careful interdisciplinary screening procedures and limited use in model US programs, such as that in place at Massachusetts General Hospital (MGH) in Boston, with the money-driven exploitation in China.

Chinese physicians have been thrust into the sink-or-swim market economy, and standards of care are being undermined by economic self-interest.3 Market forces are present everywhere in medicine, and the companies that make the state-of-the-art neurosurgical devices have added their muscle to the pressure to perform more procedures both here and abroad (Yang Shao, personal communication, January 2008). In that environment, stereotactic neurosurgery in China became a profit-driven enterprise. Neurosurgeons apparently offered the procedure to any patient whose family had the money, without any psychiatric screening.

Schizophrenia is not an accepted target for the new neurosurgery, as it was for the old psychosurgery; however, in the money-driven outbreak in China, the procedure was offered to a patient with schizophrenia whose poor outcome included adverse neurological consequences. His case history was the centerpiece of the original Wall Street Journal article.2 Within weeks of the first story, a second report announced that the Chinese authorities would be regulating these new neurosurgical procedures.4 The proposed standards were similar to those in place at MGH (Bin Xie and Yang Shao, personal communication, December 2007).

The old psychosurgery

Recently, the American public was again exposed to the most appalling practices of that old era of psychosurgery on public television's presentation of "The Lobotomist" on the American Experience with the bone-chilling documentary of transorbital frontal lobotomy (the so-called ice pick operation) by Walter Freeman.5 Freeman, like Ant—nio Egas Moniz (who was awarded the Nobel Prize in physiology or medicine for his discovery of prefrontal lobotomy), was not a neurosurgeon or a disciplined scientist. However, he introduced and adapted Moniz's lobotomy in the United States while working with James Watts, who was a qualified surgeon.

Freeman and Watts began operating on patients with schizophrenia who were selected from Saint Elizabeths Hospital in Washington, DC. Freeman believed that patients with violent and aggressive tendencies would be pacified by the procedure.6 As early as 1939, Freeman and Watts began operating on children with schizophrenia, including a 4-year-old boy.6 Freeman, who was a "showman" and far more zealous than Watts, argued for psychosurgery early in the patients' illnesses rather than reserving it for patients with intractable illnesses.

In his zeal to make lobotomy more widely available, Freeman experimented with cadavers and, adapting the work of an Italian psychosurgeon, invented and personally performed the first transorbital lobotomy in his own office. It was a blind procedure, since he never visualized the field. He used an actual ice pick inserted via the tear duct through the orbital plate into the frontal brain. His target was the frontal thalamic tracts, which he attacked by moving the instrument "15 to 20 degrees medially and about 30 degrees laterally."6 Watts rejected Freeman's cavalier approach to neurosurgery, but transorbital lobotomy (the ice pick procedure) was widely heralded as the new cure for mental illness by the media whom Freeman assiduously courted. Without the need for a surgical suite and using unmodified electroconvulsive therapy as anesthesia, Freeman went on to perform the procedure on almost 3000 patients in hospitals all over the United States.

In the infamous newsreel footage shown in movie theaters in the early 1950s and included in "The Lobotomist," Freeman can be seen performing the ice pick procedure without even using the standard precaution of sterile surgical gloves. (Freeman was famously annoyed with sterile procedures and refused to wear a surgical mask or gloves.6) Like most doctors during that era, he provided no informed consent and his fee was what the traffic would bear. Freeman operated on Rosemary Kennedy—his most famous, or perhaps infamous, failure. However, his most shameful legacy may be that he performed psychosurgery on children as young as 4 years as well as on rebellious adolescents.

Both the Freeman documentary and the abuse of the new neurosurgery in China brought me back to earlier periods in my own career. During my years as a student at Yale Medical School, I attended a Grand Rounds at which Freeman presented and showed the infamous newsreel footage. He apparently took pleasure in shocking his medical audience. It was the most horrifying experience of my entire medical education, made worse by the fact that none of the professors whom I admired raised any objections to the radical procedure or criticized Freeman for his cavalier disregard of sterile precautions. But it was also an important learning experience for me, and it demonstrated the insidious power of Irving Janus's "groupthink" etiquette in medicine. One did not criticize other doctors in public. In fact, I later learned that John Fulton, Yale's legendary professor of neurophysiology, had protected Freeman from professional censure, although he had very serious reservations about his scientific approach.6

Although Freeman's transorbital approach was eventually discredited and abandoned, various modified and more limited versions of the old psychosurgery continued. During the years leading up to DSM-III in 1980, the generally accepted indication was "intractable tortured self-concern."1 That may be an apt generic description of the intractable disorders for which neurosurgery is now offered: obsessive-compulsive disorder (OCD), major depressive disorder, and chronic anxiety disorder. However, in those early years during the transition from the old psychosurgery to the new neurosurgery, many other symptoms and conditions were targeted; for example, there were reports of the successful treatment of anorexia nervosa and temporal lobe epilepsy that lead to violence.

It was during this transitional era that the Massachusetts Department of Mental Health asked me to chair a committee and to develop regulations for psychosurgery for the state. One of the crucial criteria I proposed was that an outside consultant, not a member of the hospital staff, review and approve each case. That provision was rejected by the MGH neurologist who was a member of my committee, by all the other physicians, and by the Massachusetts Department of Mental Health. Some states subsequently made outside consultation a legal requirement,7 and the 1991 United Nations' (UN) resolution on the protection of persons with mental illness requires that an "independent external body" must be "satisfied" that there is informed consent and that the "treatment best serves the health needs of the patient."8

The Freeman era and the unwillingness of psychosurgeons to accept the discipline of external review left me with a negative impression of the entire enterprise. My own clinical experience with patients who had been subjected to these procedures did nothing to reassure me. Colleagues with more experience agreed that such surgical procedures definitely helped some patients, but it was difficult to identify who would benefit in advance or to explain why in hindsight.

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