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Running head: BRIEF HISTORY OF PSYCHOSURGERY & OTHER TREATMENTS

A Brief History of Psychosurgery & Other Treatments for Individuals with a Mental Illness

Ashley B. Tolbert

Longwood University

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PSYCHOSURGERY & TREATMENTS

Abstract

This paper is a brief history of psychosurgery and the other treatments that were given to patients

with a mental illness. It goes over the documented beginning of psychosurgery, which was

started by Dr. Gottlieb Burckhardt, all the way to the 1950s, where it starts to begin its popularity

decline. Along with the psychosurgery aspect of the paper, I also present a brief history on how

some of the other treatments for the mentally ill get started. Some of the other treatments are also

used to treat patients that might have a brain disorder as well. Along with the treatments, I also

present information on the surgeons that performed them. At the end of this paper, I will discuss

how these treatments could be useful in the future.

Keywords: psychosurgery, treatment, schizophrenia

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Psychosurgery is a neurosurgical treatment for a mental illness, and has been said to be

around for thousands of years, dating back to early Greece. Most attributes dealing with the

beginning of psychosurgery are given to Dr. Gottlieb Burckhardt, who is a Swiss psychiatrist.

Burckhardt first attempted psychosurgery in 1888 (Stone, 2001). Today, most medical historians

do not know a lot about how Burckhardt wanted to find a way to cure mental illness with

surgery. His only research was done on six or seven patients that had been diagnosed with

schizophrenia. The procedure that was done on his patients was bilateral localized topecotomies,

which is the selective removal of the cerebral cortex (Manjila, Rengachary, Xavier, Parker, &

Guthikonda, 2008). Burckhardt performed this procedure in the Wernicke’s and Broca’s areas of

the brain, along with the temporal and parietal lobes (Manjila, et al., 2008). Most of the patients

slightly improved after a couple of surgeries. Although they improved some, they also developed

some different difficulties after surgery, such as speech problems and some suffered from

seizures. Burckhardt believed that it would be possible to follow a psychiatric disease from place

to place in the brain (Stone, 2001). After his research was presented at the Berlin Medical

Conference in 1889 (Manjila, et al., 2008), then later came out in a journal, the medical

community was critical about his work. The medical community thought he was reckless and

irresponsible and that his work was clearly immoral (Stone, 2001). Burckhardt never conducted

another study or performed anymore surgeries after he heard what was said about his research.

One of the patients that he operated on had been one of the unruliest in the psychiatric

clinic, her name was Fran B. She had been diagnosed with schizophrenia among the other six

patients. Her temper was so bad that she would scare the workers that had to help her.

Burckhardt truly cared about the well being of his patients and wanted to help cure them (Stone,

2001). Since Fran B.’s condition was the worst of the other patients, he wanted to try surgery to

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try and regulate her actions. After the first couple of surgeries, her behavior improved but she

still yelled at the workers and had a bad temper, but did throw fits as before. It took five

surgeries for Fran B. to become normalized, and the only major side effect of all of them was

that she had become word deaf (Stone, 2001).

Burckhardt did not just develop his curiosity about psychosurgery on his own, he was

influenced by people that were performing similar things during his time. He was influenced by

Fritsch and Hitzig, who did their research in the 1870s, which was during the time that

Burckhardt was working in psychiatric clinics. Fritsch and Hitzig used electrical stimulation then

performed abalations on dogs and studied their behavior afterwards (Manjila, et al., 2008).

Friedrich and Goltz also influenced Burckhardt with their research dealing with dogs and

psychosurgery. Goltz found that if they removed the neocortex of the dog, then it becomes easily

enraged, but if they removed the temporal cortex the dog was calm and tame (Manjila, et al.,

2008). Burckhardt was also interested in Jules Bernard Luys with his research on the brains of

patients with dementia (Manjila, et al., 2008).

Modernized Psychosurgery Introduced

After Burckhardt’s work essentially faded away into the background, another man

discovered what Burckhardt had been working on, and his name was Egas Moniz. Before he was

Egas Moniz, he was Antonio Caetano, but he had to change his name to hide from the authorities

(Getz, 2009). He introduced modern psychosurgery in 1935. Although Burckhardt was the first

one to actually do research about psychosurgery and study it, Moniz is remembered as the father

of psychosurgery (Getz, 2009). In 1936, Moniz developed the leucotomy. During this procedure,

the connection between the prefrontal lobe and the rest of the brain was broken. Moniz wanted to

operate on the area of fibers that joined active neurons (Macmillan, 2000). When he first started

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doing the operations, he used alcohol to dehydrate and destroy that area of the brain. After a

while of doing this, he decided to change his operational direction and wanted to use something

that was more mechanical. Since he did not have any medical training, he got his surgeon to drill

holes above each frontal lobe and insert an instrument called the leucotome. The leucotome was

the first psychosurgical instrument designed and Moniz created it (Collins & Stam, 2015). This

instrument would severe certain tissues in that specific section of the brain. Moniz and his

surgeon operated on close to 20 patients, but out of all of them only seven were considered cured

of their disorder. In 1949, he won the Nobel Prize that he had always dreamed of winning (Getz,

2009).

Phineas Gage’s case was instrumental to developing the psychosurgery methods that

have been used (Macmillan, 2000). The incident that happened to him helped researchers

improve their theories on some of the observations they had been making for their research. The

frontal areas of the brain could be operated on without interfering with vital processes: the

intelligence of the patient (Macmillan, 2000). Although Gage’s incident gave way to some of the

research that Moniz and other researchers were conducting, none of them credited him with

influencing them (Macmillan, 2000).

Jacobsen and Fulton (1934) are known for their research with chimpanzees. They trained

two chimpanzees, Becky and Lucy, to complete two tasks. One task dealt with showing them

something had been put into a cup then putting something in front of those cups and leaving it up

for an extended period of time. For them to correctly complete the task, the chimpanzees had to

remember and choose the correct cup the item was in. The other task dealt with putting together

different things to reach the fruit. The delay task had a couple of different levels, but only one

was mentioned and that was the five-minute delay. Normal chimpanzees could choose the

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correct cup even with that long of a delay. The assembling task had three levels, each getting

more difficult than the first. After training the chimpanzees for months, Jacobsen and Fulton

conducted surgery on both and removed just one of the frontal lobes. It was not stated which side

was removed first. When the recovery period was over, Jacobsen and Fulton tested Becky and

Lucy on the same two tasks, and they found that there was no difference in their performance.

Once they had tested the chimpanzees enough times to know that what they had been observing

was correct, Becky and Lucy underwent another surgery to remove the second frontal lobe, again

it was not stated which one was taken out before. Unlike the first time, there were some drastic

differences that appeared. Becky and Lucy’s reactions were completely different from each

other.

Before the operation, Becky always needed reassurance from the humans that she was

around. When given the assembling task, she could complete it with no problem, but when it

came to the delay task Becky could not solve it unless it had a small delay time. She threw major

tantrums when she failed and sooner or later would not even enter the cage she was to be tested

in. The first operation had no impact on her behavior, but after the second one she was more

willing to participate than before and did not get upset when she failed. Lucy had been monotone

before the surgery and could handle when she made a mistake on something. After the second

surgery, she started having major tantrums about failing. The procedure that both chimpanzees

underwent was called frontal abalation (Macmillan, 2000).

Freeman and Watts (1942) developed what Moniz had created and instead of calling the

leucotomy, they decided on the name lobotomy. They also coined the term psychosurgery

(Macmillan, 2000). Freeman and Watts were inspired by Moniz and decided to conduct surgery

as he did. When they published their book, Psychosurgery: Intelligence, Emotion, & Social

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Behavior following Prefrontal Lobotomy for Mental Disorders, Freeman and Watts stated that

they disagreed with Moniz’s theory (Macmillan, 2000). Freeman and Watts believed that

lobotomy interfered with the connection between the cognitive and emotional sides of the

personality (Macmillan, 2000). During the 1940s, Freeman popularized the bilateral prefrontal

lobotomy (Stone, 2001). In 1946, Freeman introduced the transorbital ice pick lobotomy (Collins

& Stam, 2015). Freeman tested many other instruments before deciding upon the ice pick. It did

not break or bend like some of the others that he had tried. Freeman caused a lot of uproar in the

neurosurgeon community because of his choices of instrument and operation locations. Freeman

believed that his lobotomies could be performed outside the normal operating room, so that it

would cut down on the excessive wait that normally comes with a hospital visit (Collins & Stam,

2015). In 1952, Freeman designed a more reliable instrument to operate with and he called it the

orbitoclast (Collions & Stam, 2015). Freeman and Watts had always been on good terms until it

came to agreeing on locations for the operations. Watts was a neurosurgeon so he firmly believed

in keeping the surgeries in the operating room in the hospital. Freeman on the other hand wanted

to take the operation elsewhere. Freeman ruined the relationship between himself and Watts

when he decided to conduct a surgery in the office that the two shared at the time (Collins &

Stam, 2015). When Freeman started to perform these ice pick operations, he would use no

anesthesia, but instead would use electroconvulsive therapy (ECT) to make the patient

unconscious (Collins & Stam, 2015). Most lobotomies shown in the media today are depeciting

Freeman’s version of the ice pick lobotomy.

Although Freeman and Watts completed many lobotomies throughout a decade, their

main concern was not for the patient to be relieved of their symptoms, but to achieve that the

patient could function in society normally (Johnson, 2011). They believed that a patient could

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function properly if they could hold a job after being operated on. This was the way they

determined if their procedure was a success or not (Johnson 2011). According to one of their

patients, she only held a job because she had too. She was ashamed of the job she had and did

not enjoy it. She stated that a child could have done her job and that the pay was horrible

(Johnson 2011).

During this time, lobotomies were not just used for curing mental illnesses between the

1940s and 1960s, but also to treat patients with chronic pain that could not be traced to the

source (Raz, 2009). Most of the time this method was only used after other treatments had failed

because there was still a stigma around the procedure. Patients that had chronic pain consulted

with their physicians and were given pain killers to try and ease the pain while they were trying

to figure out where the source of the pain was coming from. These patients had to be given a

high dosage of pain medicine, which ended up in some of them becoming addicted to them. This

procedure was also used when physicians were worried about the patients that had become

addicted (Raz, 2009).

Although there were many supporters of lobotomy, there were also many that were

against it for various reasons. Some of the ones who were against lobotomies were psychiatrists

and psychologists. They were against the procedure because it took away the one component

they thought psychological problems came from: anxiety. When patients undergo lobotomies,

they are getting a major part of their brain destroyed, and those parts control many emotions,

including anxiety. Many of the doctors that were against these procedures were more in favor of

the antipsychotic drugs that were becoming vastly popular. They claimed that the medicine

helped relieve the symptoms but at the same time was not a long term cure, so that more of them

could stay in business. They felt that the lobotomy would have crashed psychology in a sense.

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Stigma about mental illnesses was still prevalent during the late 1930s and early 1940s. It

caused some people that suffered from mental illnesses to go untreated because they feared they

would be put out of their community. Many people suffered from mental illnesses in the late

1900s, and earlier, were either homeless or put into asylums. Neither environment was good for

their health because they were not getting the proper care that they needed. Many times the

asylums were compared to jails and were possible worse than the streets. Even though there were

so many suffering from mental illnesses, there possible was not a medication to help them and

psychosurgery was looked at as a last option.

During World War I, sexually transmitted diseases were a big problem during the war,

especially for soldiers. If the people who had the disease lived long enough, it would start

impacting the brain. This would cause people to become immobile or even cause psychological

problems. In 1917, Julius Wagner von Jauregg injected a weakened strain of malaria into some

of the soldiers because he noticed that it stopped the symptoms (Getz, 2009). Ladislav von

Meduna noticed that some of the patients he observed were relieved if they had epilepsy, and

that most who did have it were not terminally ill. From his observations, he believed that both

conditions could not coexist and he started using seizure therapy (Getz, 2009). Influenced by

Meduna’s work, Ugo Cerletti and Lucio Bini developed the first electroconvulsive therapy

(ECT) or electroshock therapy. Ludwig Puusepp operated on three patients, that had been

diagnosed with depression, using a procedure similar to Burckhardt’s. Puusepp was much better

known for his work with brain tumors (Getz, 2009).

Walter Dandy operated on a patient, Joe A., in the 1930s to remove a brain tumor. Once

Joe A. returned home, he was put into the care of Richard Brickner. Brickner observed Joe A. in

the weeks of him being home, and said that Joe A. seemed better after surgery and that he did not

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lose any functioning even though he lost part of his frontal lobe (Getz, 2009). He even still had

the same IQ as before the surgery. Joe A. is a good example of a person that the lobotomy

worked for. He was able to do all of the things he could before the surgery, but he did not have

the tumor that was making him act the way he was.

Psychosurgery does not take away all emotional responses, but it does cause them to

dramatically decrease (Marsh & Katz, 1985). It does sometimes damage the ability for learning

new things, and causes constant sedation. Since the procedure is to either disconnect or remove

part of the brain, it also causes some issues with retrieval of memories. In most cases, when a

patient has a lobotomy performed on them, when they come out of it they are either

nonresponsive or have reverted back to their old personalities. For example, the sister of John F.

Kennedy, Rosemary Kennedy, was said to have some sort of mental disability. As she aged, her

condition got worse and she became violent towards others. This caused her father to agree to a

lobotomy for her since she was not in a sound mind to decide herself. He had hoped that the

lobotomy would calm her so she could go back to the way she was. After the lobotomy, it

became clear that something had happened and it made Rosemary completely unable to care for

herself. Rosemary was sent to a home so others could care for her, and she became the family

secret. In this sad case, the lobotomy performed on Rosemary did take all of her emotional

responses away, but maybe if the surgery had been done differently or if something had not gone

wrong then maybe she would not have had to live in an institution until she died.

Electroconvulsive Shock Therapy

As mentioned above, Ugo Cerletti and Lucio Bini developed the first ECT. This method

of treatment is still used today, but at one point in history was looked down upon and was

stopped being used. ECT is used to treat patients with severe depression that cannot be treated

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with medications. Most of the general population do not even realize that it is becoming more

and more popular because they still think of it being associated with torture (Dahl, 2012).

Although ECT has improved over the years, the basic procedure is still in place. The treatment

jolts the patient’s brain with an electrical charge, the new component here is that the patient is

unconscious during the whole treatment. Although many doctors suggest ECT as treatment for

their depression if medication is not working, there are many doctors and former patients who

are completely against anyone using this form of treatment. These doctors and former patients

argue that it is not worth risking going in for treatment because of the side effects, the main one

being short term (working) memory loss (Dahl, 2012). Even though patients have been

undergoing ECT treatment for over 70 years, doctors are still not sure how exactly it works to

ease the depression in the patients (Dahl, 2012). ECT is considered a fast working treatment and

that is essential when it comes to high risk patients. Most patients after a couple of sessions of

ECT have felt that their depression had improved. This is important because this could prevent a

suicide attempt (Dahl, 2012).

Along with the believers that ECT has gained over the years, there are also the protesters

that come with it. They believe that it is too risky to undergo treatment because of the potential

memory loss that could occur after treatment. Some of the protesters are former patients that

underwent ECT. They claim that they are brain damaged because of the treatment that caused

their memory loss. When a patient is going through their ECT treatments, one of the side effects

is memory loss, but once treatment is over, as in no more sessions, then the fog will start to lift

for most patients (Dahl, 2012). It is just like any other treatment that has serious side effects,

such as chemotherapy.

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The doctors and former patients that protest the use of ECT call it a quick fix and that the

depression will return. Patients go to around 6-12 sessions (three per week) and once they reach

a certain point, the doctor in charge will either put them on medications or tell them they need to

come back once a month for something called maintenance ECT (Dahl, 2012). The maintenance

ECT is for patients that cannot find a medicine that works properly for them. ECT is an approved

treatment by the APA (American Psychiatric Association)(Dahl, 2012). It requires that a nurse,

psychiatrist, and an anesthesiologist must be present during treatment (Dahl, 2012). The

treatment should only be performed on patients who have voluntarily said they are willing to do

it, unless the patient cannot provide informed consent (Dahl, 2012).

Although ECT is still the same therapy used in the 1940s and 1950s, some things have

changed. Before it was modernized, patients had to stay awake during the whole process. That

means that they could feel and see everything. Nowadays, patients undergo anesthesia and are

given a muscle relaxant. The only part of the body that is not impacted by the drugs is the right

foot (Dahl, 2012). This is so that the doctor can monitor when the patient is having a seizure.

This is done by wrapping a blood pressure cuff around their right leg so that it cuts off enough

circulation to not let the muscle relaxant through, but not enough to hurt them (Dahl, 2012).

ECT does have a high relapse risk but sometimes some patients need a quick fix (Dahl,

2012). It is life or death for some patients, and ECT might be what will save them from

themselves. Even though ECT can help high risk patients, many psychiatrists stray from it

because of the stigma that comes along with it. So many media outlets have portrayed this type

of treatment as violent and painful, that many patients that are given the option of ECT turn it

down because of something they saw in a movie. There are some psychiatrists out there that

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hope one day patients and other psychiatrists will look at ECT as the next option instead of the

last option (Dahl, 2012).

Patient Privilege

Snyders (2012) talks about the consent part of the treatment in the chapter

Electroconvulsive Therapy May Not Be Helpful that was included in the book, Mental Illness. In

this chapter, Snyder talks about this man named Ray Sandford. Ray Sandford had been

diagnosed with severe manic depression at the age of 19, but when he was interviewed for this

chapter he was 54 years old. Sandford’s case was important because he had been saying that he

did not want to undergo ECT since the hospital had his hearing, since they claimed that he was a

danger to himself and others so he could not make that decision for himself. Consent is an

important part of getting any type of surgery. It proves that the patient is of a sound mind and

that they willing want the surgery. It says a lot about what the medical community considers

sound of mind when they will not even let a man that can speak for himself say something

pertaining to his case. Sandford was still considered a risk to himself and to others just because

of his previous actions from when he was younger (Snyders, 2012).

Schizophrenia & Treatment

Standard treatment for people with schizophrenia, was known as dementia praecox, was

psychosurgery in 1935 through 1955 (Getz, 2009). During the 18th century, they had a word,

cretinism, which stood for a certain level of retardation, to remind people that the people that

were mentally ill were still human. Mental illness did not gain acceptance in England until King

George the III’s state degraded and the people accepted it because they loved him (Getz, 2009).

Schizophrenia had limited treatments and puzzled most physicians and psychologists. Some of

the treatments included safeguarding therapy, which was placing the patient in a locked room,

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occupational therapy, and another where the doctor and patient talk about what the patient could

or could not do (Getz, 2009). Psychosurgery was used on patients with schizophrenia because it

prevented the disease from spreading, which would cause the symptoms of the disease to worsen

(Soares, 2013). A lobotomy was not always seen as a cure for the patients with schizophrenia,

but a way for them to be able to function in society (Johnson, 2011). The use of psychosurgery

diminished during the 1950s, which was around the time that antipsychotic drugs became

tremendously popular (Soares, 2013).

Manfred Joshua Sakel, a Polish Jew who had fled Nazi Germany, found in 1927 that

when he lowered the blood sugar in people who abused drugs and who had been diagnosed with

schizophrenia the symptoms they suffered from had vanished (Getz 2009). Sakel started giving

high amounts of insulin to patients and this caused them to go into a coma. Sakel claimed that his

procedure, even though it was a harsh treatment, had a success rate of 88% (Getz, 2009). The

treatment was also labor heavy and each patient needed a certain amount of care during

treatment. In the 1940s, insulin therapy became popular, but would soon be replaced later by

ECT (Getz, 2009).

Chronic Pain

Even though most psychosurgery procedures, especially lobotomies, have a lot of stigma

towards them, that does not determine the future for these practices. Lobotomies are still used on

patients that are too hard to manage in institutions today because other forms of treatment do not

work for them. Psychosurgery could become popular again and it could be used to our

advantage. These procedures could be used on a multitude of patients, not just ones with mental

illnesses. It could be used on certain prisoners, such as pedophiles. Since most methods of

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conditioning prisoners out of feeling that way about children, maybe surgeons could find a way

to use lobotomies to eliminate the feeling for children.

From Mical Raz’s (2009) article, he mentioned that besides using lobotomies for chronic

pain, they also used it for terminal illnesses, like cancer. It really was not explained how exactly

they used the lobotomy procedure to stop the spread of cancer, but if it worked, it could be used

in all hospitals to help patients. This could be used instead of putting the patient through the

rough process of chemotherapy. Until the theory that it could potentially help cancer patients is

backed up with more research, it should not be attempted because there is also a lot of risks

involved, such as internal bleeding in the brain.

Brain Stimulation

There is a lot of controversy on the idea of classifying Deep Brain Stimulation (DBS) as

psychosurgery. DBS is when neurotransmitters are implanted into the brain and then electrodes

are sent out the different specific areas of the brain (Sachdev, 2007). In other words, it is similar

to ECT, except that it is inside the brain and reaches a deeper level of the brain. This treatment is

mostly used to help patients with Parkinson’s disease, Tourette syndrome, and tremors (Sachdev,

2007). Recently, the idea of using this method to help treat psychological disorders, such as

depression or obsessive compulsive disorder (OCD), has come up. Sachdev (2007) states in his

article that since DBS does not cause permanent damage to the brain like lobotomy does. Since it

does not leave lesions on the brain, Sachdev argues that it should not be considered

psychosurgery because of this.

Even though this method of treatment is not approved by any medical board, researchers

are still trying to figure out if this would be a more effective way of helping people (Sachdev,

2007). In the article, Sachdev (2007) states that DBS should not be classified as psychosurgery

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because he feels that would be degrading and stop all research on this technique. He even talks

about the fact that some researchers and surgeons feel like they should not call it psychosurgery

anymore because it is not actual surgery on the psyche (Sachdev, 2007). Some researchers and

surgeons feel that it should be called neurosurgery for mental disorders or something along those

lines because that is what it is (Sachdev, 2007). Most surgeons prefer this method because it is

less invasive and does not damage as many things in the brain as other types of psychosurgery

could.

Then there are some researchers that categorize DBS as psychosurgery without giving it a

second thought. Some of these researchers include Juckel, Uhl, Padberg, Brune, & Winter (2009)

and they wrote an article called Psychosurgery and deep brain stimulation as ultima ratio

treatment for refractory depression. In this article, they talk about how DBS is a milestone for

psychosurgery because it is starting to make it less damaging for the patient’s brain (Juckel, et

al., 2009). Instead of making a huge change to the brain itself, the DBS treatment just interferes

with abnormal transmissions going through the brain (Juckel, et al., 2009). The only major side

effects that come along with have DBS done is that the patient can get an infection or there could

be some bleeding inside the skull, which happens with most psychosurgeries performed (Juckel,

et al., 2009).

Ending Thoughts

Lobotomy has always had a stigma about it since it was started but that could change. It

just depends on who is researching it and how it is presented to the public. Most people only

associate it with horror movies and it would never cross their mind that some people now get

them. It should not be the first option that is looked at when dealing with trying to make the

symptoms of a mental disorder better, but it should not be the last. Especially for the people that

16


are already suffering from their symptoms. This could be there way of still being able to function

but not have to worry about feeling a certain way all the time. The technique that was used for

the lobotomy could be improved drastically to help minimize side effects and causalities.

Dealing with the other treatments, like ECT and insulin therapy, those have the potential

of making a comeback. ECT is still used today but only in the most extreme cases when the

patient consents to it or the patient is incapable of giving consent. ECT could become popular in

the future because it might not have long term results, but it could potentially be better than

taking medicines that keep one constantly down. Granted, when the patient first starts ECT

treatments they go through a cloudy phase, but after a couple of sessions, it subsides.

DBS could also be helpful in the future as well. Since some think that it is a milestone for

psychosurgery now, one can only think about what it would be in the next 50 years or so. DBS

could be helpful in the future because it does get to the deeper parts of the brain that ECT cannot

get too and it does a lot less damage than actual surgery on the brain does. If the two were

combined, then maybe one could drastically improve the health of many without making any

lesions to the brain since the parts that are normally receive lesions are important.

I believe that psychosurgery and ECT could be useful in the future, and that both of these

procedures could resurface and become more popular throughout the medical community. It

would be easier for this to happen, if the stigma that was attached to these procedures was gone.

Most physicians, psychologists, and psychiatrists do not suggest it to their patients because they

think that it is a type of punishment or they think of the old movie horror scene. If it was used

more, then the surgeons that perform the surgery could potentially improve the way it is done,

and make it more efficient. If the public was more aware of the benefits and the risks of both

surgeries, then maybe they would be more open to having the procedure done if they needed it.

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