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Nabeel Sait
English 1103
September 21, 2012
Psychosurgery
In the mid nineteenth century, a railroad company was expanding their line across
Vermont. The workers came across a huge stone, which had to be removed in order to keep the
track as straight as possible. Phineas P. Gage was the foreman in charge of the group responsible
for building the rail. Removing rocks was Gage’s expertise. He had to drill a whole in the rock
and fill it halfway with explosives. Sand has to be put in to make sure the explosion goes in
instead of out. A meter long metal rod, weighing 13 pounds, is used to pack down the sand.
While Gage was preparing the charge, the metal rod scraped the rock and created a spark,
prematurely igniting the explosives. The shock sent the metal rod flying into Gage’s head,
lodging it in his frontal lobe. Surgeons quickly operated to remove the rod and see if the damage
could be somehow mended. Gage lived, and he returned back to work after his operation. This
incident became the light bulb for modern psychiatric neurosurgery, or psychosurgery.
Psychiatric neurosurgery involves the surgical ablation or disconnection of brain tissue
with the intent of altering abnormal affective and behavioral states caused by mental illness
(Eskandar et. al 2001). It has become a highly controversial topic in the field neurosurgery.
Many people look down on psychosurgery because it may cause unforeseen effects, removes
emotional connections, and has potentially life threatening risks. However, psychosurgery makes
mental illness more manageable, has been more effective than other therapies, and has had many
recent advances.
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The history of psychosurgery predates the start of recorded history itself. The earliest
procedures involved open operations with excision of both frontal lobes (frontal lobectomy) or
disconnection of the frontal lobes from the remaining brain using a blunt instrument (Eskandar
et. al 2001). Numerous reports exist of prehistoric examples of trepanation. Although the
therapeutic purpose of trepanation is open to speculation, it likely included the treatment of
psychiatric illness. The most well documented example is a skull found in the Neolithic burial
site of Ensisheim in Alsace, France, which dates to roughly 5100 BC (Robinson et. al 2012).
Since the skull shows signs of healing, the individual was alive well after the operation. Which
means it was in fact an operation and not trauma. Trephination is the removal of a circular piece
of bone. Literature on trephination for the relief of neuropsychiatric symptoms including
affective and psychotic disorders can be dated to 1500 BC. Thus, the history of psychosurgery is
as ancient as the recorded history of psychiatric disease itself (Mashour et. al 2005).
The birth of modern psychosurgery is attributed to the Swiss psychiatrist Gottlieb
Burckhardt. Influenced by the climate of brain–behavior correlation in the latter half of the 19th
century, and in particular the demonstration by Mairet of hypertrophic temporal gyri in
schizophrenic patients, he performed the first psychosurgical procedures of the modern era in
1888 (Mashour et. al 2005). Burckhardt published a report of his experience in 1891, in which he
described three of the procedures as successes, two as partial successes, and one which resulted
in the death of the patient. Despite the functionally eloquent location of his lobectomies, he made
little mention of any associated postoperative deficits. After his initial report was met with
significant disapproval by his peers, Burckhardt did not pursue his experiments any further
(Robinson et. al 2012).
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One reason for controversy in psychosurgery is because the operation may cause
unforeseen effects to the patients. An example of this is Henry Gustav Molaison. Molaison was a
victim to severe epileptic episodes. He suffered from seizures for many years. The surgeons
observed that his hippocampus was atrophic, or “wasting away”. They hypothesized that
removing the vestigial region of his hippocampus might solve the problem. After the surgery,
Molaison almost never suffered form seizures. His problems were all but cured. However, after
the surgery, Molaison could not remember anything for more than a day. Molaison was
influential for the discovery of the function of the hippocampus, memory formation. Incidents
like this could occur again, that is why many argue that psychosurgery is unethical. It could
potentially do more harm than good to the patient.
Psychosurgery is used only as a last resort for most cases. However, some patients
become too reliant too reliant on the surgery. It makes them unable to help themselves by regular
means. Many people who have mental illnesses can usually learn cope with their complications.
However, psychosurgery becomes an option only if it is necessary. The surgery changes people.
In the case of Phineas Gage, a week after the operation, people started noticing that he wasn’t the
same man that knew before. The man everyone thought was intelligent and kind became a
violent alcoholic who couldn’t even hold a job. Gage’s friends found him “no longer Gage,”
Harlow wrote. The balance between his “intellectual faculties and animal propensities” seemed
gone. He could not stick to plans, uttered “the grossest profanity” and showed “little deference
for his fellows” (Twomey 2010). The impossible case of Gage is a perfect example of how
surgery can affect one’s family.
The worst aspect of psychosurgery is the irreversible facet. Once part of the brain is
removed, and the damage is done, it cannot be put back. Any postoperative characteristics in the
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patient become permanent. Even death is a possible postoperative outcome. Families who choose
to go with surgery often know the potential consequence of their loved ones. It is an incredibly
difficult choice to make. For that reason, many opponents of psychosurgery say that it should not
even be an option. Paralysis is fairly common as well. Some people are completely cured of their
illness, but become bed-ridden due to paralysis.
Even though the potential outcome of the operation may be deterrent for most families,
the ones who successfully complete the operation with no complications are relieved. Most
operations are completed to succession with no postoperative problems. Psychosurgery makes
the mental illness much more manageable for the patient. It gives them a chance to finally return
to life and family. It is much harder to cope with violent schizophrenia, but if it is more
manageable, someone who couldn’t hold a job could finally support his or her family. Those
with violent or aggressive behaviors can be “tamed”.
The success rate for psychosurgery has improved a lot since the 19th century. The
effectiveness of psychosurgery in alleviating symptoms or in restoring normal functioning was
assessed in both studies by standard psychiatric tests, examination of patients, and interviews
with close friends or family members. In Mirsky's study, 14 of the 27 patients had very favorable
outcomes, were enthusiastic about the surgery, and would undergo the operation again under
similar circumstances. The remainder of the patients had results, which ranged from only
moderate improvement to worsening of their condition, and their feelings about the surgery were
mixed. If the number of those who experienced moderate improvement is added to those who
were very much improved, however, the success rate in Mirsky's study would be 21 out of 27
(78%) (The National Commission for the Protection of Human Subjects of Biomedical and
Behavioral Research 1977).
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Psychosurgery has proven to be more effective than psychoactive drugs or electrotherapy.
Often both methods, being reversible, don’t permanently solve the patients’ problems. If patients
fail to take their medication or not attend their electrotherapy session they might fall victim to
their illness. Operation is only used as a last resort, but if the effects are positive, the patients will
not have to worry about repeated payment for expensive therapies such as psychoactive drugs or
electroshock therapy.
The most significant innovation to propel the minimalist vision of psychosurgery was the
development of surgical stereotaxis. There was a general feeling that the principles of
psychosurgery were sound but that smaller and more specific structures should be targeted to
achieve optimal therapeutic benefit while avoiding unnecessary morbidity and unwanted
neurologic deficits (Robinson et. al 2012). The stereotactic neurosurgical method uses minimally
invasive approach to psychosurgery. Stereotactic surgery enabled a much more circumscribed
lesion, resulting in fewer side-effects and less mortality. Furthermore, developments in the
neurobiology of emotion provided more refined targets for neurosurgical intervention (Mashour
et. al 2005). This means that more patients will have a higher chance of success in comparison to
the frontal lobotomy approach. Advances in psychosurgery give patients another chance at life.
Patients can see loved ones that they haven’t met in a long. Families can make connections with
the patient that couldn’t be formed before because of their illness. It gives hope to those who
have lost all faith in seeing their family together again.
While the history of psychosurgery may seem grim to most, the future holds a promising
outcome for victims of mental illness. Psychosurgery may be unpredictable, it may change the
patient, it could be life threatening. However, with research, the future of the operation will make
mental illness more manageable, it will be more successful than other therapies, and it will allow
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patients to go home. More research is definitely required in order to better help people. The
development of psychosurgery is linked to the development of all of the clinical neurosciences,
as well as the underlying cognitive and basic neurosciences. A multi- disciplinary approach with
careful regulation will be essential to the advancement and ethical administration of such
therapies for medically refractory psychiatric disease (Mashour et. al 2005).
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Works Cited:
[Anonymous]. 1977. Report and Recommendations: Psychosurgery. The National Commission
for the Protection of Human Subjects of Biomedical and Behavioral Research. 1- 76
Eskandar EN , Cogrove GR , Raush SL . 2001. PSYCHIATRIC NEUROSURGERY. Functional
and
Stereotactic
neurosurgery
[2005
May
11,
cited
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20,
2012]
http://neurosurgery.mgh.harvard.edu/functional/Psychosurgery2001.htm
Mashour GA, Walker EE, Martuza RL. 2005. Psychosurgery: past, present, and future. Brain
Research Reviews 48 409–419
Robison RA, Taghva A, Liu CY, Apuzzo ML. 2012. Surgery of the Mind, Mood, and Conscious
State: An Idea in Evolution. World Neurosurgery. 662-682
Twomey S . 2010. Phineas Gage: Neuroscience's Most Famous Patient. Smithsonian. [2010 Jan,
cited
September
21,
2012]
http://www.smithsonianmag.com/history-
archaeology/Phineas-Gage-Neurosciences-Most-Famous-Patient.html