Is Lobotomy Back? The Controversial Return of Psychosurgery

Last year a team of Harvard investigators headed by neurosurgeon G. Rees Cosgrove published a technical report bearing the ponderous title Magnetic Resonance Image-Guided Stereotactic Cingulotomy for Intractable Psychiatric Disease. Although steeped in medical jargon, the report’s central thesis--that psychiatric diseases can be treated by the selective destruction of healthy brain tissue--dates back to a much earlier, less sophisticated age when the search for a surgical cure for mental illness spawned an entire medical specialty known as psychosurgery.  Psychosurgery enjoyed a brief period of global acceptance around the time of World War II but was quickly driven from the medical mainstream with the advent of better, nonsurgical methods of treating the mentally ill. Now, almost half a century after psychosurgery’s demise, the Harvard Medical School and a handful of other centers are hoping that new and improved surgical techniques can revive it. Today’s neurosurgeons are also trying to rename the field psychiatric surgery, presumably to avoid the Hitchcockian overtones of the older moniker. But, as rock star Prince discovered, shedding the name that made you famous isn’t easy. 

In their 1996 paper that appeared in the respected journal Neurosurgery, Cosgrove and his co-workers described a brain operation designed to relieve emotional distress and reduce abnormal behavior. Between 1991 and 1995, they performed cingulotomies--which means, essentially, that they burned dime-size holes in the frontal lobes of the brain--on 34 patients suffering from one of the following afflictions: severe depression; bipolar disorder, or manic-depression; obsessive- compulsive disorder (ocd); and generalized anxiety disorder. The target of their operations, the cingulate gyrus, is a thin ribbon of gray matter believed to play a role in human emotional states. The authors used a computer-guided technique known as stereotaxis to advance an electrode into the cingulate gyrus, then cooked the tissue with electric current.  Cingulotomy produced major clinical improvement, as judged by psychiatrists, in a little over a third of the patients; another quarter of them had a possible response to surgery. Not stellar results, to be sure, but the Harvard patients all had severe disease that had proved resistant to all other available therapies. Any good outcomes in this population might be significant, and the investigators believed that their results were good enough to warrant a larger trial of cingulotomy. 

Despite its high-tech approach, however, the Harvard paper still looks anachronistic, to say the least. Finding a paper extolling the virtues of psychosurgery in today’s medical literature is rather like finding one advocating bloodletting. Modern neurosurgeons destroying normal brain to treat mental illness? To borrow from Samuel Johnson, this is akin to a dog walking on its hind legs--the question is not how well the act can be done but why it’s even attempted.  In spite of its elevated reputation, neurosurgery is a crude business, even--or especially--to a neurosurgeon, and I’ve been in practice for ten years. When confronted with an exposed brain at the operating table, I feel as if I’m about to repair a computer with a chain saw. The living brain has a surreal fragility; its porcelain surface is laced with delicate arteries that begin as thick cords but quickly branch into finer and finer threads. Looking at the surface of the brain is like looking at a satellite photo of a large city--one immediately senses a function far more complex than what is visible.  The idea that a sophisticated derangement in brain function, like ocd, can be cured by frying holes in the frontal lobe looks as patently absurd as recovering a lost file from a floppy disk by burning it with a curling iron. But experience suggests that such lesions can work, if they are done correctly and on the right patients.