The Origins and Persistence of Psychosurgery in the State of Iowa

NEUROSURGICAL FOCUS Neurosurg Focus 43 (3):E8, 2017 The origins and persistence of psychosurgery in the state of Iowa Francis J. Jareczek, BS, BA,1 Marshall T. Holland, MD,2 Matthew A. Howard III, MD,2 Timothy Walch, PhD,2 and Taylor J. Abel, MD2 2Department of Neurosurgery, 1University of Iowa Carver College of Medicine, Iowa City, Iowa Neurosurgery for the treatment of psychological disorders has a checkered history in the United States. Prior to the ad- vent of antipsychotic medications, individuals with severe mental illness were institutionalized and subjected to extreme therapies in an attempt to palliate their symptoms. Psychiatrist Walter Freeman first introduced psychosurgery, in the form of frontal lobotomy, as an intervention that could offer some hope to those patients in whom all other treatments had failed. Since that time, however, the use of psychosurgery in the United States has waxed and waned significantly, though literature describing its use is relatively sparse. In an effort to contribute to a better understanding of the evolution of psychosurgery, the authors describe the history of psychosurgery in the state of Iowa and particularly at the University of Iowa Department of Neurosurgery. An interesting aspect of psychosurgery at the University of Iowa is that these procedures have been nearly continuously active since Freeman introduced the lobotomy in the 1930s. Frontal lobotomies and transorbital leukotomies were performed by physicians in the state mental health institutions as well as by neurosurgeons at the University of Iowa Hospitals and Clinics (formerly known as the State University of Iowa Hospital). Though the early technique of frontal lobotomy quickly fell out of favor, the use of neurosurgery to treat select cases of intractable mental illness persisted as a collaborative treatment effort between psychiatrists and neurosurgeons at Iowa. Frontal lobotomies gave way to more targeted lesions such as anterior cingulotomies and to neuromodulation through deep brain stimulation. As knowledge of brain circuits and the pathophysiology underlying mental illness continues to grow, surgical intervention for psychiatric pathologies is likely to persist as a viable treatment option for select patients at the University of Iowa and in the larger medical community. https://thejns.org/doi/abs/10.3171/2017.6.FOCUS17227 KEY WORDS history of psychosurgery; transorbital lobotomy; anterior cingulotomy; deep brain stimulation; University of Iowa EUROSURGERY for the treatment of psychological dis- other hospitals, it has continued to progress and at times orders has a checkered history in the United States. prosper. Unfortunately, any assessment of the state of psy- Prior to the era of antipsychotic medications, indi- chosurgery is biased because, in large part, literature de- Nviduals with severe mental illness were often institutional- scribing the historical span of psychosurgery at individual ized and subjected to extreme therapies with little evidence institutions and neurosurgical divisions is lacking. Addi- of efficacy in a last-ditch attempt to palliate their symp- tional research and publication would provide an important toms. For example, treatments included hydrotherapy10 and index for the history of psychosurgery in the US. In an ef- insulin shock therapy.20 fort to contribute to a better understanding of the evolu- When psychosurgery in the form of frontal lobotomy tion of psychosurgery in the US, we describe the history of was first introduced, the underlying premise of its dis- psychosurgery in the state of Iowa and particularly at the ruption of pathological connections in the brain led to its University of Iowa Department of Neurosurgery. rapid dissemination and uptake across the US. This initial An interesting aspect of psychosurgery at the Univer- progress was due in large part to the efforts of its major sity of Iowa is that psychosurgical procedures have been proponent, psychiatrist Walter Freeman. Since that time, almost continuously active since the introduction of the lo- however, interest in (and the infamy of) psychosurgery in botomy by Freeman in the 1930s. Mental health providers the US has waxed and waned significantly. At some hos- and neurosurgeons in the state of Iowa were immediately pitals, psychosurgery has disappeared completely, and at enthusiastic about the lobotomy introduced by Freeman ABBREVIATIONS DBS = deep brain stimulation; FDA = Food and Drug Administration; MHI = mental health institution; OCD = obsessive-compulsive disorder; SUI = State University of Iowa; VA = Veterans Administration. SUBMITTED April 10, 2017. ACCEPTED June 7, 2017. INCLUDE WHEN CITING DOI: 10.3171/2017.6.FOCUS17227. ©AANS, 2017 Neurosurg Focus Volume 43 • September 2017 1 Unauthenticated | Downloaded 09/26/21 07:51 AM UTC F. J. Jareczek et al. and the potential benefit it could bring to patients suffering from intractable mental illness, and it was performed to varying extents by physicians in the state mental health institutions as well as by neurosurgeons at the University of Iowa Hospitals and Clinics (formerly known as the State University of Iowa [SUI] Hospital). Although the early technique of frontal lobotomy quickly fell out of favor, the use of neurosurgical techniques to treat selected cases of intractable mental illness persisted through the years as a collaborative treatment effort between the psychiatrists and neurosurgeons at Iowa. Frontal lobotomies gave way to more targeted lesions such as anterior cingulotomies and further refinement by similarly targeted yet less destructive neuromodulation through deep brain stimulation. As knowledge of brain circuits and the pathophysiology underlying mental illness continues to grow, surgical intervention for psychiatric pathologies is likely to persist as a viable treatment option for selected FIG. 1. Leucotome advertisement from 1950. Reproduced from Brain patients at the University of Iowa and in the larger medical 73(3):v, 1950 (https://academic.oup.com/brain/issue/73/3). community. orbital technique, which was thought to reduce the inci- The Early Years of Psychosurgery in Iowa: dence of these complications while maintaining therapeu- tic efficacy.24 Watts, the more conservative of the two, was Practices at the State Mental Institutions and opposed to neurosurgical interventions being performed the Work of Dr. Russell Meyers at the State by individuals without any formal surgical training and University of Iowa left the partnership in the mid-1950s. Having established a methodology that was rapid, minimally invasive, and with Manipulation of the frontal lobe to treat mental ill- few apparent complications, Freeman turned his attention ness was first performed by Portuguese neurologist An- to disseminating his technique nationally. tonio Egas Moniz and neurosurgeon Pedro Almeida Lima During his travels through Iowa, Freeman trained psy- in 1935 when they injected alcohol to produce a lesion. chiatrists at the state mental health institutions (MHIs) at Subsequent refinement of the technique led to the design Cherokee, Clarinda, Independence, and Mount Pleasant of a “leucotome” (Fig. 1), a metal instrument designed to (Fig. 2). The procedure was initially accepted with skep- physically remove a small volume of brain tissue consis- 6 ticism and reserved for “deteriorated” patients who had tently—or at least as compared with the alcohol injection. “a great deal of emotional tension” and for whom other The leucotome, or leukotome, as it has more recently been conventional treatments of the era had failed. These in- spelled, was a straight metal instrument with a retractable effective procedures could include psychotherapy, hy- wire loop that projected laterally from the tip of the device. drotherapy, insulin shock therapy, narcotherapy, malaria After an opening was made in the patient’s skull above the therapy, electroconvulsive therapy, or a combination.11,21 In frontal lobe, the instrument was inserted—without direct response, the head of the University of Iowa Psychopathic visualization—into the subcortical white matter. The wire Hospital cautiously described psychosurgery as having “a loop was then extended and the instrument rotated to cre- useful application in hopeless cases.”16 ate “precise” spherical “cores” of 1-cm diameter. Moniz As reports of positive outcomes began to emerge from and Lima’s first group of patients received 6 lesions on the Iowa MHIs5,21 and other institutions across the country, each side. The procedure could be repeated if the physi- the procedure became more widely accepted. Interesting- cians decided an adequate response was not observed after ly, an early publication based on questionnaires suggests the initial surgery.6 that very few lobotomies—a reported total of 16—were In 1936, after attending a presentation by Moniz at a performed in Iowa prior to mid-1949.14 Other reports pub- conference in London, psychiatrist Walter Freeman and lished by individuals performing these interventions indi- neurosurgeon James Watts from Georgetown University cate that the actual number of procedures was significantly brought the technique of frontal lobotomy to the US. While larger—more likely totaling in the hundreds. At the Mount they initially used the technique described by Moniz, Free- Pleasant MHI, for example, some providers presented sur- man and Watts soon modified it to more completely disrupt gery “as a necessity and often times the only means for connections between the frontal lobes and

Load more