The Initial Epoch of Psychosurgery in India: A Retrospective Data Review from Mysore Government Mental Hospital

Abstract

Background:

In the early 20^th century, psychosurgery had gained worldwide popularity for treating mentally ill persons, especially in western countries. We attempt to chronicle its journey in the Mysore Government Mental Hospital (MGMH), now the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.

Methods:

Archived case records and registers of patients admitted from 1939 to 1947 were reviewed to identify those who had undergone psychosurgery. Case records of the identified patients were assessed for clinical information, including the details of psychosurgery.

Results:

Among the patients, 107 had undergone psychosurgery, primarily leucotomy. Schizophrenia (51.5%) was the most common diagnosis in them, and 33.7% of all patients were reported to have improved. Yet, inconsistencies were found about the presence and degree of improvement. Possible side effects were not consistently documented.

Conclusion:

Psychosurgery was adopted at the MGMH very soon following its introduction in the western world. However, ambiguity about its benefits and risks was noted in the current study.

Key Messages:

- Psychosurgery [lobotomy] was adopted early in MGMH, in the context of unknown long-term risks.

- The most common diagnosis in patients undergoing psychosurgery was schizophrenia.

- This study confirms the findings of earlier studies noting unclear benefits and lack of assessment of long-term side effects of psychosurgery, in an Indian setting.

The first published account of psychosurgery was in 1891 by Gottlieb Burckhardt, a psychiatrist from Switzerland. He hoped to calm very excitable patients by destroying a strip of cerebral cortex between the sensory and motor areas, but was met with severe criticism and discontinued the procedure.^1–3 In 1910, Ludwig Puusepp, a neurosurgeon in Estonia, made knife cuts between the frontal and parietal lobes in three manic-depressive patients. Puusepp regarded the outcome as very poor.^2,4

Leucotomy/lobotomy, that is, a type of psychosurgery characterized by ablation or disconnection of the frontal lobes, was developed in 1935. Its pioneer Egas Moniz was conferred the Nobel Prize in 1949. ⁴ The urgent need for an “efficient” treatment to cope with the many psychiatrically disturbed soldiers and veterans of World War II, unavailability of medications, crowded asylums, inadequate availability of psychotherapy, and the optimistic reports of the results of psychosurgery combined to produce a mood favoring the wide-scale adoption of this type of therapy. ² Psychosurgery received widespread use in the USA, United Kingdom, Australia (since 1945), and Japan in the early 20^th century.^4–7 However, leucotomy started to fall out of favor as the follow-up neurologic sequelae became more evident. ⁸ Its gradual disuse could be attributed not only to scientific as well as social criticism but also to the invention of newer pharmacological agents.

Glimpse into the History of Psychosurgery in India

Psychosurgery was first introduced in India at the Mysore Government Mental Hospital, (MGMH, now the National Institute of Mental Health and Neurosciences [NIMHANS]), Bengaluru, by Dr. M.V. Govindaswamy and Dr. Balakrishna Rao, surgeons at the Mysore Medical College. This was contemporaneous with the early British psychosurgical operations in 1940 in Bristol. ⁹

In the initial years, 25 patients underwent psychosurgery, and the treating doctors were encouraged by the results and were hopeful of this treat- ment, despite its insufficient theoretical premise. ¹⁰ Psychosurgery began to be used more frequently, and its use gradually spread to other centers in India, such as Ranchi (European Mental Hospital, now the Central Institute of Psychiatry), as well as Madras (Madras Medical College) and other cities. ¹¹

This paper describes the use of psychosurgery on patients admitted at the MGMH between 1939 and 1947 and discusses its clinical correlates, outcomes, and impact on further developments in psychiatry and neurosurgery in India.

Methods and Materials

We used the registers of the hospital and manually searched for case notes documenting any form of psychosurgery for patients admitted till 1947. The sociodemographic and clinical data were retrieved from the case records. The first psychosurgery was done on a patient admitted in 1939, and hence the records of patients admitted from 1939 to 1947 were assessed. The study was approved by the Institute Ethics Committee.

Results

Profile of the Cases

Among the 2584 admissions from 1939 to 1947, 116 individuals underwent invasive brain procedures. Nine patients with a diagnosis of epilepsy who underwent various other invasive investigative methods like pneumo-encephalography were not included in the present analysis, which thus describes the 107 persons on whom psychosurgeries were performed.

Among the 107 patients, 68 (63.5%) were males, and 58 (54.2%) were married. Seventy-five patients (70.1%) were from the Mysore Kingdom, and 79 (73.9%) were aged 21 to 40 years ( Table 1 ).

Table 1.

Socio-demographic Background of Patients Who Underwent Psychosurgery (N = 107).

Socio-demographic Data		n (%)
Sex	Male	68 (63.5)
	Female	39 (35.5)
Marital Status	Unmarried	58 (54.2)
	Married	44 (41.1)
	Widowed	2 (1.9)
	Not mentioned	3 (2.8)
Age range	2–20 years	16 (14.9)
	21–30 years	45 (42.1)
	31–40 years	34 (31.8)
	41–50 years	9 (8.4)
	Above 50 years	2 (1.9)
	Age not mentioned	1 (0.9)
Residence	Mysore Kingdom	75 (70.1)
	Outside the Mysore Kingdom	28 (26.2)
	Not mentioned	4 (3.7)

The most common diagnosis in patients who underwent lobotomy was schizophrenia (51.5%, Table 2 ). Most patients had been admitted for a long duration (inpatient care duration range: 9–2497 days, median duration: 300 days), with not much change in their condition after admission. Almost a quarter (26%) were operated upon within a month of admission. Almost all patients (103 out of 107) had undergone anterior prefrontal leucotomy. One patient underwent transorbital leucotomy, and three underwent exploratory craniotomy (they had head injury/skull fracture noted in the records). Discharge was mostly after a few months (but in one instance, after a week). Progress notes on the outcome were specifically recorded in 37 (34.5%) patients. At discharge, only a small fraction of patients, that is, two (1.9%), were recorded as “cured”, while 36 (33.7%) were recorded as “improved.” Eight (7.5%) patients died, including three who died shortly after the surgery, while the others died several months after the surgery. Of the remaining, 27 (25.2%) had not improved, and in 36 (33.7%) cases, the information was not noted. Thus, there is considerable ambiguity about the outcome of the procedure.

Table 2.

Psychiatric Diagnosis, Nature of the Intervention, and Outcome in Patients Who Underwent Psychosurgery.

Diagnosis	n (%)	Intervention			Outcome
		Anterior Prefrontal Leucotomy n (%)	Transorbital Leucotomy n (%)	Exploratory craniotomy n (%)	Improved n (%)	Not Improved n (%)	Died n (%)	Not Mentioned n (%)
Schizophrenia	55 (51.5)	55 (100)			17 (30.9)	17 (30.9)	5 (9.1)	16 (29.1)
Depression	14 (13.1)	14 (100)			7 (50)	3 (21.4)	1 (7.2)	3 (21.4)
Depressive reaction with head injury	1 (0.9)			1 (100)				1 (100)
Mentally defective	8 (7.5)	8 (100)			2 (25)	2 (25)		4 (50)
Mentally defective (dumb)	1 (0.9)	1 (100)				1 (100)
Mentally defective – Ganja addict	1 (0.9)	1 (100)						1 (100)
Catatonia	2 (1.9)	2 (100)				2 (100)
Epilepsy	1 (0.9)		1 (100)					1 (100)
Epilepsy (depressed fracture of skull)	1 (0.9)			1 (100)				1 (100)
Old fracture of the parietal bone	1 (0.9)			1 (100)			1 (100)
Miscellaneous	22 (20.6)	22 (100)			10 (45.5)	2 (9.1)	1 (4.5)	9 (40.9)
Total	107	103 (96.3)	1 (0.9)	3 (2.8)	36 (33.7)	27 (25.2)	8 (7.4)	36 (33.7)

The procedures were also performed on nine patients diagnosed as “mental defective/imbecile”, of whom only one patient was at times unstable and harmful, while the rest did not show any symptoms of violence. Prefrontal leucotomy was also performed on an intellectually handicapped patient who had speech impairment as well, admitted by the Magistrate’s order as he was found “wandering the streets alone.” This patient’s details were not known; his name was mentioned as “Man (name not known) squint-eyed, small-pox face.” There was no record of consent, and, likely, the process of seeking and recording consent from the patient/family was not a routine prerequisite at that time.

Brief Qualitative Description of Case Notes

At least two-thirds of the case notes had sufficient clinical information, including details of procedure and outcome (Figure S1 is a deidentified picture of the typical case note. It may be observed that, before undergoing psychosurgery, this patient received several injections of ammonium chloride, a pro- convulsant frequently prescribed for admitted patients.)

In this section, we attempt to summarize four case notes, including progress notes, to have a better perspective of the clinical aspects.

Following are a few case vignettes of patients who underwent psychosurgical interventions.

Case 1

The first patient who underwent leucotomy at the MGMH was Mr. R, a 30-year-old male doctoral student in Chemistry diagnosed with “schizophrenia.” He had been treated earlier in Ranchi and Madras. The patient complained of hearing voices, as well as seeing “tape-worm-like” figures before his eyes, and seemed to have chronic paranoid delusions. He had an affair with a lady student. He was anxious to marry her, but she refused him. The doctor attributed this unrequited love as the main factor for the mental ill health of the patient. He was referred to the MGMH, admitted in November 1938, and discharged in February 1939 after treatment with iron and liver extracts. The reasons for admission were hallucination, delusions, suicidal tendency, and sleeplessness. His brother reported that the patient was “addicted” to masturbation. The doctor described the patient as the “overture of impotence and castration complexes.” He was readmitted in October 1939 as he had no improvement and underwent Bilateral Anterior Prefrontal Leucotomy on November 21, 1939. Follow-up notes for this patient are not available.

Case 2

Mr. H, a 30-year-old married gentleman, was a resident of Bangalore City. He was diagnosed with “catatonia” and was admitted in July 1943 with reasons of “refusal of food, voluntary resistance, lying flat on his back with rigidity of the limbs, does not respond to questions.” The patient was mute and had violent fits. He was given Glycerine enema, nasal feed of milk, Phrenazol, Mist Hepatica, and Mist Carminative. As there was no improvement, he underwent Anterior Prefrontal Bilateral Leucotomy in December 1944. According to the progress notes, in the immediate few weeks following the procedure, he still seemed to be in a rigid and catatonic state. He was indifferent to his surroundings. Further follow-up notes are not available.

Case 3

Ms. KS, a 24 year-old married lady from Secunderabad, was diagnosed with “depressive reaction” and admitted in 1947, with the reasons being “irrelevant talk, does not sleep and does not take food.” In 1948, she underwent Bilateral Anterior Prefrontal Leucotomy. She was treated with Penicillin and carminatives before the procedure. Not much improvement was seen in her mental state. Then, in 1949, she underwent Bilateral Transorbital Leucotomy. She was then treated with Electro Convulsive Therapy (ECT) daily for ten days in April 1949. The patient was then discharged, as she improved, in July 1949.

Case 4

Ms. S, a 22-year-old married lady, a resident of Poona District, was diagnosed as “Mental defective with schizophrenic tendencies” and admitted in August 1947, the reasons being “restlessness, wande- ring tendency, mental deficiency, being feeble-minded.” She have had two prior admissions in 1942 and 1946 in Poona Mental hospital. After admission at MGMH, records show that she was treated with Mist Pot and Mist Alba and Sodium Bicarb. In September 1947, Bilateral Salpingectomy was done under chloroform anesthesia. In January 1948, Bilateral Anterior Prefrontal Leucotomy was done, also under chloroform anesthesia. As per the notes, the patient’s condition was not improving after the procedure. She was discharged at request in June 1948.

Discussion

In early 20th century India, MGMH was often regarded as a leading “modern” mental hospital and offered advanced treatments, with an emphasis on medical investigations, early physical treatment, and recoveries, an approach which was in contrast to many other mental hospitals in British India, though keenly advocated in the UK. ¹²

The patients undergoing psycho-surgery at the MGMH came from diverse social backgrounds and were from all over India. It is unclear whether this was due to the popularity of the MGMH or specific knowledge about the psychosurgical procedures (as being a “modern” treatment) that brought patients from distant places to the MGMH. Psychosurgery was performed not only on patients who were poor and uneducated but also on well-to-do ones. The very first patient who underwent leucotomy happened to be a highly educated individual who had been treated by prominent British and Indian psychiatrists and psychoanalysts and whose family chose the procedure as a means of treatment. Whether this reflected a real need, or the appeal of technology, remains unclear.

More than half the subjects who underwent psychosurgery were dia- gnosed with schizophrenia. This was similar to Egas Moniz’s first 20 pati- ents who underwent lobotomies, of whom eight were diagnosed with schizophrenia, as well as Rao and Govindaswamy’s 25 patients who under- went the surgery, of which all had schizophrenia.^10,13 However, Crow noted that while anxiety and tension in schizophrenic illness can be relieved by lobotomy, patients with schizophrenia, on the whole, were not favorable subjects for the procedure. ¹³

The case records also indicate other notable facets. Some patients underwent multiple surgeries (vignette 2 above and some others), though with little evidence of benefit. Psychosurgery was, on occasion, combined with ECT. It was noted that, in one case, though the patient had improved well with “herbs” (Rauwolfia serpentina extracts), the doctors at the MGMH decided to use surgery rather than the “herbs.” The use of Rauwolfia extracts to treat insanity had by then been reported extensively in medical journals in India but it had not been widely used in the West or, indeed, even in mental hospitals within India. ¹⁴

There is considerable ambiguity about the outcomes of the procedure. Upon examination of the case notes, in many cases, improvement appears to correlate to an “emotionally blank attitude”, “the lack of initiative”, and so on, suggesting that reduction in boisterousness and aggression and improved manageability could have been the primary treatment goals (e.g., Figure S1/notes on January 13, 1947). It remains speculative whether some of the behavioral changes were the unpleasant residue of the original symptoms or a consequence of the procedure. In multiple case notes, discharge notes were not always congruent with the progress notes. Hence, making a confident impression of the proportion of positive outcomes based on both the condition at discharge and the progress notes is difficult. Side effects, particularly long-term adverse outcomes, have not been recorded in any of the cases, as most patients were discharged into the family’s care soon after. It is possible that the reduction in boisterousness made care at home feasible.

Rao and Govindaswamy, in their initial report, were hopeful of the benefits to be derived from this procedure, after seeing modest benefits (some improvement was seen in 6 out of 25 cases described). The surgeries they reported were done during 1942 and 1943. The specific cases they documented could not be traced in our archival review. The doctors at MGMH were aware of the several criticisms of the procedure “made on humanitarian grounds and some on the grounds that a more serious disorder has been inflicted on the patient than he is already suffering from.” ¹⁰ With the benefit of hindsight, it would seem that a more cautious approach in terms of performing the procedures, monitoring, and reporting the outcomes could have been more appropriate.

Growth and Decline of Psychosurgery in Independent India

Formal neurosurgical services were initiated in independent India and had a considerable focus on psychosurgery. This was further exemplified by the decision to establish a full-fledged neurosurgery department at the newly established All India Institute of Mental Health (which was attached to the MGMH), and the faculty chosen had been trained at Bristol (one of the early centers for psychosurgery in the UK). ¹⁵ This and other new centers for neurosurgery in independent India were few and invariably attached to the medical colleges in major cities. The last psychosurgery (prefrontal leucotomy) was probably performed at MGMH in the mid-1970s, but it probably continued to be used in some parts of India into the 1980s, whereas the procedure had declined in countries like Japan in the 1960s. In 1975, the Japanese Society for Psychiatry and Neurology (JSPN) adopted a resolution condemning psychosurgery; it stated, “Psychosurgery… should not be practiced as medicine.” ⁶ As per a literature survey of 1971 to 1976 data, approximately 400 psychosurgeries may have been conducted in the US each year, compared to 200–250 in the UK and 30–60 in India. ² The US Congress considered a ban on psychosurgery in 1974 but found sufficient evidence for the efficacy of modern procedures, like cingulotomy and anterior capsulotomy, to support further research into similar treatments. ⁴

There is little evidence of unease or resistance (from civil society or the medical profession) to the practice of psychosurgery in India. The procedure was lauded as an example of the application of modern treatment methods, till its use declined as other drug treatments became available, and there was hardly any inquiry or strident criticism, unlike in the West. The halo of a “modern” technological solution to an otherwise vexatious problem was probably sufficient to deflect any criticism. Hundreds of individuals are thought to have undergone this procedure, but there are very few research studies or comments about its use or usefulness. In any case, its use, probably mostly by the well-off in the later years, perhaps insulated it even further from the public gaze and the human rights movements. The course of the use of neurosurgical procedures for psychiatric disorders is fluctuating, and a consensus statement and guidelines for India have been presented recently by the Neuromodulation Society of India and the Indian Society for Stereotactic and Functional Neurosurgery (ISSFN). ¹⁶ Also, Section 96 in Chapter 12 of the Mental Healthcare Act, 2017 of India notes that “psychosurgery shall not be performed as a treatment for mental illness unless - (a) the informed consent of the person on whom the surgery is being performed; and (b) approval from the concerned Board to perform the surgery has been obtained.” It also notes that “the Central Authority may make regulations for the purpose of carrying out the provisions of the concerned section.” ¹⁷

Conclusion

The use of invasive brain procedures, as mentioned in the paper, shows how quick the adoption of newer treatment technologies was in the past. However, a reappraisal suggests that the procedure’s success was not as promising as described in earlier research. The questions about debates on, and criticism of, such procedures, which were so obvious in some countries, have strangely been missing in both the scientific and public spaces in India. Though the chance of a cure through psychosurgery may have seemed preferable to the possible life sentence of incarceration in an institution, the reality now appears less favorable than anyone would have then hoped for.