There are now few surviving surgeons or psychiatrists from the early days of psychosurgery. But one exception is the British psychiatrist John Pippard, who is still on the Medical Register sixty-three years after he qualified as a doctor.

It was in the 1950s, as a consultant psychiatrist at Claybury Hospital in Essex, that Pippard made his name in leucotomy. In 1955 he completed a thesis on leucotomy at Cambridge University, where he had studied medicine, and during that decade published several articles on psychosurgery in medical journals. The surgeon Wylie McKissock who carried out thousands of psychosurgical operations named a particular type of cut the rostral P in his honour.

In 1962 Pippard published the results of a survey of psychosurgery in Britain, which showed that the number of operations had declined to about 500 a year (from an average of over 1100 a year in the late forties and early fifties). Interestingly, Pippard did not put that decline down entirely to the introduction of neuroleptic drugs in the way that people do nowadays. Instead, commenting on Tooth and Newton’s earlier survey of psychosurgery, he has this to say:

“The survey threw little light on the reasons for the decline in popularity of this form of treatment, but it was considered that, more than anything else, the undesirable side-effects of the operation explained it. It is also perhaps not surprising that many psychiatrists, continuing to care for the failures of leucotomy in hospital, should have become prejudiced against neuro-surgical procedures; the success of ataractic and other drugs and the increasing attention given to social influences and to occupational and recreational activities in hospital has further reduced the interest in surgery.”

Pippard’s survey found a large regional variation in the use of psychosurgery, ranging from 20 operations per million inhabitants in the North-East Metropolitan Region (which included Pippard’s own hospital and also Runwell Hospital where another psychosurgery enthusiast, Rolf Strom-Olsen, was superintendent) to 1.3 operations per million inhabitants in the neighbouring East Anglian Region. Nearly half the mental hospitals in Britain did no psychosurgery at all during 1959; at the other extreme one hospital did 45 operations. (My suspicion is that it was Runwell Hospital, but Pippard didn’t say). Pippard wrote approvingly of this hospital: “I have visited this hospital and discussed many of the patients operated upon with the consultant responsible for their treatment. It appeared to me that the cases had been carefully selected and the results of the operation seemed satisfactory in a high proportion, not only to the patients themselves but also to the relatives.” Pippard seemed to be more worried about hospitals that used little or no psychosurgery: “In general I get the impression that leucotomy is not sufficiently considered as a treatment in many cases which could, perhaps, be effectively treated only in this way”.

In later years Pippard turned his attention to a different form of treatment, ECT. He carried out surveys of ECT in the 1980s and again in the early 1990s, worked as a member of the Mental Health Act Commission panel of psychiatrists, and co-authored the chapter on ECT, the law and consent in the 1995 Royal College of Psychiatrists’ ECT handbook. There were of course other psychiatrists, for example Walter Freeman in the USA and William Sargant in Britain, who continued to use psychosurgery with as much enthusiasm as ever, even while the profession as a whole was losing interest in it.

A few years ago Pippard looked back on his psychosurgery years in an article entitled “Leucotomy: a qualified defence of ‘then’”, which appeared in the medical journal QJM (2001, volume 94, page 451).

“Leucotomy (known as lobotomy in the US) and electroconvulsive therapy (ECT) are the only physical treatments for mental illness devised in the 1930s that are still used today. Few drugs were available at this time, other than sedatives and amphetamines. The new treatments offered hope for patients with severe psychotic illness, the severely anxious, obsessional or depressed, and those exhibiting violently disturbed behaviour, all of whom were many in number…
In the more paternalistic medical culture in which leucotomy was first proposed, questions of consent were considered less seriously than they are today. Leucotomy in the form, for example, of stereotactic tractotomy and cingulectomy is still used occasionally at a few neurosurgical centres, mainly for intractable depression (especially in the elderly) and for obsessional illness. However, the Mental Health Act (1983) forbids psychosurgery without the consent of both the patient and the Mental Health Act Commission (MHAC). MHAC approval is given only after thorough assessment by three Commission members, including a psychiatrist. I performed this function over three years in the 1980s, and found it much harder, more worrying and a more controversial task than making a clinical decision 20 or 30 years ago.
Past practice may only be judged fairly when its context is understood: simply applying current ethical standards and the wisdom of hindsight not only over-denigrates the past, but underestimates the future. Consideration as to how much of our current best clinical practice will be deemed inadequate 50 years from now gives us a fairer standard by which to judge our past decisions.”

Read the whole article here

It is interesting that Pippard refers to the medical culture of the 1940s and 1950s as “paternalistic”. Almost all those involved in psychosurgery have been men. (Effie Hutton at the Burden Neurological Institute was a notable exception in the early days of psychosurgery.) The majority of patients meanwhile have been women. Women out-numbered men nearly two to one in the first thousand patients treated in England and Wales; nowadays they out-number men by slightly more than two to one.

The “paternalistic” (and that, I think, is putting it politely) attitude of psychiatrists towards their patients is revealed in some of Pippard’s case histories from the 1950s. Here are a few examples:

“A woman of 34, terrified in childhood by constant quarrels between her overbearing and aggressive mother and her cyclothymic father, felt herself inferior to her more favoured older sister and was a cowed, enuretic, much punished child, who early developed obsessional rituals against her fears. She was further handicapped by recurrent attacks of acute rheumatism and dyspnoeic from mitral stenosis. Her mother and sister interfered in her marriage and her husband demanded fellatio. Though partly relieved by leucotomy of the depression which had totally incapacitated her for a year she remained immature, insecure and still had obsessional ruminations and compulsions.”

“An actress of 50 had never really achieved anything so satisfying in her life as playing in Maeterlinck’s Blue Bird at the age of 8. A lifetime of hypochondriasis, with frequent visits to hospitals in two continents, had given her life some meaning and provided excuses for not having done better in her career. When her mother died she became agitated and depressed and her hypochondriasis assumed tremendous proportions. With the relief of depression by open rostral leucotomy a year later she reverted to her normal level but was perhaps more difficult to live with because of an accentuation of her shrewishness and an increase in absentmindedness.”

“A deaf little woman with tinnitus… lost her home in an air-raid and had to live in an uncongenial neighbourhood away from the friends of her former years, her family had grown up and left her, and her personal contacts were limited to a few cronies in the local pub; only there did she brighten up at all. There were no obvious post-operative personality deficits and her unobservant husband had not seen any change in her.”

“A 42 year old housewife, a sociable person of extraverted personality, gave up her work as a milliner at 21 to care for her elderly parents… Behind a kindly front she was seething with indignation against her sister, whose illegitimate child she brought up…standard leucotomy made her bland and dull and it was not long before she was able to travel by bus for the first time in 14 years. At follow up nearly 2 years later she had grown plump and was giggly and rather fatuous, voicing her thoughts without concern for their effect on others. Her housework fully occupies all her days; she can no longer read since she cannot understand what she reads…Patient and husband call this result “a complete success”, and he rather likes the severe frontal lobe deficit syndrome.”

Howard Dully has started his own blog about lobotomy. Very cool!
Be sure to check it out.

http://howarddully.blogspot.com/

The City Council of Dundee in Scotland has created an interesting website, “Life at Liff”. The website is based on an exhibition which explored the treatment of mental illness in the city. For many years this treatment was centred on the Victorian asylum near the village of Liff just outside Dundee (hence “Life at Liff”).

Dundee, incidentally, is one of just two centres for psychosurgery in the UK. The other is at the University of Cardiff if Wales. At Ninewells Hospital in Dundee a psychosurgery team, currently consisting of psychiatrist Keith Matthews and surgeon Muftah Eljamel, have carried out more than 30 operations since 1990, all of them on people diagnosed as depressed or obsessive-compulsive.

In a section on surgery, the “Life at Liff” website tells us that:

The pre-frontal leucotomy was introduced in Dundee by Dr Bell in 1946. The operation was carried out in Maryfield Hospital. Two years later Bell reported that the operation had been performed on 53 patients, of whom 50 had improved, 2 showed no change and 1 tragically had died.
He noted:
‘The [improved] patients
include many previously restless or violent and requiring continual nursing care and supervision, who are now able to lead a relatively normal life under medical hospital conditions.’
With the discovery of new anti - psychotic drugs in the 1950s, leucotomies became unnecessary.
The operation was last performed in Dundee in 1959. Causing irreversible damage to the brain, leucotomies are now considered unethical. Psychosurgery is still carried out
as a treatment, but at a much more advanced level.

So in the 1940s and 1950s doctors did these damaging and unethical things called leucotomies whilst nowadays they perform more advanced, and presumably ethical, psychosurgery? There is of course nothing unusual about this view. Jack el-Hai’s recent book about Walter Freeman, The Lobotomist, tells us on the first page that lobotomy disappeared a quarter of a century ago.

Certainly you won’t find recent textbooks or articles in the medical press talking about lobotomies; they talk about neurosurgery for mental disorder or anterior cingulotomies or capsulotomies and so on (which simply refers to the particular bit of the brain being operated on). But does this change in terminology reflect the disappearance of one, discredited, type of operation and its replacement by a completely different one, or is it simply an attempt by psychiatrists and surgeons to distance themselves from controversy?

Egas Moniz is generally credited with the invention of psychosurgery, although there had been attempts previously, for example by the Swiss psychiatrist Gottlieb Burckhardt, to do similar operations. Moniz (or rather the neurosurgeon Almeida Lima working under Moniz’ instructions) drilled holes in his patients’ skulls, inserted instruments into their brains, and then, either by means of injecting alcohol or cutting out some tissue, introduced a “lesion”, that is, a bit of brain was destroyed. And that, basically, remains unchanged. They may have more sophisticated tools and techniques, they may have thought up different names, but the basic principle remains the same: a lesion is made in the brain in the hope of alleviating the symptoms of mental illness.

Moniz coined the terms psychosurgery and leucotomy (cutting of the white matter) to describe his operations. He was awarded a Nobel prize for his “discovery of the therapeutic value of leucotomy in certain psychoses”. In Britain both terms were adopted, leucotomy being used almost exclusively in the 1940s and 1950s and psychosurgery becoming more a popular term during the 1970s. For example the Mental Health Act 1983 talks about psychosurgery.

In the US Walter Freeman decided to call his version of the operation a lobotomy rather than a leucotomy. Others followed his example and psychosurgical operations became known as lobotomies. Freeman then went on to develop the type of operation that nowadays is associated with his name - the assembly line, no qualified surgeon required, electroshock for anaesthesia, ice-pick through the eye socket, lobotomy. It is this type of operation that most people think of when the word “lobotomy” is used and these particular operations - transorbital lobotomies - are of course no longer done.

But, while Freeman was hammering ice-picks into eye sockets, elsewhere neurosurgeons were carrying out psychosurgical operations with all the care usually accorded to neurosurgery and not an ice-pick in sight. Neurosurgeon James Poppen’s description of his “operative technic” in a 1951 volume called “Studies in lobotomy” takes up three pages (the operation itself took thirty minutes) and contains details such as:

After the buttons were removed and all bone dust washed out, the dura was opened with a semicircular incision with its base toward the mid-line. The dural flaps were held up by a suture tied in the mid-line. The underlying brain was then examined and described. In a number of cases, biopsy specimens were taken for histologic and biochemical study. Having selected a representative gyrus, a block of tissue at least 1cm was resected with minimal mechanical thermal trauma.

And other neurosurgeons were busy developing new techniques. The stereotactic frame, which the American neurologist/neurosurgeon team of Spiegel and Wycis adapted from animal experiments to human use in the 1940s, enabled surgeons to find their bearings more easily and target more specific areas of the brain. The anterior cingulotomy, which is still used at Massachusetts General Hospital and at Dundee, was first described in an article published in the Lancet in 1952. The anterior capsulotomy, which is used in Sweden and Wales, was pioneered in France in the 1940s. So it is not possible to draw a clear dividing line between crude early operations and sophisticated modern ones. Nevertheless, today’s psychosurgeons try to distance themselves from their predecessors and sometimes go to bizarre lengths to do so. The psychosurgery team at Dundee University for example refer to the “indiscriminate and crude procedures of antiquity”. Antiquity? They are talking not about classical or medieval or even Victorian times but about the 1940s, 50s and 60s.

In a review of the book “Madhouse” about Henry Cotton the Israeli newspaper Haaretz mentions us:

“Even after Cotton’s death his students continued to perform tooth extractions and tonsillectomies, until 1960. Even the inception of a treatment that was thought to be innovative at the time - lobotomy, the surgical removal of part of the brain’s frontal lobe by inserting an ice pick into it, which was supposed to replace other treatments - did not lead to the end of the amputations and other surgery. (Incidentally, the developer of the lobotomy, who performed hundreds of the procedures, won the Nobel Prize for Medicine and also a great deal of support, until the real results of the treatment were revealed: The destruction of the brain tissue affected the functioning of the patient, who became a kind of zombie. Recently, several lobotomy patients’ families have asked that the Nobel Prize be rescinded.) The studies that pointed to the danger and stupidity of Cotton’s methods were buried in the archives of Johns Hopkins and the management of the hospital in New Jersey.”

Procedure once considered legitimate medical treatment

(CNN) — Howard Dully was 12 years old when he was told he was going to the hospital for some tests.

“I remember having big black swollen eyes one day and staying in the hospital for a few days because apparently I had an infection,” recalls Dully, now 56, who lives in San Jose, California.

That’s all Dully can remember of the transorbital or “ice pick” lobotomy performed on him more than 40 years ago.

Many in the medical community consider lobotomies barbaric by today’s standards, but there was a time when the procedure was an accepted treatment for those suffering from severe mental illness.

Throughout the 1930s, ’40s and most of the ’50s, the main route of treatment for most of these patients was to keep them institutionalized in often filthy, deplorable conditions until they got better on their own. Many remained for years, even decades.

Then came the lobotomy. It was first performed in 1935 in Portugal by Dr. Egas Moniz, who later would win the Nobel Prize in physiology and medicine for the technique.

Neurologist Walter J. Freeman quickly brought the lobotomy to the United States, first performing it in 1936. A few months later the procedure made the front page of The New York Times with the headline “Surgery Used on the Soul Sick.”

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Remember Lena Zavaroni, the Scottish child star who sang for President Ford in the White House?

At the age of eleven she had sell-out concerts at the London Palladium and appeared in concerts and TV appearances in the US, South Africa, Japan, Germany, Holland and Austria. The following year, 1976, she sang in the Royal Variety Show; in 1977 she had her own summer season in Eastbourne; in 1979 her own BBC TV series. She was said to be Scotland’s richest teenager.

But underneath the success Lena was a deeply unhappy teenager who, under pressure to maintain the image of a child star, had became anorexic.

“When they tried to fit me into those costumes, they would talk about my weight. I kept wondering how they expected me to fit into these dresses. I was a plump little girl and I was also developing into a woman. I wanted to be just right for them but I had to go to all these breakfasts, dinners and lunches.” She added: “I only became fanatical about not eating when the pressure became too much. I just wanted to have a nice shape.”

Lena continued to suffer from anorexia and depression and the 1980s and 1990s saw hospital treatment, including ECT, a brief and unhappy marriage, her parents’ divorce and her mother’s suicide. Eventually she was living on disability benefit in a council flat. (What happened to all the money?)

In September 1999, she underwent a psychosurgical operation in the University of Wales hospital in Cardiff, one of only two centres in the UK that still perform such operations. Three weeks later, still in hospital, she died of an infection. She was thirty-five years old.

A spokesman for the hospital had this to say about the operation:

“A special surgical procedure is available as a last-resort treatment for the most severe cases of chronic clinical depression. It’s not a treatment for anorexia and it’s not a lobotomy.It’s available only at a small number of specialist neurosurgical centres in the United Kingdom, of which the University Hospital of Wales is one. This is not an experimental or pioneering procedure - the NHS treatment has been performed successfully at the hospital for over six years.
Each operation is approved individually by the Mental Health Commission and surgery can only be performed after a rigorous examination of all the facts in each case.
This includes an interview with the patient and all the healthcare professionals involved.”

Coroner Dr Lawrence Addicott recorded a verdict of death by natural causes.

Read more about Lena here

I’D RATHER HAVE A BOTTLE IN FRONT OF ME . . .

Barbaric Photoshopping of the brain, as it were, is spotlighted in the radio documentary My Lobotomy, whose premiere at Bellevue I gleefully went to, mainly to act all superior to the live guests who’d no doubt be screaming, slobbering, and belching the alphabet. But these survivors—who once had ice picks rammed into their heads for various un-chic reasons—were touching and well-spoken about the ramifications of their horror, though I was most attracted to the lady who said the lobotomy actually helped her resolve her schizophrenia. I hope she got two for the price of one.

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