"A more paternalistic medical culture"

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.”