Professor Rees Cosgrove misleads the President's Council on Bioethics
On Friday June 25 2004 Professor Rees Cosgrove M.D., Associate Professor of Surgery (Neurosurgery), Harvard Medical School, and Attending Neurosurgeon, Massachusetts General Hospital, addressed the President’s Council on Bioethics on the subject of psychosurgery. (Professor Rees Cosgrove carries out the psychosurgical operations done at the MGH.)
Moniz, or rather his neurosurgeon colleague, Dr Almeida Lima, didn’t inject alcohol into the frontal lobes of all 20 patients; he injected ten with alcohol but ten were operated on with a leucotome. One was subjected to both procedures. Moniz thought that 14, not 16, of the 20 were improved (but that might be a transcription error - Professor Rees Cosgrove gets it right on the MGH /Harvard Medical School Neurosurgical website.)
But, more importantly, were Moniz' original twenty psychosurgery patients really institutionalised? In fact, only 9 of the 20 had been in the local mental hospital, the Bombarda Asylum, for over a year. Five had been there for six months or less and six had never been in the asylum but had consulted Moniz at his clinic.
The first seven patients had spent between two and eight-and-a-half years in the Bombarda Asylum before they underwent surgery. They were all still in the asylum at follow-up after surgery (the maximum follow-up period was two months).
Patients Eight and Nine also came from the asylum but had been there for just five months and one month respectively. Both were still in the asylum at follow-up, although one of them had been given permission to return home.
Patient Ten had never been in a mental hospital. She consulted Moniz at his clinic, the Santa Marta, and was diagnosed as suffering from an anxiety neurosis.
Patient Eleven had never been in an institution either, having been taken to the Santa Marta in an excited state on 26 December 1935, he was diagnosed as schizophrenic and operated on a week later.
Patient Twelve was diagnosed as suffering from a “cardiac neurosis”. She had never been in a mental hospital.
Patient Thirteen had never been in a mental hospital but was brought to the Santa Marta Clinic by her son who said she had been excited for three months. She was operated on immediately and again a couple of weeks later.
Patient Fourteen had been in the Santa Bombarda Asylum for two years.
Patient Fifteen had never been in a mental hospital.
Patients Sixteen, Seventeen and Eighteen came from the Santa Barbara Asylum (one of them via prison), but had been there a year or less.
Patient Nineteen, suffering from depression and anxiety, had never been in a mental hospital. Her family had heard about the operation and brought her into the Santa Marta Clinic.
Patient Twenty had been admitted to the Bombarda Asylum six weeks before she was operated on.
Professor Rees Cosgrove repeats the claim on the MGH/Harvard Medical School Neurosurgical website:
Here, Professor Rees Cosgrove makes the usual apologies for the early psychosurgeons: the mental institutions were overflowing and few treatments existed. But only one of the nine patients who had been in hospital for over a year was able to return home following surgery. He was suffering from depression and had been in the Bombarda Asylum for two years. Although he was allowed to go home, he was described at follow-up as lacking in initiative and confused about his age, time and money. Three patients, two suffering from mania and one from depression, who had been in hospital for only a brief period before surgery, were able to go home. None of the seven schizophrenics got to leave hospital, and only two were described as improved.
In fact, Moniz’ results were very typical of what was to follow. Psychosurgery was never going to empty the mental hospitals. Long-term patients who could leave the hospital following surgery were few and far between; those who could work and live independently were even fewer and further between. The majority of cures were obtained with the least ill patients - people who were suffering from anxiety and depression and sometimes hadn’t been ill for very long. Even Moniz, in the 1937 article cited by Professor Rees Cosgrove, admits that “Deteriorated patients obtain slight or no benefit from the treatment”.
Professor Rees Cosgrove opened his address to the President’s Council of Bioethics with the following words:
For precisely this reason, it is important not to misrepresent the past.
The modern era of psychosurgery was begun by this man, Egas Moniz, who is a very celebrated and famous Portuguese neurologist who experimented by injecting alcohol into the frontal lobes of 20 institutionalized psychiatric patients and thought that 16 of the 20 were favorably improved.
Moniz, or rather his neurosurgeon colleague, Dr Almeida Lima, didn’t inject alcohol into the frontal lobes of all 20 patients; he injected ten with alcohol but ten were operated on with a leucotome. One was subjected to both procedures. Moniz thought that 14, not 16, of the 20 were improved (but that might be a transcription error - Professor Rees Cosgrove gets it right on the MGH /Harvard Medical School Neurosurgical website.)
But, more importantly, were Moniz' original twenty psychosurgery patients really institutionalised? In fact, only 9 of the 20 had been in the local mental hospital, the Bombarda Asylum, for over a year. Five had been there for six months or less and six had never been in the asylum but had consulted Moniz at his clinic.
The first seven patients had spent between two and eight-and-a-half years in the Bombarda Asylum before they underwent surgery. They were all still in the asylum at follow-up after surgery (the maximum follow-up period was two months).
Patients Eight and Nine also came from the asylum but had been there for just five months and one month respectively. Both were still in the asylum at follow-up, although one of them had been given permission to return home.
Patient Ten had never been in a mental hospital. She consulted Moniz at his clinic, the Santa Marta, and was diagnosed as suffering from an anxiety neurosis.
Patient Eleven had never been in an institution either, having been taken to the Santa Marta in an excited state on 26 December 1935, he was diagnosed as schizophrenic and operated on a week later.
Patient Twelve was diagnosed as suffering from a “cardiac neurosis”. She had never been in a mental hospital.
Patient Thirteen had never been in a mental hospital but was brought to the Santa Marta Clinic by her son who said she had been excited for three months. She was operated on immediately and again a couple of weeks later.
Patient Fourteen had been in the Santa Bombarda Asylum for two years.
Patient Fifteen had never been in a mental hospital.
Patients Sixteen, Seventeen and Eighteen came from the Santa Barbara Asylum (one of them via prison), but had been there a year or less.
Patient Nineteen, suffering from depression and anxiety, had never been in a mental hospital. Her family had heard about the operation and brought her into the Santa Marta Clinic.
Patient Twenty had been admitted to the Bombarda Asylum six weeks before she was operated on.
Professor Rees Cosgrove repeats the claim on the MGH/Harvard Medical School Neurosurgical website:
Moniz reported that 14 of 20 severely ill, institutionalized patients showed "worthwhile" improvement after operation and coined the phrase "psychosurgery" to describe his interventions. ( Moniz, 1937) At that time, few satisfactory treatment options existed and the asylums for the insane were overflowing with the chronic mentally ill. Therefore, despite the lack of objective data and long term follow-up, an enthusiastic response was obtained from the medical community. This response resulted in Moniz receiving the 1949 Nobel Prize in Medicine and Physiology.
Here, Professor Rees Cosgrove makes the usual apologies for the early psychosurgeons: the mental institutions were overflowing and few treatments existed. But only one of the nine patients who had been in hospital for over a year was able to return home following surgery. He was suffering from depression and had been in the Bombarda Asylum for two years. Although he was allowed to go home, he was described at follow-up as lacking in initiative and confused about his age, time and money. Three patients, two suffering from mania and one from depression, who had been in hospital for only a brief period before surgery, were able to go home. None of the seven schizophrenics got to leave hospital, and only two were described as improved.
In fact, Moniz’ results were very typical of what was to follow. Psychosurgery was never going to empty the mental hospitals. Long-term patients who could leave the hospital following surgery were few and far between; those who could work and live independently were even fewer and further between. The majority of cures were obtained with the least ill patients - people who were suffering from anxiety and depression and sometimes hadn’t been ill for very long. Even Moniz, in the 1937 article cited by Professor Rees Cosgrove, admits that “Deteriorated patients obtain slight or no benefit from the treatment”.
Professor Rees Cosgrove opened his address to the President’s Council of Bioethics with the following words:
What I would like to do briefly this morning is give a very short historical perspective because I think that's paramount to understanding some of the moral and ethical issues that are involved with surgery for psychiatric illness;
For precisely this reason, it is important not to misrepresent the past.
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