Sweden

Kenneth Ögren, who writes about the early history of lobotomy in Sweden and who has previously featured on this blog, has had another article published in the Swedish medical journal Lakartidningen.
The article expands on a paper Ögren delivered at the tenth annual meeting of the International Society for the History of the Neurosciences last year, and describes a quarrel between geneticist Gunnar Dahlberg and the psychosurgery team of psychiatrist Snorre Wohlfahrt and neurosurgeon Olof Sjöqvist over Dahlberg's rather unflattering definition of lobotomy. Here is the abstract:

"A less honorable way of expressing oneself on lobotomy

Kenneth ÖGREN
University of Umeå, Sweden

“Recently, doctors started using a procedure in which a hole is drilled in the skull of the patient, thereafter a knife is inserted into the holes and than it is whipped around in the brain until the frontal lobes stops to function.”
The above quotation was published in 1947, in Sweden, in the Tidens Kalender, a widely distributed year book that among other important societal subjects covered science and medicine. Professor Gunnar Dahlberg, a well-respected chief of the Swedish Race Biology Institute, edited Tidens Kalender. Since the end of the 1930s, besides his work as a physician and researcher within the Institute, Dahlberg was a well-known publisher of popular texts on medical matters.
Why did Dahlberg define psychosurgery in this way? In 1949, the year of the nomination of Moniz for the Nobel Prize in medicine, a Swedish pioneer of lobotomy, the psychiatrist, Dr Snorre Wohlfahrt, in collaboration with the neurosurgeon Olof Sjöqvist, reacted sharply to Dahlberg’s definition of lobotomy. These two professionals joined together in short but strong criticism of Professor Dahlberg’s crude description of the procedure that would soon become honored by the Nobel committee. It is conceivable that two lobotomists spoke out against a colleague who used sloppy language about what they regarded an established new method in medicine. But, it is less understandable why Professor Dahlberg chose to belittle lobotomy in the way he did.
This paper is aimed at an analysis of what might have been a kind of psychosurgery debate in Sweden hidden within some popular publications."

From Nobel Prize to worst ever idea in 57 years

At an event jointly organised by the Royal Institution and the Institute of Psychiatry last week in London, leucotomy was voted the worst ever idea from psychiatric history. Edgar Jones steered leucotomy to a narrow victory over post-trauma counselling. Psychoanalysis and drug company advertising were the other losing ideas. Thank you Professor Jones.

VNS in the Wall Street Journal

Last Tuesday's edition of the Wall Street Journal had an article by David Armstrong about the failure of medical journals to publish authors' conflicts of interests. It featured the case of the journal Neuropsychopharmacology which had failed to warn readers that eight of the nine authors of an enthusiastic review of VNS (vagal nerve stimulation) were consultants for Cyberonics, the company that manufactures the equipment. The ninth author was a paid employee of Cyberonics, a fact which was revealed in the article. The lead author, Charles Nemeroff, is also editor of Neuropsychopharmacology.

"Charles Nemeroff, one of the nation's most prominent psychiatrists, edits the journal Neuropsychopharmacology, which this month favorably reviewed a controversial new treatment for depression.

But Tuesday, the journal said it plans to publish a correction because it failed to cite the ties of the article's eight academic authors to the company that makes the treatment, including the article's lead author: Dr. Nemeroff.

The journal's nondisclosure of the financial ties of its own editor as well as those of the other authors highlights the failure of many respected medical journals to identify relationships between academic researchers and medical companies that may benefit from positive research reports. A spate of recent lapses is prompting calls for more journals to ban offending authors from publication. In addition, medical schools are being urged to regulate relationships between their researchers and industry more closely...." More

"A sinister little pamphlet"

"Days from a Different World" is the BBC world affairs editor John Simpson's memoir of his early childhood in post-war Britain. Simpson takes one day from each year between 1943 and 1951 and interweaves his own recollections with family events and stories from the newspapers of that day.

Wednesday 12th February 1947: it was the coldest winter since 1867. Johnny visits his grandmother in the snow. And the Board of Control publishes their report on leucotomy. Simpson writes:

"A sinister little pamphlet called "Pre-frontal Leucotomy in 1000 Cases" was published that day by the Stationery Office at a price of sixpence. Based on the theory that "[s]omething must be done in some mental illnesses to break the connexion between the patient's thoughts and his emotions", it examined the results in a wide variety of patients. When successful, it said, cutting the physical links between one part of the brain and the rest had enabled a third of the people whose cases were recorded to resume their everyday activities "without that emotional tension and preoccupation with hallucinations and phantasies which has hitherto handicapped them". Another third had shown signs of improvement, though not to the point where they could be discharged from hospital. And the rest? No details were available, except that 3 per cent of them had died. It showed, said one medical writer, that the operation was well worth while in carefully selected cases. Today, pre-frontal leucotomy would be regarded by many surgeons and psychiatrists as a quite unnecessary form of torture."

The Stockton lobotomies

Stockton State Hospital, originally called the California Asylum for the Insane, was built in the 1850s at Stockton, eighty miles east of San Francisco, and by 1950 housed over four thousand patients. It was the first state hospital in California to perform a lobotomy and between March 1947 and June 1954 a total of 232 patients were operated on.

Psychiatrist and historian Joel T Braslow studied the Stockton archives for the two chapters on lobotomy in his book (originally a PhD thesis) Mental Ills and Bodily Cures: psychiatric treatment in the first half of the twentieth century (Berkeley: University of California Press, 1997).

The patients operated on at Stockton ranged in age from 19 to 88. Nearly eighty per cent of them had the diagnosis of dementia praecox (schizophrenia). Eighty-five per cent were women, even though men with the diagnosis of dementia praecox outnumbered women at Stockton. And twelve of the thirteen people who underwent a second lobotomy were women. Typically the operation was performed on violent, disruptive and unco-operative women who were subjected to frequent restraint (although Braslow found no evidence that psychosurgery was used as punishment for a single violent act).

Braslow describes how the decision to operate was made at a special clinical case conference, the "lobotomy board", which would attended by the director of clinical services, the surgeon, the hospital superintendent and the patient’s ward physician. The patient would be interviewed and then dismissed so the doctors could discuss their case and decide their fate. The proceedings were recorded by a stenographer.

In order to comply with the law, doctors then had to seek permission to operate from the patient’s relative. Braslow quotes from the letter sent to relatives:

"All forms of medical and psychiatric treatment have not been of more than temporary benefit…. Unless a more drastic therapy is carried out, there will be little hope of any further improvement….the most advanced form of treatment that is now available….The treatment suggested is a delicate brain operation performed by a qualified neuro-surgeon, which involves cutting certain nerve pathways controlling the basic emotions. This is known technically as psychosurgery or prefrontal leucotomy…In selective cases, in which there is much emotional suffering, patients who have this operation may be relieved of prolonged mental anguish, with much improvement in their basic behaviour."

Braslow estimates the mortality rate due to psychosurgery at Stockton as about 12 per cent. And most of the survivors remained in hospital. “In fact” he writes, “ during the 1950s almost an equal percentage of lobotomy patients left the hospital dead as alive (21 % vs 23%).”

But the operation was considered a success if the patient became more manageable on the ward. Braslow notes:

"Stockton physicians transformed what now would be considered neurologic sequelae into measures of effectiveness, as the following discussion among three physicians suggests.
Dr Adams:…[before lobotomy] she was regressed an awful lot – she was in restraint most of the time, would spit at people and break things up.
Dr Toller: It leaves them all pretty flat and indifferent about things. It seems to be characteristic –
Dr Adams: There is not much animation any more.
Dr Batko: Maybe that is what cures them (from a Stockton clinical case conference in 1949)".

Four of the lobotomized women also had their clitoris removed. Braslow quotes from the case history of "Rose", a young woman who was admitted to Stockton in 1944, underwent a lobotomy five years later, then had her clitoris cauterized twice and finally had all her teeth removed as she bit people.

Braslow’s father, a surgeon, worked for a while at Camarillo State Hospital, California, in the 1950s and performed lobotomies. Braslow writes at the beginning of his book:

One of his favourite stories, perhaps because of his brush with fame, recounted Walter Freeman teaching him how to perform a transorbital lobotomy. With a certain amount of flair and drama he described the procedure: “One takes a thing that looks just like an ice-pick and positions it right above the eye. Using a hammer, the pick is pounded into the skull. Then ping!!! the bone breaks enough to let the ice pick slide easily into the patient’s brain. You then swing the pick back and forth, cutting the nerves that connect to the front of the brain. That’s it.”
For my father, this memory and its recitation reaffirmed his skills as a surgeon and his belief in himself as a healer; even in spite of lobotomy's infamous history, he tells the story with pride. For myself, the story was more ambiguous. On the one hand, I found myself wanting to identify with him as a physician, and, later on, my decision to become a doctor was motivated by a positive identification with him. On the other hand, the tale increasingly perplexed me; I wondered how my father's desire to heal coexisted with his performance of this seemingly mutilating operation. My book aimed at understanding this contradiction. In the very human and often tragic dramas in that story, I tried to give voice to both doctors and patients in order to comprehend the meaning of often seemingly incomprehensible acts.