Last week, as Kitty Dukakis (twenty-six year amphetamine habit from the age of twenty; then some problems with alcohol and depression; in recent years a few short courses of unilateral ECT) was promoting the book (Shock: the healing power of electroconvulsive therapy) she has written with journalist Larry Tye, an altogether darker story of ECT emerged from the Appellate Division of the Supreme Court of New York.
Simone D, a Spanish-speaking woman, has been a resident of Creedmore Psychiatric Hospital for twelve years. Over this period she has received several courses of ECT (a total of 148 treatments) under court order. One course in 1996 was stopped because of the damage it was doing, but the courts continued to authorize further treatments even though there appears to be little hope that Simone will ever recover sufficiently to leave hospital or be allowed to make her own decisions about treatment. On this occasion the court voted, by a three to two majority, not to allow an appeal against the latest permission to administer ECT. One of the two dissenting judges had this to say:

“Simone D. was first admitted to Creedmoor Psychiatric Center in 1994 and suffers from a severe depressive disorder. Since 1995, she has undergone, over her objection but pursuant to previous court orders, at least 148 ECT treatments. Prior efforts to help her with medication failed to improve her condition. After two unsuccessful applications in July and September 2005 for permission to administer ECT to Simone D., the petitioner applied again in November 2005. The petition and supporting papers showed that without ECT Simone D. becomes depressed, stops eating and drinking, and requires nasogastric tube feeding. Allegedly, the ECT will diminish her assaultive behavior, enable her to eat, enhance self-care, and promote her ability to socialize. At a hearing on the petition, the court rejected the request of Simone D.’s counsel that it appoint an independent psychiatrist. The petitioner called one of its psychiatrists, Dr. Ella Brodsky, who opined that Simone D. lacked the capacity to make a reasoned treatment decision and that ECT is the least restrictive alternative because there is no other choice…” Read more

Last Thursday, ABC’s Primetime broadcast a report about DBS (Deep Brain Stimulation) at the Cleveland Clinic, Ohio. It featured neurosurgeon Ali Rezai and his patient Cindy Warren, who will already be familiar to viewers of the Pittsburgh Channel and readers of The Plain Dealer. Also appearing were Florida neurosurgeon Kelly Foote and his patient “Kelly”.

Emotions Via Remote Control
However, generating emotions in the operating room is not the true test of this medical trial. That comes later, when Cindy and Kelly head to their psychiatrists’ offices to have the electrodes turned on in such a way that will, they hope, alleviate some of their symptoms. It means they will need permanent pacemakers to power the signals, too.
Using a handheld device that looks similar to a TV remote, Malone [psychiatrist Donald Malone] adjusts the voltage on Cindy’s pacemaker.
“I can actually get to the point where I feel like laughing. I feel kind of giddy, tingly,” she said.
Malone said he’s aware of the power he holds in his hands. “It’s humbling,” he said. “And scary.”
And, amazingly, it’s also a mystery as to why deep-brain stimulation works. But scientists theorize that the electrical currents emanating from the implanted wires scramble the old neural pathways that carried Cindy’s depressive thoughts and patterns. Read more…

Well, something at least has not changed much in seventy years of psychosurgery. Egas Moniz theorized in a very similar sort of way.

The Cleveland Clinic used to perform ablative psychosurgery until a patient successfully sued them four years ago:

Failure to obtain informed consent for experimental surgery
Verdict for a woman who suffered brain damage and a brain infection after undergoing brain surgery. She and her husband sued the hospital, alleging battery, fraud, and medical negligence. Among other things, plaintiffs claimed that the treating surgeon had performed a combined cingulotomy and capsulotomy-the latter a procedure that was unconsented to and experimental in nature. Plaintiffs were represented by *Robert F. Linton Jr., *Mark W. Ruf, and Stephen T. Keefe Jr., all of Cleveland, Ohio.
Zimmerman v. Cleveland Clinic Found., Ohio, Cuyahoga County C.C.P., No. 399411, June 12,2002.

Lobotomy came to Britain via the United States and in the early days most of the operations were of the Freeman-Watts standard type, where burr holes are made in the side of the temples, and an instrument inserted and pivoted up and down to slice through the white matter in the frontal lobes, thus severing the fronto-thalamic connections. British surgeons however didn’t adopt Freeman’s term “lobotomy”, preferring to use Moniz’ original term “leucotomy”.
British surgeons soon began experimenting with modified procedures in an attempt to find an operation that would do less damage than the standard Freeman-Watts standard prefrontal operations. In the 1940s Hugh Cairns in Oxford, for example, experimented with cingulotomy (an operation that is still used in Scotland) while the peripatetic Wylie McKissock devised the rostral leucotomy. But Freeman’s own particular modification, the transorbital lobotomy in which an instrument is inserted through the eye socket, never became popular in Britain perhaps because it dispensed with the need for a neurosurgeon and neurosurgeons in Britain had already gained control of psychosurgery. Wylie McKissock certainly wasn’t going to relinquish his profitable week-end excursions into the English and Welsh countryside: “Freeman’s latest development of transorbital leucotomy”, McKissock wrote, “is mentioned only to be condemned: the whole technique offends established aseptic surgical principles”. What is more, he questioned its effectiveness: “From the number of patients so leucotomised who have come to me for more extensive operations, the results do not appear very satisfactory.” Wylie McKissock’s own rostral leucotomy was designed to cut much the same area of white matter as the transorbital operation, but McKissock approached from above through burr holes in the top of the head, while Freeman approached from below via the eye socket, where the skull is thin enough for the instrument to be hammered through without the need for a drill or a neurosurgeon.
There were, however, a few psychiatrists in Britain who experimented with transorbital lobotomy. John Walsh at Tone Vale Hospital in Taunton, Somerset, operated on eight women in 1949, even on three occasions following Freeman’s example and using electroconvulsive shock as anaesthetic. On one of these occasions the operation was given as a demonstration at a meeting of the south-western division of the Royal Medico-Psychological Association. Walsh was disappointed with the results, finding “no definite clinical improvements” in any of the patients.
Meanwhile, in Napsbury Hospital near St Albans, Hertfordshire, more extensive experiments with transorbital lobotomy were being carried out by psychiatrist Alan Edwards. Napsbury was one of the three “Middlesex in Hertfordshire” county asylums, opened in 1905 to house the pauper lunatics of Middlesex, where suitable sites with sufficient grounds to provide inmates with work, exercise, and recreation were in short supply due to the urban nature of the county (Middlesex now forms part of London). During the first World War, Napsbury became a war hospital; poet and musician Ivor Gurney stayed there briefly. During the 1930s cat artist Louis Wain spent the last years of his life in Napsbury. The hospital closed in 1999.
Alan Edwards operated on seventy-one patients between February 1949 and February 1950, following the Freeman’s technique (although Edwards baulked at using electronvulsive shock as an anaesthetic, preferring intravenous pentothal). Edwards found that the operation was only one third as effective as a standard leucotomy, two-thirds when he adopted Freeman’s “full frontal sweep”.

A lobotomy (or leucotomy as it was called in Britain) wasn’t necessarily the last resort for patients in the 1940s. Doctors sometimes had other dangerous and bizarre treatments (as well as second or third leucotomies) in store for those who remained in hospital.
At Mapperley hospital in Nottingham, England, Paul Weil experimented with “regressive electroplexy” for the treatment of schizophrenia. Patients were given electroconvulsive treatments at half-hourly or hourly intervals (up to nine a day) on a daily basis until they were “in a state of complete confusion and utter apathy, mute, incontinent and unable to take food without assistance”. It took up to two weeks of treatment for patients to reach this state. Six of the eighteen patients subjected to this experimental treatment had already undergone leucotomy. One twenty-eight year old man who had had a leucotomy died three days after regressive electroplexy treatment. So did one of the patients who hadn’t had a leucotomy.
The surviving patients were described as somewhat more co-operative than before treatment but soon relapsed. Two who were discharged from hospital were readmitted within months. Paul Weil admitted that the results were “unfavourable” and decided not to repeat the experiment.

If you are within reach of Atlanta, Georgia, and are depressed (but not suicidal) and would like to have electrodes implanted in your brain then you could volunteer to be an experimental subject for Helen Mayberg and colleagues at Emory University.

“The purpose of the proposed study is to evaluate the safety, feasibility and efficacy of chronic, high frequency stimulation of the subgenual cingulate white matter (Cg25WM) using the ANS Totally Implantable Deep Brain Stimulation System as an adjunctive treatment for severe treatment-refractory Major Depression in twenty TRD patients, and to investigate potential mechanisms of action of this intervention.”

More details here…

This month’s edition of Scientific American Mind contains an article about Helen Mayberg and her experiments with Deep Brain Stimulation on depressed people. The article is called “Turning off depression” and can be read on the author’s website.

The tone of the article is enthusiastic, both about Professor Mayberg

“Eat dinner with Helen Mayberg, as I happily did, and you are treated not just to a good meal (for she appreciates good food as much as good ideas) but an infectious intellectual excitement. Lively of manner, with big eyes and a ready smile, Mayberg has a knack for stretching a meal while making the time pass quickly. At 50 she combines the enthusiasm of a freshly inspired grad student with the literate veteran’s appreciation of history.”

and about her experiments

“The results were stunning. Some patients felt profound relief as soon as [neurosurgeon] Lozano turned on the electrodes, and two-thirds returned to essentially normal mood and function within months. They saw better, thought better, felt better. They talked of walking amid flowers; of “the noise” stopping; of a horrid weight lifting. Side effects were almost negligible.”

We shall see.

If you happen to be in Leipzig, Germany, this month, why not go along to the Pierogi gallery where a video work by American artist Amy Patton can be seen.

“Amy Patton’s video work A Satisfied Mind leads us on a journey into an obscure narrative landscape. It is the product of work with three small excerpts of unrelated 16mm films found tangled together in a garbage bag in Austin, Texas. The three films, one showing early aviation disasters (c.1929), one discussing amnesia among psychosurgery and electro-shock therapy patients (ca. 1969), and one showing two children who take a ride on a greyhound bus (ca. 1966), were “hijacked”, so to speak, into a narrative framework of the artist’s design.”

In 1951 the Saturday Evening Post published a two-part article about lobotomy by Irving Wallace. The author’s original title of “They cut away his conscience” had been changed to the less controversial “The operation of last resort”.

The article tells the story of Princeton graduate “Larry Cassidy” who had had a breakdown when drafted into the army. Discharged six months later he returned home but continued to suffer from anxiety and depression. Psychoanalysis didn’t help; neither did insulin and electric shock treatment and Larry and his family, encouraged by some psychiatrists and discouraged by others, sought a lobotomy. The operation was carried out in 1947, five years after his original breakdown, by private doctors in Boston (who didn’t want to be named in the article).

Wallace describes the effect of the operation on Larry. At first it seemed successful - Larry appeared to have become more cheerful and even-tempered but it soon became apparent that he had no interest in anything and no concept of socially appropriate behaviour. His wife left him and his brother had him committed to a mental hospital. His brother Jack reflects: “Now he is dulled, no longer the person that they once knew. On the other hand, some of him is still that same person. And the rest of him is happier, and enjoys certain pleasures, and does not mind what he has become. Perhaps that is better than nothing”.

Wallace summarizes the controversy surrounding lobotomy:

“Thus, in the years since its inception, prefrontal lobotomy has been the center of a heated, worldwide controversy. The neuropsychiatrists who favor the operation can back up their stand with the fact that pre-frontal lobotomy prevents insanity and suicide and alleviates pain by reducing anxiety and removing worry….On the other hand, there is the school of thought that can prove, also from factual evidence, that prefrontal lobotomy converts patients into docile, inert, often useless drones, stripping them of their old powers, giving them convulsive seizures, making them indifferent to social amenities, filling them with aggressive misbehaviour, and impairing their foresight and insight. Then, there are those who feel the operation tampers with the God substance, who feel that if it cuts out a man’s cares, it also cuts out his soul and his conscience….Neither side in the disagreement is able to marshal adequately decisive statistics as evidence - although, currently, the Veterans Administration Psychiatric Division, which has performed 1,200 of these lobotomies, is in the process ofmaking a survey of the results. Their findings may, one day, help evaluate the operation’s merits and settle the controversy. But, while surveys may seem to show whether or not the results justify the attendant changes in personality, it is doubtful if statistics will ever actually be able to solve the human equation involved. For, in trying to determine, if an operation has been good or bad, what absolute measuring stick or standard can be used to judge? And from whose point of view can judgment be made? From the point of view of the patient? Or from the point of view of those around him? Or from the point of view of the doctor in the case?”

The story, under its original title “They cut away his conscience”, was included in Wallace’s 1966 collection “The Sunday Gentleman”. In a postcript to Wallace describes the response when the Saturday Evening Post published the article:

“Whereas an average article or essay might bring me a half-dozen letters from appreciative or critical readers, the travail of Larry Cassidy inspired a small mountain of mail. Much of the mail was congratulatory; readers were deeply moved. Some of the letters, from physicians and clergymen, questioned or discussed the wisdom of Larry’s psychosurgery. Other letters came from parents or relatives of mentally ailing persons, tragic, heartrending letters, asking for more factual information, inquiring for the real names and addresses of Dr Leon Goldsmith and Dr Raymond Rogers. The editors of the Saturday Evening advised me that the double-length feature had drawn a record amount of mail, and was, in this respect, among the two or three most provocative stories they had published in a decade.”

And there is an update on what had happened to Larry in the intervening years. He had discharged himself from hospital and returned to New York where a his old college room-mate found him a small apartment. A series of unskilled jobs never lasted more than a few days due to his eccentric behaviour and inability to concentrate. Larry eventually married again and survived on a his veteran’s pension, spending his days reading, watching TV and fruitlessly looking for a job.

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.”

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.