Monday, January 21, 2008

American Experience

It has been some time since I posted to this blog or updated this site. Frankly I had to turn away for a while - it was too hard to keep it up. But tonight something is happening. My family, along with Howard Dully, are being featured on PBS's American Experience. Here is a clip of my aunt and mother:

http://www.pbs.org/wgbh/amex/lobotomist/stories/jones_qry.html

This has been a long time in coming. Howard Dully has a book out called "My Lobotomy". My family has had the chance to honor my grandmother Beulah Jones and make her story known to the world. I have accomplished what I set out to do. Beulah did not die forgotten.

I will post again after the show.

More than anything I am honored, incredibly honored and humbled, to have our family and Beulah's story remembered as an integral part of American history.

Wednesday, December 06, 2006

Edith and the Rampton leucotomies

In May 1938 sixteen-year-old Edith Haithwaite was up before the magistrates in Ripon, Yorkshire, on a charge of larceny. Edith admitted to the crime and was bound over for twelve months. Within a couple of months she had broken the conditions of her bond by associating with "a certain person". So she was up before the magistrates again and this time the punishment was harsher. Edith was remanded to an approved school. Evidently she didn't settle at the approved school because a couple of months later the magistrates were again considering her case. This time they committed her to an institution as a mental defective. She was to spend the next eighteen years incarcerated for her crime of larceny. And during that incarceration she underwent a leucotomy.
Mental defectives had a relatively brief existence in Britain. They were created by the Mental Deficiency Act of 1913 and abolished by the Mental Health Act of 1959. They were divided into three different categories: the "imbeciles" and "idiots" who would nowadays be considered to have a learning disability and the more nebulous group of "feeble-minded". The latter included people of average intelligence who had somehow fallen by the wayside, the "socially inefficient" as they were called in those days. They often arrived at their diagnosis of mental deficiency via extreme childhood adversity and institutional care or, like Edith, the courts.
In 1920 there were about 10,000 mental defectives in institutions in England and Wales; by 1946 that number had grown to nearly 60,000 with a further 43,000 under statutory supervision in the community. There were two State Institutions for "violent and dangerous" mental defectives: Rampton near Nottingham and Moss Side near Liverpool. Usually the inmates of Rampton and Moss Side had been transferred from other mental deficiency institutions and the violence and danger often consisted of self-harm, suicide attempts or window smashing. It was in Rampton that Edith ended up.
In 1927 the Mental Deficiency Act, which applied only to those in whom a defect was supposed to have been present since birth, was amended to include post-encephalitics, survivors of the encephalitis lethargica pandemic who were sometimes left with destructive and anti-social tendencies as a result of the illness.
Mental Deficiency legislation had originally received support from politicians of all parties (Liberal MP Josiah Wedgewood - the "last of the radicals" - was a notable opponent of the Act) as it was seen as a more humane alternative to incarceration in lunatic asylums, workhouses or prisons. But by the 1940s there was widespread concern about the numbers of people being held under the Act and the National Council for Civil Liberties led a campaign which exposed abuses of the Act and accused authorities of using the inmates of mental deficiency institutions as a source of cheap labour. One teenage girl featured in the NCCL's campaign had been found to be working ten-hour days in an institution's laundry and kitchen for a shilling a week, most of which was taken back to pay for a sweet ration.
George W Mackay, the Medical Superindent of Rampton, together with Sheffield neurosurgeon James Hardman introduced leucotomy into the institution in 1947. Within little more than a year twenty operations had been carried out and George Mackay had written an article for the Journal of Mental Science entitled "Leucotomy in the treatment of psychopathic feeble-minded patients in a state mental deficiency institution". The diagnosis of psychopathic in those days was given to patients who self-harmed and smashed things. Typical was AVT, a young man who had been admitted to Rampton at the age of 13 from a children's institution after two suicide attempts. An very good chess player, his only crimes were to have violent outbursts in which he smashed crockery and to be "given to homosexual practices". Following leucotomy at the age of 23 he was employed in the ward pantry and was able to look after crockery without smashing it, putting him in the "markedly improved or recovered" category. Young women could earn the label of psychopathic by showing "emotional instability" or "moral deficiency". Of the first twenty patients operated on, two had epilepsy and five were post-encephalitics. One patient was just fourteen years old and had been admitted to Rampton aged nine. Mackay was pleased with the results in this girl, saying "from being a depraved and hopeless little animal she is now quite a sociable, clean child." She had also gained a lot of weight and "would go on eating indefinitely if not stopped". One patient died and five were unchanged or worse but Mackay was not deterred and ended his article by expressing his intention to operate on "a wider group of clinical types".
Edith had agreed to a leucotomy because she had been told that it would lead to her release. It didn't. Instead it was her sister's writ of habeas corpus which finally led to her freedom when the High Court decided that her eighteen-year detention as a mental defective had been illegal as the Ripon magistrates had overstepped their authority.

Thursday, November 23, 2006

"A commendable act of humility"

John Sutherland writing in the British newspaper The Independent last month:
"We should be humble in assuming that our therapies, whatever stage scientific knowledge may have reached, can do what we think they can do. It is to me strange, for example, that Stockholm has never seen fit to withdraw, retroactively, the Nobel Prize it awarded Egas Moniz, in 1949. Moniz invented prefrontal lobotomy. He was, the committee said, "a wonderful man". Many, then, might have agreed. Now, few would.
The operation, which involved scooping lumps out of the brain, as if it were ice-cream, was subsequently popularised in the US by Walter Freeman who trundled round in his "lobotomobile", demonstrating his "ice pick and hammer technique" to any hospital that would let him in, and knocking off 10 ops a day in hotel rooms. Nothing could stop his campaign to make America mentally "healthier".
It would be a commendable act of humility, and an admission that mental health is difficult to define and fiendishly difficult to manufacture, were Stockholm to respectfully rescind that award to Moniz." (more...)

Saturday, November 18, 2006

Harvey Jackson deals with his conscience

In an article about Egas Moniz, author João Sodré criticised Portuguese psychiatrists who try to justify leucotomy with claims that it is more humane than ECT. They are not the only ones. British neurosurgeon Harvey Jackson describes in 1954 how he overcame his doubts about leucotomies:
"When originally I undertook to perform leucotomy it was not without a feeling rather of reproach, for mutilation no doubt it must be. However I first of all went to watch my psychiatrist colleagues applying chemical or electric convulsive therapy - so disturbing was the exhibition at the time that thereupon I decided that the surgical approach was probably a less traumatic measure."
And American neurosurgeon William Beecher Scoville felt that psychosurgery "is preferred to shock treatment in those depressions requiring more than short courses of shock treatment because of less emotional blunting, memory loss and relapses."

Tuesday, November 14, 2006

News from Portugal

The Portuguese radio and TV station, RTP, is running a poll to find the greatest ever Portuguese. In January there will be a programme featuring the ninety people who collected the most votes and the ten finalists will be announced - each will have their own documentary. Egas Moniz is of course amongst those nominated. A Portuguese doctor defends Moniz's Nobel Prize on the RTP website; whilst acknowledging that leucotomy could be damaging he points out that Nobel Prizes are awarded not for therapeutics but for the advancement of knowledge. Nobel Prizes for medicine and physiology are indeed usually won in the laboratory - neither of this year's winners (Andrew Z Fire and Craig C Mello) are doctors of medicine. They are awarded for discoveries and Moniz's prize was awarded for "the discovery of the therapeutic value of leucotomy" and so the therapeutic value, or lack of it, is relevant. And how exactly, in any case, was leucotomy supposed to have advanced our knowledge of either the frontal lobes or mental illness?
Another Portuguese website, Portuguese lives, has an interesting biography of Egas Moniz with quite a few illustrations. The author, João Sodré, says that Egas Moniz is not held in high regard by the people of Portugal; the friends, taxi drivers, bartenders, coffee-drinkers and passers-by he spoke to all expressed a negative opinion of the Nobel Prize winner (let's hope they have been voting). Sodré criticises Portuguese psychiatrists for defending leucotomy as a more humane treatment than ECT and wonders how far leucotomy would have got if its inventor had followed Bazett-Haldane principles of not subjecting others to medical experimentation that you wouldn't want to be subjected to yourself. Finally he tackles a popular myth about Egas Moniz - that he was murdered by a patient. He was injured but survived. It was another well-known Portuguese psychiatrist, Miguel Bombarda, who was killed by a patient.

Tuesday, October 31, 2006

"An impetus for revival"

Some of the big names of psychosurgery in the USA and Belgium are out in force in the October issue of the journal Neurosurgery. Neurosurgeons Ali Rezai (Cleveland Clinic), Bart Nuttin (Catholic University of Leuven), Chris Heller and Michael Apuzzo (University of Southern California), and Arun Amar and Charles Lui (Yale University) are joined by psychiatrist Benjamin Greenberg (Butler Hospital/Brown University) and medical ethicist Joseph Fins (Cornell University) to write an editorial and two articles.
I haven't read the articles yet, but the abstract of one, "Surgery of the mind and mood: a mosaic of issues in time and evolution" by the Yale and University of Southern California authors, sounds worrying enough:
"The prevalence and economic burden of neuropsychiatric disease are enormous. The surgical treatment of these psychiatric disorders, although potentially valuable, remains one of the most controversial subjects in medicine, as its concept and potential reality raises thorny issues of moral, ethical, and socioeconomic consequence.
This article traces the roots of concept and surgical efforts in this turbulent area from prehistory to the 21st century. The details of the late 19th and 20th century evolution of approaches to the problem of intractable psychiatric diseases with scrutiny of the persona and contributions of the key individuals Gottlieb Burckhardt, John Fulton, Egas Moniz, Walter Freeman, James Watts, and William Scoville are presented as a foundation for the later, more logically refined approaches of Lars Leksell, Peter Lindstrom, Geoffrey Knight, Jean Talaraich, and Desmond Kelly. These refinements, characterized by progressive minimalism and founded on a better comprehension of underlying pathways of normal function and disease states, have been further explored with recent advances in imaging, which have allowed the emergence of less invasive and technology driven non-ablative surgical directives toward these problematical disorders of mind and mood.
The application of therapies based on imaging comprehension of pathway and relay abnormalities, along with explorations of the notion of surgical minimalism, promise to serve as an impetus for revival of an active surgical effort in this key global health and socioeconomic problem.
Eventual coupling of cellular and molecular biology and nanotechnology with surgical enterprise is on the horizon."

Friday, October 27, 2006

"The new lobotomy?"

Today's cover story at the The Tyee is "The new lobotomy?", an article by Canadian journalist Danielle Egan. The article takes a much more interesting and critical look at DBS (deep brain stimulation) than most articles on the subject do.
"Eights months ago, surgeons drilled two holes into the skull of a wide-awake Vancouver man and inserted spaghetti-sized electrical wires down through the two sides of his frontal lobes. They left behind a remote control brain pacemaker, which regularly shocks his brain with three volts of electricity, 24 hours a day, seven days a week, powered by a battery pack that sits on his neck. The device is meant to treat his severe depression. It's part of a controversial clinical trial of a procedure called deep brain stimulation (DBS) that's jointly run by UBC and VGH, and being partly funded by B.C. health care.

As part of the trial, which is co-sponsored by a Texas-based medical device manufacturer, researchers will also implant five other British Columbia patients through a multi-centre trial also happening in Toronto and Montreal. DBS is also being tested at centres all over the globe, as a treatment for obsessive-compulsive disorder, anxiety, eating disorders, addictions and even violent behaviour. But emerging data on this new technology is raising questions about the effectiveness of the procedure, the link between health care and profits, and the ethics of quick-fix psychological treatments....

It's the same physiological rationale used to describe lobotomies and their modern counterparts, known as psychiatric neurosurgeries, which are said to be making a comeback at select centres round the globe, including a UBC program started in 2000. DBS is being held up as a good alternative to psychiatric neurosurgeries, because it doesn't involve permanently destroying pieces of the brain, and because the device can be turned off." (more...)

"And sometimes not"

In his book about Henry Cotton (Madhouse: A Tragic Tale of Megalomania and Modern Medicine)Professor of Sociology and Science Studies Andrew Scull muses on the trust we place in psychiatrists:
"As members of a healing profession that likes to trace its lineage back at least as far as classical Greece and the fabled Hippocrates, physicians pronounce themselves the guardians of our physical welfare - and, in the case of that subordinate branch once called by the derisive term of "mad-doctors" and now preferring to own to the title "psychiatrist", our mental welfare as well. Like all of those who make the most well-founded and broadly socially accepted claim to the title of professional, medical men (and these days medical women) operate in an arena where the ordinary disciplines of the marketplace seem to fail, or to perform poorly. As lay people, we lack access to their specialized knowledge and expertise, even though the content of their cognitive world may be quite literally of life and death importance to us. In a poor position to second guess their expert judgments or even, in many instances, to grasp the foundations on which their diagnoses and prescriptions are based, and ill-equipped to assess the quality of the care we are about to receive, we are perforce at their mercy. Elaborate social rituals persuade us to grant these strangers our trust, and reassure us that they are motivated, not by the self-interest of the marketplace - the hidden hand that allegedly guides so much of civil society - but by a higher ethical standard, a genuine concern for our well-being and survival and a willingness to subordinate their interests to ours. And so it sometimes proves.
And sometimes not." (Madhouse: A Tragic Tale of Megalomania and Modern Medicine.Yale University Press, page 276)

The author has this to say about psychosurgery: "Lobotomy, in my judgment, even by the standards of the 1940s ought ultimately to be seen as indefensible, as a number of informed and perspicacious critics argued at the time. But a proper examination of that issue is a debate place and another time." (page 285)

I hopefully asked Professor Scull if he was thinking of writing a book about the history of psychosurgery but sadly it is not on his list of things to do in the immediate future.

Thursday, October 12, 2006

Sir Wylie McKissock, Part II: the patients

Wylie McKissock’s patients came from all walks of life, from doctors and nurses to rag and bone men and domestic servants. They ran the gamut of psychiatric diagnoses from schizophrenia and affective psychosis to neurosis and personality disorder. (A few had no psychiatric diagnosis and were operated on for the relief of pain or tinnitus.) Some had been incarcerated for years, some had never been in a mental hospital. In age they ranged from teens to seventies.
Many were – one way or another – casualties of war: a veteran of the Normandy campaign, physically and mentally injured in the front line; an elderly woman bombed out of her home who found it difficult to settle in a new area; a nursing sister who broke down under the stress of trying to protect her patients from enemy bombardment; a widow unable to cope when her son was posted overseas; a blind man who became obsessive about switching off lights after being prosecuted for contravening blackout regulations; a prostitute who was arrested and certified after being found sleeping on War Department land.
Some patients, especially those with a diagnosis of schizophrenia or mental deficiency, were leucotomised in the hope not so much of a cure and return to life outside an institution, but in an attempt to render them less of a management problem within the institution. “The patient who showed great improvement” wrote Dr Cook of Bexley Hospital, Kent, where by 1943 McKissock had leucotomised 13 violent schizophrenic patients (one died), “was a typical example of the use of leucotomy in chronic schizophrenia. The patient was by far the most violent, animal-like catatonic whom even the most senior nurses in the hospital could remember, and after twelve years of “unapproachableness” she had for over a year been up and about, playing the piano, knitting and doing embroidery. She was still as mentally ill as she ever was, but the nursing relief was very great and she was much happier”.
But psychiatrists at St Lawrence’s Hospital, Caterham, were less impressed with the results on their mental defectives and decided to put an end to the visits of McKissock and his assistant McColl after 5 of 43 leucotomy patients (nearly all under the age of forty) died and others suffered mental deterioration or epilepsy.
It was this particular use of leucotomy – to control the behaviour of institutionalised patients – that was curtailed by the discovery of new drugs in the 1950s. McKissock himself noticed that by 1958 there had been “a marked diminution in the number of deteriorated schizophrenics offered for surgery although a number of dangerous or disturbed patients are still referred and can often be adequately sedated by a standard prefrontal operation”, but he doesn’t appear to have made the connection with the introduction of major tranquillisers. In fact, he generally showed little interest in psychiatry or indeed in the fate of his own psychiatric patients.
Women outnumbered men by three to two amongst those leucotomised by McKissock and, although they were found in all diagnostic categories, they especially dominated the depressed group. Many had unhappy marriages and a few appreciative words from their husband post-leucotomy could catapult them into the recovered category (“he rather likes the severe frontal lobe deficit syndrome” or “Barbara is undoubtedly a much pleasanter companion to live with”). Their misfortune was to fall into the hands of psychiatrists before the advent not of a new drug but of a means of escape via easier divorce and more financial independence for women

Saturday, September 30, 2006

Sir Wylie McKissock

Part I: the surgeon

By the late 1950s an estimated 20,000 leucotomies had been carried out in Britain. A few were performed by general surgeons, a few by psychiatrists, but the vast majority were performed by neurosurgeons. And of these neurosurgeons Sir Wylie McKissock (1906-1994) was probably the most prolific, responsible for at least 3,000 leucotomies.
McKissock, who in spite of his Scottish name hailed from Staines in Surrey, is remembered for his achievements in neurosurgery including the treatment of head injuries (he received an OBE for his wartime work) and the treatment of subarachnoid haemorrhages and intracranial aneurysms; and for setting up the world-famous Atkinson Morley's neurological service. He became President of the Society of British Neurosurgeons and received a knighthood on his retirement in 1971. But his contributions to British psychosurgery seem to have been quietly forgotten.
When McKissock died in 1994, obituaries in the The Times and The Independent newspapers made no mention of psychosurgery. Other tributes were likewise reticent on the subject. For example, psychosurgery was entirely absent from an 800 word article in the Journal of Surgical Neurology in 1988 even though the author Alan Richardson was himself a practitioner of psychosurgery, and a ten page reminiscence in the British Journal of Neurosurgery two years after McKissock's death containes only the following brief reference to psychosurgery:
"His links to psychiatry were related to his large practice in the 1940s and 1950s as a leucotomist of extraordinary surgical speed, associated with a peripatetic service visiting major institutions in the UK in his motor car with the instrument set in the boot".
These expeditions in his motor car took McKissock all over the South of England and Wales; among his destinations were St Andrews in Northampton, Graylingwell in Chichester, St Lawrence's in Caterham, Pen-y-Val in Abergavenny. The institutions (many of them Victorian Asylums) were often situated in pleasant rural locations and in those days the roads were comparatively empty. A visit from a well-known neurosurgeon would have been quite an event and doubtless the red carpet was laid out for McKissock. The operations themselves were quickly done - 15 to 30 minutes each - and so all-in-all these excursions must have been a reasonably agreeable way for McKissock to supplement his income.
Why did McKissock travel round the country rather than having the patients brought to his neurosurgical unit? In the early days of psychosurgery he claimed it was "owing to the extremely unpleasant and dangerous habits of the unfortunates who have been submitted to me for operation, and to the lack of proper facilities for dealing with the habits of such patients in my own neurosurgical unit." By the 1950s he had become more circumspect, claiming instead it was out of consideration for patients who could be treated in familiar surroundings and receive visits from relatives.
McKissock doesn't seem to have troubled himself much over the ethics of psychosurgery, although his excursions sometimes resulted in death or disability (some patients were left in what McKissock himself described as a "harmless vegetable state"). What little he wrote on the subject of psychosurgery is largely confined to notes on technique. He admitted that the operation was "academically and scientifically unsound" but felt it was justified if the "experienced psychiatrists" who selected patients felt there was no chance of a cure with other methods of treatment or a spontaneous recovery.
In the early years of his career as a psychosurgeon McKissock used the standard Freeman-Watts technique of leucotomy, drilling two burr holes in the side of his patients' skulls and severing the connections to the frontal lobes. He was scornful of specially designed leucotomes, referring to John Crumbie's as a "mechanical egg-whisk" and preferring to operate with an ordinary brain needle. In the late 1940s, as psychosurgeons were experimenting with different techniques in an attempt to avoid some of the complications and devastating effects on personality associated with the standard leucotomy, McKissock devised the "rostral leucotomy" in which holes were drilled in the top of the skull and the cut made in a downwards direction, undercutting Brodmann's areas 9 and 10 of the frontal cortex. Neuropathologists commented that the resulting lesion was similar to that of Freeman's transorbital leucotomy although McKissock approached from the opposite direction to Freeman. McKissock had little time for Freeman's transorbital operation, considering it an offence against "established aseptic surgical principles". The rostral leucotomy did not however entirely replace the standard procedure; even at the end of the 1950s McKissock was still using the standard technique on a minority of patients.
The last sighting of McKissock in the literature is an appearance at the November 1958 meeting of the Neurological Section of the Royal Society of Medicine where he talked about having performed 125 rostral and 19 standard leucotomies the previous year.

Thursday, September 28, 2006

The dark side of the healing volt

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

Friday, September 15, 2006

Primetime DBS

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.

Saturday, September 09, 2006

The Napsbury lobotomies

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".

Saturday, August 26, 2006

After leucotomy

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.

Helen Mayberg wants guinea pigs

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...

Friday, August 18, 2006

"Walking amid flowers"

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.

Tuesday, August 08, 2006

"A Satisfied Mind"

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."

Friday, August 04, 2006

"They cut away his conscience"

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.

Tuesday, July 25, 2006

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."

Saturday, July 22, 2006

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

Monday, July 17, 2006

"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."

Thursday, July 13, 2006

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.

Thursday, June 29, 2006

Walter Freeman describes his technique




In July 1948 American psychosurgeon Walter Freeman visited the Burden Neurological Institute in Bristol, England, and delivered a lecture on transorbital lobotomy. The paper was published in The Lancet later that year. In this extract he describes his surgical technique.
"We have found that transorbital leucotomy* can be performed satisfactorily in the postconvulsive phase of electro-shock. Electro-shock appears to have a generally disrupting effect on cortical activity, temporarily abolishing the psychotic manifestations and bringing the patient into a brief period of increased adaptability. When leucotomy is also performed, the effects of the electro-shock seem to be at least protracted, and often permanent. A few operations under ordinary anaesthesia have been performed by others, however, and equivalent results are reported. Nevertheless, electro-shock requires so little preparation and is so familiar to the psychiatrist that it seems to be the method of choice.

To maintain the patient in a somewhat prolonged phase of coma, two convulsive doses of electricity are given, the second about one or two minutes after the first convulsion has subsided. After the second convulsion a towel is placed over the patient's nose and mouth to prevent contamination by saliva and nasal secretions. The upper eyelid of the patient is pinched between thumb and finger, bringing it away from the eyeball. The point of the transorbital leucotome is then introduced into the conjunctival sac and moved around against the roof of the orbit until the top of the vault is encountered. The leucotome is brought parallel with the bony ridge of the nose, and its base is tapped lightly with a hammer to drive it through the orbital plate. To aim the leucotome properly the shaft must press rather strongly on the eyeball, but no harm to the globe has been noted except for occasional subscleral haemorrhage.

The transorbital leucotome consists of a tool-steel shaft 12 cm. long and 4 mm. in diameter, tapering for the last 6 cm. to a rather fine point with a slight bevel. Its handle is 7 cm. long and 8 mm. in diameter and equipped with a cross-arm at the base. The shaft is graduated in centimetres, a double line being marked at 7 cm. which is the most frequently used point.

When the leucotome has reached the 4 cm. level, its handle is pushed laterally as far as the margins of the orbit will permit to sever the fibres in the lower portion of the thalamofrontal radiation. It is again returned to mid-position and gently driven to a depth of 7 cm. always in the plane of the bony ridge of the nose. At this depth it is possible, by swinging too far, to lacerate arteries in the depth of fissures on either the medial or the lateral surface of the frontal lobe; and, since the thalamofrontal radiation is a rather narrow band in the region, a movement of only 15-20 degrees laterally and medially is sufficient. When the sweeps of the instrument have been made, it is withdrawn, and moderate pressure is maintained over the eyelids for several minutes to prevent excessive bleeding into the orbit.

Unless the patient is still deeply unconscious, an additional electroconvulsive shock should be administered before the other side is operated on. Patients seem to tolerate multiple convulsions quite well. In view of the refractory period, it is usually necessary to increase the time of passage of the electric current by repeated tripping of the switch until the convulsive threshold is reached. No complications have been encountered in doing this. After the convulsion has subsided, the other side is operated on in the same way." (W Freeman, Transorbital leucotomy, The Lancet, 4 September 1948, 371-373)

Although Freeman had coined the term "lobotomy" some years previously, he (or perhaps the editors of The Lancet) reverted to Moniz's term leucotomy for a British audience.

Saturday, June 17, 2006

Monkeys like Becky

The Catalan Culture in New York festival earlier this year included a showing of Joaquim Jordà and Núria Villazán's 1999 film "Monos como Becky" ("Monkeys like Becky"):
"One of the mainstays of the Barcelona School of the 60s, Joaquim Jordà later turned his talents to screenwriting before returning to direction in the 90s. Monkeys Like Becky shows his old subversive spirit still shines brightly. One of the oddest mixtures of reality and fiction recently seen, the film is based on the true story of the Nobel Prize winning Portuguese neurologist Egaz Moniz. In the early 30s, Moniz attended a conference in London in which an American biologist presented a docile, rather charming monkey named Becky; the biologist then showed a film in which Becky was shown to have been formerly a wild, savage beast. The transformation was said to be caused by an incision into the central lobe of the Becky's brain. It dawns on Moniz that such a procedure might prove effective with schizophrenics, and thus the practice of mental lobotomies was born. Using both staged sequences and documentary footage, Jordà and Villazán wryly capture the intersection of science, psychiatry and social control."

The All Movie Guide entry for "Monkeys like Becky" says that director Joaquim Jordà himself underwent a psychosurgical operation. Other reviews say the same about Jôao Maria Pinto, the actor who plays Egas Moniz and one review says that they both had lobotomies, so I don't know what to believe.

Physiologist John Farquar Fulton who, along with psychologist Carlyle Jacobsen, conducted the experiments on Becky claimed to have been the inspiration behind Egas Moniz' decision to operate on mental patients. Here he relates his account in the Alpha Omega Alpha lecture read at the Montreal Neurological Institute, 8 January 1948:
"The operation of frontal lobotomy was introduced as a result of a brief report made at the International Neurological Congress at London in 1935 by Carlyle Jacobsen and myself on behavioral changes which developed in two of our chimpanzees, Becky and Lucy, following bilateral ablation of the frontal association areas. Their story can be briefly told.
In the summer of 1933 we had word from Dr Perrin Long of Johns Hopkins that he wished to dispose of two tame chimpanzees which had been used for the common cold project. He said that they were both accustomed to human beings, having been brought up in the laboratory since their early infancy. The opportunity to use these animals for frontal lobe studies seemed ideal for they could be readily managed. One was a very affectionate animal (Becky) and the other a crotchety old maid who had resisted Dr Long's advances for some three years. Dr Carlyle Jacobsen, who at that time was developing training techniques for a study of the frontal lobe function, took the two animals for a period of intensive training which continued from October, 1933 to March, 1934. The chimpanzees proved ideal subjects, co-operating effectively in all of the training procedures which consited of the delayed-reaction test, problem boxes, and another, more involved, procedure known as the stick-and-platform problem that Dr Malmo has no doubt described to you.
Both animals were operated upon in March, 1934, within a few days of one another, one frontal area being removed in each instance (areas 9, 10, 11, and 12 in the Brodmann scheme). The animals were then tested for another trhee months but no sign of deficit or behavioral change could be detected. In June, the second frontal area was removed from each animal, again within a day or two of one another, and every effort was made to have the lesions both symmetrical and equivalent for each animal. Following this procedure there was no sign of reflex change in either animal and on superficial inspection their cage behaviour did not seem to have altered particularly. On closer scrutiny, however, it was evident that a profound change had occurred, for prior to the second operation both animals showed frustrational behaviour, i.e., when unrewarded after having made the wrong choice in the discrimination test or in the delayed re-action procedure, both animals had temper tantrums and, if unrewarded many times in succession, signs of experimental neurosis became apparent. Following the second operation the animals seemed devoid of emotional expression. If a wrong choice were made, the animal shrugged its shoulders and went on dooing something else - as Jacobsen said picturesquely: "It was as if the animal had joined the happiness cult of the Elder Micheaux and placed its burdens on the Lord." Animals with bilateral ablation also failed the double stick-and-platform test....
Following the paper in which the behavioral changes in our two chimpanzees were described at London in August of 1935, Dr Egaz Moniz of Lisbon arose and put the question that if frontal lobe removal prevents the development of experimental neuroses in animals and eliminates frustrational behaviour, why would it not be feasible to relieve anxiety states in man by surgical means? At the time I was a little startled by the suggestion for I had envisaged a bilateral lobectomy which, though possible, would be a very formidable undertaking in a human being. Dr Moniz, as you are well aware, had other ideas and within a year he had developed his leucotome, carried out leucotomies on some 50 cases and published a book on the subject."

Egas Moniz himself however downplayed the contribution of Becky and Lucy to the development of psychosurgery. In his 1956 account, "How I succeeded in performing the prefrontal leukotomy", he devotes only seven lines to the work of Fulton and Jacobsen in the midst of a wider discussion of experiments on animals and the results of damage to the frontal lobes in humans. There is no mention of the conference in London.

Friday, June 09, 2006

"Vegetables don't cry"

Psychiatrist Eileen Walkenstein describes a lobotomy she witnessed in 1949:

Yes, sadism in medicine and neurosurgery and psychiatry is, alas, still rearing its ugly head and destroying human heads in its wake.
My own introduction to modern neurosurgery occurred in my second or third year in edical school - occurred, literally, in one fell swoop, cutting its way into my own brain and leaving the scar even now, some twenty years later.
I refer to the transorbital lobotomy, otherwise known as the ice pick operation. Techniques of this wounding were perfected to such a degree that all that was required was an ice pick-like instrument - no sutures, no bandages - internal bleeding and destruction of nerve pathways and irrevocable death of brain cells with just a thrust of the ice pick... and all that's evident on the outside are two black eyes - that clear up in time - and memory loss - that doesn't clear up so well... and a state of docile vegetation - that goes on forever. With a flick of the wrist the animal gets changed into a plant - modern alchemy!
My medical school class was invited to see a demonstration of such a transorbital lobotomy, one of the several type of lobotomies. The neurosurgeon, on the staff of a university medical school, stood before the class strutting in a sedate, self-important manner. I remember how good looking and smooth he appeared, a typical Hollywood symbol of the handsome doctor whose patients go ga-ga over him... and how entirely devoid of character he was. He was meticulously groomed, hair perfectly in place, skin very white and smooth shaven - a perfect representative of White Anglo-Saxon America. He wore a suit and tie and looked as if he were addressing a businessmen's luncheon meeting of the Kiwanis Club. After some introductory remarks he opened the door and the nurse and orderly pushed a stretcher into the room. Walking in with them was an attractive young black man, eighteen years old, looking frightened and bewildered. The neurosurgeon paid no attention to him but continued discussing with us how the operation would be conducted, and he seemed proud of the fact that they didn't even need anesthesia for the operation - that knocking the patient out with "a couple of electric shock treatments would be adequate anesthetization". (I guess when you're contemplating slashing up the brain substance, a little cell damage more or less is not too relevant.)
The young black man in wrinkled hospital garb stood cowering in the corner in sharp contrast with the urbane, smooth, self-possessed, polished physician. Finally the doctor turned to the patient, mentioned his diagnosis... Schizophrenic Reaction...and that he was a recent hospital admission... and told him to get up on the stretcher. The young man backed up, his shoulders hunched like a scared cat being attacked by a growling bulldog, his eyes darting this way and that in a futile attempt to seek some way of escape from the inevitable. The nurse and orderly then held his arms, brought him to the stretcher, and somehow managed to get him to lie down on it, shackling his wrists and ankles. The doctor applied the electrodes to the young man's temples, the current was turned on, and the young man's body jerked convulsively for several seconds. The doctor said smoothly, as though nothing had just happened, that he thought he'd give another dose of electric current to be sure he's knocked out completely. Again the current was turned on, again the captured victim was convulsively responding with his entire body to the electricity searing through his brain cells.
(This patient - if he were not poor, not black, not welfare-experimental-animal material - what treatment would then have been meted out to him?... need one ask such an obvious question? What treatment for this young black man had he been in the doctor's own family, for instance? This is the criterion. If you treat me, no matter who I am, in any way different from the way you would treat your family members and colleagues and peers, then you don't deserve to be in a service profession - get out and get into business! In business you treat everyone with equal contempt, independent of their blood realtionship to you - business is business. So get out of the service and helping professions, you doctors, educators, priests, et al. who would dehumanize us - get into the material world - unadulteratedly corrupt - and practice your corruptions on my pocketbook but not of my flesh, my intellect, my spirit!)
I find it very difficult to get back and face that patient who has just had his second electroconvulsive assault. Since leaving him there I have just now busied myself with phone calls, checking my calendar, eating a homemade milk-and-honey popsicle, and just plain vacating for a while. The subsequent scene is so horrible not only in itself but in all its ramifications that I've been avoiding delving in and confronting it.
Well, back again - that patient was, after the second electric shock, completely limp and "anesthetized". (I have never, neither before nor since tha incident, heard of using electricity for anesthesia!) The surgeon then took an instrument from his pocket in a pointedly and overly nonchalant manner and showed the ice-pick-like tool to the class. He then lifted one eyelid of the patient's an stuck the pick up - he made a point of showing that he was having some trouble getting the pick through the skull and into the brain at the first try and he grimaced at the class and said something about the "thickness of the boy's skull". A few of the more obvious racists in the class gave him his anticipated reply by snickering - some of the students, already uncomfortable, had their discomfort increased at this remark. After the pick penetrated the skull, he flicked his wrist back and forth with the pick slashing into the brain substance, severing forever, in an instant, those connections that nature had labored to achieve over millions of years. The Brain-Killer, named Neurosurgeon, repeated the ceremony via the patient's other eye socket.
I was not the only one who gasped at the outrage I had just witnessed. One girl, Dottie, her head probably full of the sterile operative techniques with sterilization of instruments we'd been taught to observe prior to and during the operation, raised her hand and asked about using an unsterilized instrument, to which the surgeon retorted with a pretty-boy smile: "Well, I didn't wipe it on my bootstrap."
Who was there to raise the bigger question - by what right had this surgeon, knowing almsot nothing about the patient except that he was black, eighteen, on welfare, and a new hospital admission, butchered this young man's brain for the education of a class of young doctors-to-be. Who were all those responsible for all the steps required to bring that patient's brain in contact with that butcher's ice pick?
The show was over - the showman strutted in front of the room, titillated at his own performance - at the suave, nonchalant way he imposed a gruesome spectacle on a class of horrified doctors-to-be.
The young man, never to be whole again, lying stretchered out before us, was wheeled out of the room, out of most of our lives. He will always be a part of mine - seared forever in my brain, in my guts.
May, as Goethe promised, the pain be halved now that I've shared it with you...may the load of it be lighter for me. It will never be lighter for that young man - he is beyond weights and measures - beyond the pain of butcheries - vegetables don't cry.

"Vegetables don't cry" was published in Blue jolts (true stories from the cuckoo's nest), edited by Charles Steir, New Republic Books, Washington DC, 1978.

Tuesday, June 06, 2006

The New York Times on DBS

Vera Hassner Sharav of the Alliance for Human Research Protection criticises a recent New York Times Magazine article on Deep Brain Stimulation:
"The surgical implant has been tested in 12 severely depressed patients in an uncontrolled trial —with no placebo comparator. This is the sole basis for the claim made that this treatment works in 8 out of 12 treatment resistant patients. In the “success” case example of the article, Deanna Benjamin, a 41 year old former nurse who underwent the experimental surgical implantation, she continues to take a combination of powerful drugs—the antidepressant, Effexor and antipsychotic, Seroquel...

As has been documented by science writer, Robert Whitaker, no matter how radical or unsubstantiated the claims, whenever psychiatry has launched a new treatment—such as, lobotomy, insulin coma, electro-shock, new generation antidepressants (SSRIs), second generation neuroleptics (‘atypical antipsychotics’)—the uncritical press, most especially The New York Times—enthusiastically endorsed every one of them. Indeed, the Times has a long record of allowing its pages to be used by medically licensed salesmen who, in true snake oil sales tradition, were in the business of selling hope rather than scientifically proven safe and effective treatments."

More...

Tuesday, May 30, 2006

Marie Mandy's grandmother

Belgian film-maker Marie Mandy has made a documentary about her grandmother Madeleine who underwent a lobotomy at the hands her psychiatrist husband in the 1950s.

The film, Madeleine au Paradis (Madeleine in Heaven), was shown at the Reel madness film festival in London in 2003:
"At the age of 90 Madeleine reflects on her life and impending death. A gentle and poetic meditation on life's great themes - childhood, love, marriage and war interwoven with a rich narrative, which chronicles experiences of mental breakdown and psychosurgery. This intimate documentary honours all aspects of human experience."

Sunday, May 28, 2006

You get to vote!

If anyone is in London on Tuesday 18th July why not got along to the Royal Institution where an event called "From Bad to worst: the worst ideas on the mind" is being held.

"From bad to worse: the worst ideas on the mind

Prof Edgar Jones , Dr Joanna Moncrieff , Richard Webster , Prof Simon Wessely

The human mind is complex, mysterious and vital to who we are, so it's probably no surprise that over the years some treatments for mental conditions have turned out to be complicated, ridiculous and damaging to patients. In this fun and interactive event four experts will each name and shame an idea from psychiatric history and try to get the audience to name it ‘worst idea on the mind’.

As ideas on the mind go, it’s tough to get much bigger than psychotherapy. Invented by the psychological legend Sigmund Freud in the 1890s, it’s been one of the most common mental therapies ever since. But has it led to more sagging therapist’s couches than actual good? Leucotomy is better known as a prefrontal lobotomy, and is a famously radical surgical therapy that can dramatically change a patient’s behaviour. It hasn’t been practised widely since the 1950s – could it be the worst-ever idea on the mind?

It might be surprising to see post-trauma counselling nominated as the worst idea – or even a bad idea – on the mind. But some studies have shown that forcing people to talk to therapists soon after a traumatic event may actually hinder their natural coping mechanisms and make them more likely to develop psychological problems in the future. Finally, drug company advertising may be a new idea, but it’s also been nominated as the worst. If you’ve ever been exhorted to ‘ask your doctor’ about a new medication you might want to come along and see what our panel has to say.

So which of these ideas on the mind should never have entered our heads? In the end it will be the audience who decides as it all goes to a vote and one idea takes the most dubious honour in psychiatry."
Judging from the brief biographies of the participants, it is diffult to see who will be presenting the case against leucotomy. Joanna Moncrieff will presumably be paired up with drug advertising; and Richard Webster with Freud. But that leaves Simon Wessely and Edgar Jones, both of whom have a particular interest in military psychiatry and neither of whom, as far as I know, have ever written anything about psychosurgery.

Friday, May 26, 2006

Lobotomised orphans

The following article appeared in the Montreal Mirror in November 2000.

The Kristian Perspective
Lobotomized by the state
by KRISTIAN GRAVENOR
I'm running my fingers through the bristly black hair of 48-year-old Paul Saint-Aubin, an illiterate hunchback sitting at a breakfast table in Joliette. My index finger feels a series of parallel grooves that run diagonally to his forehead, almost meeting the souvenirs of two other surgical incisions that stand perpendicular to his bushy eyebrows.

He's an exceptionally easygoing guy considering the journey that followed the day the Grey Nuns told his mother--a native from the Wolinak reserve--that he died as a baby. The nuns kept him in an orphanage until age 11, then sold him into farm slavery along with six other boys where, for six years, Saint-Aubin was forced to subsist on horse and pig feed. One day when he was caught eating raw eggs in the chick coop, the man of the house tossed him onto a fence, resulting, he says, in permanent damage that has caused his back to slant dramatically forward.

As a 17 year old in 1969, Saint-Aubin pulled a Barrabas against his brutal overlords. The police came, and although being of sound mind, he was deemed "profoundly retarded" and was sentenced "indefinitely" to a mental hospital. Although effectively mute at the time, he was offered no legal representation before being sent away.

Once inside the cuckoo bin, he was doped with dozens of different medications, including Largatil, known as "the liquid straitjacket," suffered electroshock, isolation, sexual abuse and experimental brain surgery. "I was forced into straitjackets and they made me sleep in the worst section of the hospital, full of piss and shit," he says.

In 1987, after 18 years inside, his mother, who ran a pet grooming operation in Laval, used new access to information laws to find out about her long-dead son. She discovered that the nuns had lied about his fate. The two were reunited for just three years before she died of cancer in 1990.

The heart-wrenching saga might merit a skeptical ear were it not for the immaculately documented records kept by his friend, Rod Vienneau. In the last three years, the middle-aged Joliette native has doggedly researched and written a thousand letters to elected officials around the world publicizing the cause of Saint-Aubin and of other so-called Duplessis Orphans that up until the mid-'70s were tossed into psych wards with no justification.

"The province would give the nuns 75 cents a day per child in the orphanage, but they gave $2.75 a day if they were in psychiatric hospitals," says Vienneau. A UQÀM report from last year estimates that the Catholic Church made $70-million (in 1999 dollars) from the manoeuvre.

Vienneau points out that parallel victims, such as Mount Cashel or natives sterilized in Alberta were compensated for their sufferings, yet in June of this year, Premier Bouchard declared the Duplessis Orphan issue closed. "Premier Bouchard is in a clear conflict of interest," says Vienneau. "He represented the Church in court in 1961 and several members of his family are important members of the Quebec clergy."

Sitting calmly at the table is Vienneau's wife--and mother of his six children--who recounts how, after her mother died of tuberculosis, she too was forced into six years in a Catholic-run insane asylum. She tells of the ice-baths, nights spent on a bare-spring mattress, sexual abuse and other memories of her own private hell. She was sprung after her younger sister escaped to tell her father of the shocking turn of events. Amazingly, the nuns wrote to the village priest to have the sisters recommitted.

Saint-Aubin, and the thousands of others whose lives were shattered at the hands of the Church seem no closer to the compensation that they are so rightly due. Saint-Aubin, who now works inserting rubber rings inside twist-off caps, shyly makes a last sad request. "If you could ask your readers, I don't have a television and I'd really like to have one." (Montreal Mirror, 23/11/2000)


Paul Saint-Aubin's lobotomy scars can be seen on this 2004 CBC-TV news programme.
According to CBC=TV, about 350 of the Duplessis orphans were given lobotomies.

Saturday, May 20, 2006

It's been done before...

Scotland recently legislated to put DBS (deep brain stimulation) in the same category as psychosurgery, making it a treatment that can only be given with a person's consent. England and Wales have done nothing, although experiments in the treatment of depression and OCD (obsessive compulsive disorder) are starting at the University of Bristol and Queen Elizabeth's Hospital, Welwyn Garden City respectively. In the absence of specific legislation DBS could be carried out on people without their consent or even a "second opinion" from a Mental Health Act Commission psychiatrist.
The treatment must therefore fall within the scope of section 63, for which neither consent nor a second opinion is required. Even though we doubt that any doctor would, in practice, implant electrodes in a detained patient without that patient's consent, this would seem to make such action theorectically legal, if perhaps particularly vulnerable to challenge under human rights law" (Mental Health Act Commission Tenth Biennial Report 2003).
The Mental Health Act Commission may consider the use of DBS without consent unlikely, but it has been done before.

In a 1980 article Robert G Heath of Tulane University in New Orleans and co-authors described the case of an anorexic patient who was opposed to the operation: "Initially, she refused to wear the pacemaker, and restraints were required to keep it operating. During the past year, however, she has showed gradual change. Compulsive rituals have been significantly reduced, and she states she now wants to wear the pacemaker because it makes her feel pleasant and relaxed." (R G Heath, R C Llewellyn and A M Rouchell,The cerebellar pacemaker for intractable behavioural disorders and epilepsy: follow-up report, Biological Psychiatry vol 15, no 2, 243-256) However, she still had to be tube-fed and was described by the authors as only "minimally improved".
Read the article here

And more about Robert Heath's experiments here.

Sunday, May 14, 2006

Naomi Ginsberg

Allen Ginsberg's mother Naomi underwent a lobotomy in New York's Pilgrim State Hospital in 1947. Allen signed the papers. Naomi remained incarcerated, dying nine years later in New Jersey's Greystone State Hospital.
Naomi was the subject of one of Allen's best known poems, "Kaddish for Naomi Ginsberg 1894-1956".

Friday, May 12, 2006

And who is going to hold 50,000 clickers?

The November/December 2005 issue of Mother Jones contained an article by Lauren Slater about Deep Brain Stimulation (DBS) entitled "Who holds the clicker?" The title was taken from the following exchange at a meeting of the President's Council on Bioethics
DR. COSGROVE: It's a little computer that's telemetry, via telemetry, the same way you do cardiac pump pacemakers, the same technology.
And the neurologist or the psychiatrist, as we do for patients with Parkinson's disease, you can select which contacts, the current, the pulse duration, the frequency, and you do that all through the little hand held device that is superimposed over the pulse generator.
PROF. SANDEL: Who holds the clicker? Like where is that, in the doctor's office?
DR. COSGROVE: The doctor has that, yeah, yeah.
The patient can turn the device on or off with a magnet that they just pass over the device. So they only have the ability to turn it on or off. The physician is the one who has the ability to program.

The Guardian recently published an article about DBS, written by the paper's science correspondent Alok Jha, which, in its uncritical enthusiasm for the procedure, was reminiscent of early media coverage of psychosurgery. This topic was covered by Gretchen Diefenbach and co-authors in their analysis "Portrayal of Lobotomy in the Popular Press: 1935-1960" (Journal of the History of Neuroscience1999 Apr;8(1):60-9). They noted that: "in most cases mention of negative side effects was either absent or cursory." In the Guardian article there is no mention at all of any risks or side effects to brain surgery. Just as the early articles on psychosurgery stressed the precision of the operations ("the psychosurgeon… cuts at exactly the right angle in exactly the right plane") so too does the Guardian article ("Brain scans are used to pinpoint which parts of the brain are acting incorrectly"). It may be possible with modern scanning techniques to accurately locate structures inside the brain, but can we be sure they are acting incorrectly? Do we even know what correct is?

The Guardian article claims that an "estimated 50,000 people in the UK who suffer from depression but cannot be helped by drugs or electroconvulsive therapy" are potential candidates for DBS. But it doesn't say how they arrived at that estimate. If these people haven't been helped by ECT, then they must be taken from the ranks of ECT survivors and there are probably some 200,000 of those in the UK. So 50,000 who hadn't been helped (and were prepared to continue with evermore invasive treatment) would represent quite a high failure rate for ECT.

The true purpose of the article is revealed in the following passage:
Identifying suitable volunteers for the trial will be crucial. "It can either be people referring themselves or health professionals referring them," said Dr Malizia. "They must have good medical information from the past and they must be anchored to a local clinical service that will carry on looking after them."
But if there are really 50,000 candidates for DBS in the UK there should be over 300 in the Bristol area. So why do Andrea Malizia and his colleagues need the help of the Guardian to recruit eight patients?

Although the Burden Neurological Institute wasn't mentioned in the article, Andrea Malizia and David Nutt are part of the Bristol Neuroscience Group which includes the BNI, and Nik Patel is a neurosurgeon at the Frenchay Hospital, where the BNI is based. It is a shame that Alok Jha didn't even glance into the bizarre history of brain experiments at the BNI (coming to this blog soon!).

In response Sophie Corlett (the acting chief executive of MIND) urged caution - "Regrettably, miracle cures invariably aren't" and pointed out "If the NHS cannot currently fund comparatively cheap treatments such as therapy, how are we to expect that 50,000 people will be able to benefit from an expensive, invasive operation?"
She also mentions something Alok Jha ignored - the ethical problems associated with DBS:
And who's to say that deep brain stimulation is the solution for these people? A narrow medical model of depression, a complex problem, fails to do justice to human psychology and the human condition. We hope that this research leads to positive results, but we also hope no one will ever suggest that using "hair-thin electrodes" to apply electricity "into the core of the brain" will be a substitute for a cohesive and holistic approach to mental wellbeing.

Saturday, April 29, 2006

Matthew Collings' father

British art critic and broadcaster Matthew Collings has written about his father who underwent a leucotomy and committed suicide.

In an article in the Independent Newspaper, "Sculpted time", (3 April 2006, page 39) Collings writes:
"Among his crowd in Chelsea he was seen as a romantic figure, good-looking like a film star, moody, fascinated by art. He fulfilled a stereotype. It was partly the culture of the time, which was literary existentialism inherited from Paris. Partly it came from what was going on is society generally: the aftermath of the Second World War, all the tragedy, death, bravery, etc. I suppose it was a way of positively mythologizing a horror to which there really couldn't be any answer. In any case, my father was a romantic bohemian type but he was also ill - he'd had an unsuccessful brain operation and he'd received a head injury in the war. Plus, unknown to anyone, a part of his brain that hadn't been attended to during his operation was being attacked. After his death an autopsy revealed a tumour. It could have been removed by surgery if it had ever been diagnosed while he was alive. It may have been the cause of his symptoms.

The brain operation was a leucotomy, performed immediately after the war. He came back depressed from a POW camp. It was in East Germany - the Russian army liberated him. I think he signed up for the RAF partly because he had some emotional disturbance in his life. Perhaps he was already suicidal. He had an alcoholic father and a domineering mother - the father walked out and never returned. When war broke out Arthur was in a reserved occupation, working as a draughtsman for the Admiralty. However, he joined the Pathfinders as a navigator. The Pathfinders was known to be a particularly dangerous section of the RAF. They flew ahead of bombers laying down flares to light the target. He was shot down, his parachute failed to open correctly and his head was injured.

He was in the camp for two years. He suffered a breakdown. He thought he was Jesus. He gave away his blankets. In Britain a psychiatrist examined him - he was free now so why wouldn't he pull himself together? He was accused a malingering. He punched a psychiatrist in the face. Later the leucotomy was done...

Arthur's depression didn't clear up. He had girlfriends, he socialised and he was good company, interested in ideas and culture and history, and in psychology and what made everything tick. But he had dark moods, terrible headaches, he couldn't concentrate, he couldn't work with any ambition or intensity. His inability to keep an even keel gradually caused him to be self-pitying and cruel. He caused scenes. He disappeared for days on drink binges...."
After a broken engagement with the sculptor Elisabeth Frink who made a portrait bust of him, Arthur met and married Matthew's mother, a nurse. Collings continues:
"When my father died my mother was seven months pregnant. He just went out one day and never returned. The the police called and said he was dead on one of the Channel Islands. He'd been secretly saving up the sleeping pills my mother served him each night, one by one, in a Swan Vesta matchbox. He took them all..."

Friday, April 21, 2006

Psychosurgery in France

France, along with Germany, Spain, Scotland, Wales, Belgium, the Netherlands, Finland, Sweden and Italy (that I know of, there may be others) is one of the Western European countries that still practises psychosurgery. Along with, for example, Spain and Italy it is one of the few where agressive behaviour in psychiatric patients is still considered an indication for surgery.

In 2002 the National Committee for Medical Ethics (CCNE) produced a report on psychosurgery, Opinion no 71. The report was prompted by two different requests for guidance on the ethical implications of psychosurgery. One concerned the following case:
"a 20 year old patient, suffering from severe psychiatric disorders (agitation, hetero-aggressivity, threatened self-mutilation) for which he had been hospitalised almost continuously since 1995. Since his condition is proving refractory to the usual psychiatric medication, surgical procedures are being considered so as to try and reduce his potential for violence and make him less dangerous to others. The health caring team hopes in this way to be able to provide more humane treatment than the almost prison-like incarceration which is his present lot."
The other request came from neurosurgeons in Grenoble who use Deep Brain Stimulation to treat people with Parkinson's disorder and want to expand into psychiatric disorders.

Opinion no 71 was largely favourable to psychosurgery, with the usual caveats about consent, committees and follow-ups, although they stopped short of recommending its use for agressive behaviour.

The report provoked a critical response from one French psychiatrist, Alain Bottero, who wrote a spirited twenty-page article, L'ethique au secours de la psychochirurgie? (When medical ethics come to the aid of psychosurgery), in the French psychiatric journal L'evolution Psychiatrique, vol 70, 2005. Bottero expresses his disappointment at his fellow psychiatrists' silence in the face of the report - apparently psychiatrists in France have traditionally been less enthusiatic than neurosurgeons about psychosurgery.

Bottero begins his article with a scathing attack on the National Committee for Medical Ethics (CCNE) for having produced a report that is rambling, repetitive, error-ridden and at times incoherent. Was there, he asks, so much pressure from neurosurgeons who were waiting for the go-ahead to operate on psychiatric patients that there was no time to proofread the document? If, he points out, Boileau was right in saying "Whatever we well understand we express clearly", then there are certainly some doubts about the Committee's understanding of psychosurgery.

The author criticises the report for claiming that new functional neurosurgery treats symptoms whilst leaving the personality intact, unlike old lobotomies. New techniques are just less mutilating, and they are not even new, he says.

Bottero takes the Committee to task for its failure to address the concerns of psychiatrists, in particular the lack of a scientific rationale for psychosurgery (and here he points out that the hypotheses of the neurosurgeons haven't advanced much since the 1940s)and the lack of evidence for both the efficacy and safety of psychosurgery.

Finally, Bottero takes issue with the concept of "treatment-resistant" disorders. Psychosurgery is usually justified - and Opinion no 71 is no exception to this - by stressing the intolerable suffering of the patients and their failure to respond to other treatments. But Bottero argues that neurosurgeons are ill-equipped to understand the fluctuating course of mental disorders and their responsiveness to environmental influences. The best response to treatment failures, he says, is not necessarily ever more drastic treatment until the treatment of "last resort" is reached; a completely different approach may be called for in order to build up a therapeutic relationship which will give the patient hope.

In conclusion:
"The CCNE has been too hasty in taking up its position on neurosurgery for mental disorder. It is up to psychiatrists to make it clear that such interventions remain ethically dubious for at least three reasons that can no longer be ignored. Their efficacy remains unproven; they are dangerous and have serious irreversible side-effects; there are other therapeutic options available which, even if proof of their efficacy is lacking, should nevertheless be actively explored and encouraged because they are a lot less dangerous.... Consent and protocols won't change anything when it comes to a question that still has no satifactory response: the lack of scientific validity for interventions that carry with them the risk of breaching the integrity of the personality."(Bottéro A. L'éthique au secours de la psychochirurgie ? Evol. psychiatr. 2005 ; 70)