Following an absence of about a decade, psychosurgery has returned to England. Psychosurgery, sometimes called neurosurgery for mental disorder (NMD), is surgery in which tissue in the brain is destroyed in order to alleviate the symptoms of mental illness – nowadays in Britain usually depression or obsessive-compulsive disorder. The last operations in England were done in London in the late 1990s. Since then patients from England have been able to go to the Advanced Interventions Service at Dundee in Scotland, or the University Hospital of Wales in Cardiff to have operations.
The report of the Care Quality Commission (CQC) into the use of the Mental Health Act, published last month, contained news of one such operation being carried out at Frenchay Hospital, Bristol, in February this year. Psychosurgery is regulated by section 57 of the Mental Health Act and every operation has to be approved by a panel from the CQC (or previously the Mental Health Act Commission), so we know exactly how many operations have been carried out since 1983 when the Act came into being. According to the CQC, the patient, a woman, had been unsuccessfully treated with deep brain stimulation for depression prior to psychosurgery. Deep brain stimulation involves implanting electrodes in the brain and was first used in psychiatry over fifty years ago. The technique is similar to that used in the treatment of Parkinsons, and in recent years psychiatrists have shown renewed interest in it.
It was at Bristol, at the Burden Neurological Institute (BNI), that Britain’s first psychosurgical operations, or leucotomies as they were called in those days, were carried out nearly 70 years ago, as were the first British experiments with electroconvulsive therapy (ECT). The BNI was an independent institution, set up in the Stoke Park Colony in 1939 with money from the Burden family. In 2000 it moved to the Burden Centre at Frenchay Hospital. You can read a brief official history here on page 5 of a report from Bristol University, which has pictures of the old BNI building (now demolished) in Stoke Park as well as the new one at Frenchay. The history concludes:
“The independent dedicated research institute is now a rare thing. Independence can bring challenge but can also offer great intellectual and scientific liberty. The story of the BNI has shown just how fruitful such an environment can be – and offers a challenge to current research to maintain into the future”.
The brief history said nothing about the BNI’s experiments with psychosurgery or ECT, although they are mentioned on Bristol University’s webpage about the BNI: “Notable achievements of the BNI include the development of electroencephalography, leucotomy and electro-convulsive therapy”.
Here is a little bit more about the history of the BNI and early experiments with ECT and psychosurgery.
The BNI was founded in 1939 with a donation from Mrs Rosa Gladys Burden, the second wife and widow of the Reverend Harold Nelson Burden, the superintendent of Stoke Park Colony for Mental Defectives. You can’t go far in neuropsychiatry circles in Bristol without coming across evidence of the Burdens’ wealth: the BNI, the Burden Centre, the Burden Trust, the Burden medal and prize, the Burden professor… You can even get married in the Dame Rosa Burden room at Clevedon Hall (in real life she was plain Mrs Burden, not Dame).
So who were the Burdens, and where did their money come from?
There were three Burdens: the Reverend Harold Nelson Burden (1860-1930) and his two wives, Katherine Mary Garton (1846/7-1919) and Rosa Gladys Williams (died 1939). Harold Burden was a bankrupt cattle-dealer turned mission worker and curate who somehow amassed a fortune while running institutions where people deemed “mentally deficient” were detained. He was born in Hythe, Kent, the son of a grocer. His father died when he was 12. On the 1881 census Harold is living with his mother and sisters and is described as a grazier, but 5 years later he had become bankrupt. On 25 September 1888 he was ordained a deacon by the Bishop of Carlisle, at the request of a Canadian Bishop. The next day he married Katherine Mary Garton and the couple set off to do mission work in Canada. Katherine, or Kate, was from a family of Yorkshire tobacco manufacturers who had moved to Shoreditch in London. She had connections with the church (one of her aunts had married George Huntington, rector of Tenby) and in 1870 she had been an assistant to Octavia Hill. On the 1871 census she is a 24 year old teacher at the St Barnabas orphanage for girls in Pimlico. Kate was some twelve years older than her husband, but after her marriage (or possibly before) she began taking about a decade off her age.
Things did not go well for the Burdens in Canada. They had two babies, both of whom died. Harold became ill and, after three years, they returned to England. Harold spent two years studying at Cambridge University, based at Ayerst Hostel, which was a short-lived attempt to allow poorer students to study at Cambridge without paying prohibitive college fees. Whilst there, he wrote a slim volume about his work in Canada, another book about mission work more generally in Canada and a short novel, Duty’s call: a story of a girl’s work in the service of others, and her reward, with some brief sketches of undergraduate life. The plot of the novel is interesting in so much as it provides a glimpse of the author’s views on money and social status. Mary Katherine Summerfield is a “beautiful heiress of good family” from Devon who goes to London and is presented at court, but grows weary of balls and parties. She decides to work amongst the poor of the East End, adopts a motherless girl from the slums, and returns to Devon to marry the local squire’s son, Gerald Eastwood. Even the little girl from the slums turns out to be an heiress.
In 1895 the Burdens moved to Bristol, the area with which their names would always be associated, and where they founded their institutional empire. The first institution run by the Burdens was the Royal Victoria Home for Women, which housed women prisoners and inebriates. When the 1898 Inebriates Act was passed, allowing magistrates to send habitual drunkards to reformatories, the Burdens expanded with the purchase of Brentry near Bristol as well as properties in other parts of the country, all converted into reformatories. In 1904 Harold Burden was appointed to the Royal Commission on the Care and Control of the Feeble Minded. Peter Carpenter, who has written the Oxford Dictionary of National Biography entry on Harold Burden and two articles about the Burdens*, is at a loss to explain just how he obtained this appointment. The supply of inebriates was drying up as magistrates realized that reformatories didn’t work, but the Burdens anticipated the Mental Deficiency Act of 1913 and began converting their reformatories into institutions for mental defectives, or colonies as they were called. They set up Stoke Park which, with over 1,500 inmates, became the country’s largest colony. It appears to have been a very profitable business: the Burdens were able to buy Clevedon Hall to use as their private residence and when Harold died in 1930 he left nearly £150,000 (over £7 million today). Peter Carpenter is again at a loss to explain exactly how such a vast sum was acquired. Kate Burden died in 1919, and a few months later Harold married Rosa Gladys Williams, possibly the Gladys Williams who on the 1901 census was working as a store-keeper at the Royal Victoria Home and on the 1911 census was living with the Burdens and described as an adopted daughter.
In 1933 Harold Burden’s widow Rosa donated £10,000 to set up the Burden Mental Research Trust which was to be under the control of Richard Berry (1867-1962), the director of medical services at Stoke Park Colony. Previously a professor at Melbourne University, Australia, Richard Berry’s speciality was measuring heads, estimating brain size and devising tests to identify mental defectives. In 1931, together with colleague R.G. Gordon, he published a book The mental defective: a problem in social inefficiency. The authors describe the threat facing society in the following terms:
“But today, as a result of a scientifically ignorant and lavish expenditure on the socially unfit, the danger to the fit is becoming so menacing as to threaten their extinction… the mental defective is often responsible for the making of the slum, and swells the ranks of the drunkards, vagrants, criminals and prostitutes – all more or less direct charges on the community”.
The answer was to test children at the age of 11 and then send them either to senior school or a colony for mental defectives:
“…on those who did not pass this test no more public money should be spent, except that which is necessary for their maintenance in the Colony to be described, and this need be comparatively little… the cheap labour, is of course, provided by all the inmates above the level of the idiot-imbecile class, who are largely useless for any purpose whatsoever”.
The authors mention that a “misconception about existing colonies for defectives is that they are financial drains on the public, or are run for the purpose of screwing profits for unscrupulous proprietors out of the unfortunate inmates”. They may exist, but the authors had never seen one. Hadn’t they?
Another gift followed to set up the Burden Neurological Research Institute, which was opened in 1939 a few months before Rosa’s death. The British Medical Journal (20 May 1939, 1046-7) reported on the inaugural ceremony:
“The finely equipped building of the Burden Neurological Research Institute, for investigation into the causes of mental defects and abnormalities and borderline conditions, in Stoke Lane, Stapleton, Bristol, was inaugurated by Sir Thomas Inskip, M.P., Secretary of State for the Dominions, on May 12 in the presence of a distinguished company of neurologists and others from London and elsewhere”.
The ceremony included a blessing on the institute by the Bishop of Bristol.
The first director of the institute was Frederick L. Golla (1878-1968), formerly professor of pathology of mental diseases at the University of London. His speech was reported in the article:
“Professor Golla spoke of his hopes and plans for the new enterprise. Only those, he said, who had realized how the multiplicity of competing claims, both medical and administrative, hampered the work of the large hospital clinics would fully appreciate the advantages of such a research institute. For all such workers the Institute spelt freedom, a freedom as yet unknown in mental hospitals under public administration”.
Researchers at the Burden certainly wasted no time in taking advantage of that freedom. Before the end of the year Lothar Kalinowksy, a doctor who had been working with Ugo Cerletti in Italy when electroconvulsive treatment had first been tried on people, had demonstrated the technique at the BNI and it was enthusiastically taken up by Frederick Golla and colleagues. After tests on sheep, five patients from nearby Barnwood Hospital (another private institution where there were no obstructive public administrators) were selected as human guinea pigs and given a total of 75 shocks (in those days psychiatrists weren’t afraid of using the word shock). As Frederick Golla and colleagues wrote in The Lancet (30 December 1939, 1353-5), there was no therapeutic purpose to the experiment. It was designed “to throw light on the relative advantages and dangers of the method” – “relative” because convulsive therapy where the convulsions were produced with drugs rather than electric shocks was already in use. The authors concluded that:
“From the technical point of view there can be no doubt that the electrical method is greatly superior to any hitherto employed for the production of severe convulsions. For the operator, only a small amount of training and experience is necessary, and a knowledge of physics, though desirable on general grounds, is not essential. It was thought at first that the conditions for inducing a fit in safety would be very critical, but this does not appear to be so, and it is possible that the method may eventually be made simpler than that described here. In any case the apparatus is comparatively cheap and portable, and the preparation of the patient need take no more than a minute”.
In 1941 the first leucotomies in England were performed at the BNI. Psychosurgery at the BNI was abandoned a few years later after a controlled trial by Lilian (Effie) Hutton (1904-56), only to be taken up again in 1959. Over the next two decades 150 people underwent multifocal frontal leucotomy, where electrodes are implanted in the brain and the current switched on to gradually destroy tissue. A further 70 patients underwent ablative psychosurgery at Frenchay Hospital. (These figures come from R. Cooper 2002 Professor Golla of Frenchay and the Burden Institute, 34-5.) The people undergoing multifocal operations had electrodes left in their brain for months. Ray Cooper, scientific director of the BNI, explained: “the patients go home and are able to lead normal lives. The sockets are normally covered with a piece of gauze and some kind of a head scarf”; a photograph shows a man with two 34-way sockets attached to his head (R. Cooper 1977 Electrode implantation techniques. In Psychosurgery and Society, edited by J.S. Smith and L.G. Kiloh, 57-66). This technique was abandoned in 1980; there were plans to re-introduce it in the mid 1990s (Mental Health Act Commission 7th biennial report, 113) but nothing came of the plans. The operation carried out in February 2010 was an anterior cingulotomy, an operation developed by Hugh Cairns in Oxford in the 1940s and more recently used at Dundee.
* P.K. Carpenter 1996 Rev Harold Nelson Burden and Katherine Mary Burden: pioneers of inebriate reformatories and mental deficiency institutions. Journal of the Royal Society of Medicine vol 89, 205-9; P.K. Carpenter 2000 Missionaries with the hopeless? Inebriety, mental deficiency and the Burdens. British Journal of Learning Disabilities vol 28 (2), 60-64