Think lobotomy and most people think of the USA and the excesses of neurologist Walter Freeman. But the operation, in which the connections between the frontal lobes and the rest of the brain are severed, was actually used – per head of the population – more in the United Kingdom than in the USA. British neurosurgeon Sir Wylie McKissock performed thousands of lobotomies (or leucotomies as they were called here) during the 1940s and 50s, possibly even more than Walter Freeman. Yet, while Walter Freeman has featured prominently in several books (David Shutts’ Lobotomy; Jack Pressman’s Last Resort; Jack El Hai’s The Lobotomist, Howard Dully’s My Lobotomy), the psychosurgical career of Wylie McKissock has been quietly forgotten. Until, that is, Tuesday 8 November, when BBC Radio 4 broadcast a programme by Hugh Levinson entitled The Lobotomists which gave equal billing to Egas Moniz, the Portuguese neurologist who was responsible for the first 20th century attempts at lobotomy (there had been previous attempts at the end of the nineteenth century by Swiss psychiatrist Gottlieb Burckhardt), neurologist Walter Freeman, who was responsible for promoting the operation in the US, and Sir Wylie McKissock, the British neurosurgeon who carried out thousands of leucotomies in the United Kingdom. The programme can be listened to here and there is an accompanying article here.
The programme had found some interesting contributors, including people who had worked with McKissock, although those who had undergone the operation (or someone who knew them) were notably missing and were represented by an archive item with a man talking about his wife who had been left badly damaged by two operations. As far as I know she is the only person to have received compensation for having been left disabled by psychosurgery, although I don’t think the programme mentioned this. There is one important point on which I would take issue with Hugh Levinson. In his article he says:
“The reason for its popularity was simple – the alternative was worse…. The chance of a cure through lobotomy seemed preferable to the life sentence of incarceration in an institution. ‘We hoped it would offer a way out,’ says [retired neurosurgeon] Mr Brice. We hoped it would help.'” Continue reading the main story
No, it wasn’t that simple, and to be fair to the writer, the radio programme did mention the “host of other factors” including the press, and the needs of society, that encouraged doctors to experiment with psychosurgery in those days (and still do in these days, although the numbers are smaller). But the programme also referred to mental illness in those days as being “untreatable”, and talked about people being “stuck in asylums”, one contributor even said admission to a mental hospital at that time was “almost a death sentence”. Such ideas are often produced in an attempt to justify leucotomy, but even a cursory glance at the evidence shows a much more complicated picture. The first leucotomy in Britain was performed in 1940. Ten years previously the Mental Treatment Act 1930 had replaced the 1890 Lunacy Act. The name says it all: Mental Treatment Act. You no longer had to be a certified pauper lunatic to enter one of the asylums. They were now hospitals, they accepted voluntary patients, they acquired outpatient departments – all because psychiatrists managed to convince the government that they had the ability to successfully treat mental illness as long as access to mental hospitals was opened up and they could intervene in the early stages. They wanted more not fewer patients. They had bookfulls of treatments. And the 1930s brought more: in particular insulin coma treatment and convulsive treatment. The use of both these treatments pre-date the use of psychosurgery in the UK. So it was never the case that psychosurgery was the only treatment available. Neither was it the case that people never got out of mental hospitals. There were admissions and discharges, just as there are today. The average length of stay was longer and the proportion of discharges lower than today but again there were various reasons for this, not just the availability of treatments. Most importantly there was never any evidence that psychosurgery held out any realistic hopes of signficantly reducing the numbers of people in mental hospitals. The operation, in any case, was not limited to people who had been in hospital for years, being performed as well on people who had only spent a small amount of time in a hospital and on people with neuroses who had never been in hospital at all. And when it was performed on people who had been in hospital for years it was sometimes in the hope of making them more manageable and less demanding on nursing staff rather than in the hope of a recovery and return to life outside the hospital.
One thing that the programme did not have time to explore was Wylie McKissock’s motivation. Why did he spend his weekends travelling the country carrying out thousands of leucotomies? Was it just filthy lucre? The programme did not say how much he was paid for these operations although presumably the information is there in hospital annual reports or financial records. Also missing was an attempt to relate the operations of the 1940s and 1950s to those of today. In the 1940s and 50s in Britain, the majority of psychosurgical operations were of the standard, or Freeman-Watts, type, such as those carried out by McKissock. Sometimes a slight modification of this technique was used – McKissock developed his own technique of “rostral leucotomy”. But a few surgeons were experimenting with a different type of psychosurgery, in a way more akin to Egas Moniz’s original operations, where lesions were made in the brain without severing all the connections to the frontal lobes. For example Sir Hugh Cairns in Oxford in the late 1940s developed the cingulotomy. And these types of psychosurgical operation gradually became the predominant ones as the number of standard leucotomies fell. As psychiatrist John Pippard (who incidentally was interviewed for the programme) wrote in 1962 in the results of a survey of leucotomy in Britain: “The standard or its anterior modification still accounts for nearly one-fifth of all operations; it is on the way out, but all too slowly, and should finally be abandoned.” But it was to take over a decade to disappear entirely. In the mid 1970s there were still a few standard leucotomies being done, but the most common operation was at that time Geoffrey Knight’s subcaudate tractomy, which continued to dominate British psychosurgery until the late 1990s. The only operations to survive into the 21st century are capsulotomies and cingulotomies, performed on small numbers of people in Cardiff and Dundee and, as from last year, Bristol.
When speculating about current medical practices future generations might look back askance at, someone suggested chemotherapy (for cancer) while Zbigniew Kotowicz (who has written an academic article about the origins of psychosurgery and surely had a more interesting contribution to make) mused about plastic surgery. But why the need to stray outside of psychiatry? What about current psychosurgical operations? Or deep brain stimulation (DBS) for psychiatric disorders? The programme touched on the role of the media in promoting leucotomy in the early days and I was reminded of the recent enthusiastic media response to a press release from Bristol University’s Neuroscience about how pioneering world first radical new (yes, the press release used all those words) treatment “could help people who suffer with severe and intractable depression.” In fact, although the press release generated several “deep brain stimulation hope for depression” news stories, it was the story of a woman for whom DBS (used in psychiatry in the 1950s, then largely abandoned and now being tried again, as an offshoot of its use in the treatment of Parkinson’s Disease) had been a failure, to such an extent that afterwards her doctors decided she needed an old-fashioned ablative psychosurgical operation – the first one to carried out in England for about a decade. What was “new” about it? Apparently, according to the press release, a piece of equipment called a guide tube (manufactured by Renishaw for whom Steven Gill, head of Functional Neurosurgery Research Group at Bristol University is a consultant):
Some patients do not respond to DBS or are not suitable for it, in which case the option of an ‘Anterior Cingulotomy’ using implantable guide tubes (GTAC) has been specifically developed in Frenchay and this patient was the first to have it.
Does the use of guide tubes, however useful they might be to the surgeons, make the operation significantly different from the cingulotomies that have been performed for years by neurosurgeons in Dundee?
Here is how they do it without guide tubes at the Advanced Interventions Service in Dundee.
ACING [Anterior cingulotomy] takes place under general anaesthesia. A stereotactic frame ring is fixed to the skull before a volumetric CT and MRI scan is performed. The CT and MRI images are then imported into planning software specific to the stereotactic frame. Fixed points within the brain are localised to adjust the stereotactic cube in order to overcome any tilt, yaw, or rotation of the brain within the frame. Once the targets are identified, the software automatically calculates the frame coordinates.
Two small incisions are made 2.5cm from the midline and just anterior to the coronal suture. A six-millimetre tip radiofrequency lesion generator probe is then inserted to the previously-located target and the lesion is created by heating the probe to 70º Celsius for 90 seconds.
The targets are 7 mm lateral to midline, 20 mm posterior to anterior portion of frontal horn, and 1 mm above the roof of the lateral ventricles. The intended lesion has a diameter of 8-9mm.
It is possible that the use of guide tubes makes the operation easier to do, or safer, and that surgeons in Dundee are planning on adopting the Bristol techniques. Perhaps it really is, within neurosurgical circles, newsworthy. But the fact that no-one thought to ask, and the story was reported as an uncomplicated one of “hope for depression” has interesting parallels with the old broadcasts featured on The Lobotomists.
Within the confines of a half-hour slot it was impossible to do justice to such a complex subject; the programme left me hoping Hugh Levinson has an hour-long documentary or a book in him.