The second talk I'd like to give is on something really completely unrelated, but it's on psychosurgery. And the question I'd like to pose is, why did psychosurgery fail the first time around? And the first time around is really between about 1935 and 1970, about 35 years. A lot of work here was done by Daniel Nichinson, and I also have to acknowledge my son, who wrote a thesis on the use of psychosurgery in visual reality for the treatment of PTSD and what that meant. Sociologists of science are fascinated by the observation that science is never taken outside of a social context. Psychosurgery is a great example of that, but we don't usually talk about it. So I would like to argue that psychosurgery was different, because very rarely do operations actually come to public scrutiny. And psychosurgery is a very notable exception. Frontal leucotomy and lobotomy were introduced in the late 1930s. They were hailed and popular in the 1940s and 1950s. They were actively vilified in the 1970s and made a felony in California and Oregon. And very few people have actually looked at why that happened. So it seems to me that psychosurgery came in four phases, and we're now in the fourth. First was the introduction of operations. Then the search for better operations. Then a severe and bitter condemnation of psychosurgery and psychosurgeons, for reasons that I will show you is completely external to the operation that was done. And then a slow and careful renaissance in the current milieu, which was really stimulated by three things. One is a minimally invasive approach. The second is very careful patient selection and outcome studies as a function of the operation. And the third is the incorporation of good practices and medical ethics. So what we will do is talk about phase three, the decline, which was due to, I will argue, a complex set of unanticipated social, political, and scientific dynamics. We will talk very briefly about the first and second phase, and we can ask the question, could the past demise of psychosurgery have been prevented and predicted? If you look at management of medical illness, of mental illness, between 1800 until quite recently, this is what it looked like. It was the Adams family writ large. Great things were done in the way of comfortable restraints. The one on the left was not particularly loved. The one on the right existed in every medical institution. This was people being restrained and treated by being put in baths. They were put there all day to keep them calm. There was a women's ward on the left and a men's ward on the right. These were in Massachusetts until quite recently. On the left, you see an electroshock machine. On the right, you see the victim of electroshock. And here's another way in which electroshock was given. And there are wonderful descriptions, which are actually very tragic, that talk about what patients saw. They were lined up and brought to a room where the electroshock was being done. And if you look at the last paragraph, one attendant stands at the head of the table to put the rubber heel in their mouth so they won't chew their tongue during the convulsive stage. On the other side of the table stand three other attendants to hold them down. The only comforting thing from those times was the sight of some of the quieter and more controlled patients comforting the terror-stricken one. The idea was calm them down. So there was a limited pharmaceutical prior to the 1950s. Opium, alcohol, emetics, blistering, scarification, and violence. In 1900, the sanitarium movement opened. So you had exercise, fresh air, movements, amusements, crafts, and labor, but they didn't do very much. In 1930, the recovery rate was estimated in Mississippi at 14%, although some people cited 90%. Between 1930 and 1940, people used convulsive therapy with metrazole, with insulin, with electric shock, and also psychotherapy. The psychotherapists were actually extremely powerful as a medical movement in the 1930s and 1940s. By 1940, also, you had occupational therapy and attempts to humanize the treatment of the mentally ill. And then, in 1940, you had surgery. Surgery looked really good as an alternative to what was being done before. It looked really good until you had chlorpromazine, and we'll go through this. So frontal lobe surgery. The science was based on work that Fulton did on chimpanzees. However, Moniz, who got the Nobel Prize for this and for other things not quite related, really argued very strongly that he had thought about this idea independently of Fulton. The idea was that you had converging or fusing neuroanatomical, neurophysiological, and behavioral observations about the function of the frontal lobe. Remember that this was a time that Papes also got the Nobel Prize for doing work on the limbic system. Psychiatric disease was a huge social problem, seemingly without end. Lobotomy held out the first prospect of, and I use the word carefully, a cure. If you could interrupt the fibers, you could cure the problem. It was perceived as a remarkable revolutionary and humanitarian accomplishment. These are the two individuals who are most notably in the United States associated. One is James Watts on the left, a neurosurgeon who, after a short time, became very upset that Walter Freeman, a neurologist on the right, was doing this operation unsterilly using an ice pick through the top of the orbit without any surgical training and divorced himself from the elements to do this. He worked most actively in Washington, D.C. until, as you will see, Dr. Freeman took this on the road. What people don't see is the effect of the press. The press loved this. They were all over it. They were invited to attend procedures. They lauded and popularized the operation. They gave case histories, and I'll show you some photographs that show that this was absolutely magnificent. Psychiatric patients were benefited by the blunting of strong and unwanted emotions. It was a benign alternative to what was being done because families were reunited and wives became obedient. There was tranquility. This was called the Stepford phenomenon. Here's a picture of a lobotomy being done. You can see Dr. Freeman. And if you look at the two people over here, these two are certainly pressed. This one is probably pressed, and this one was identified as pressed. So that's what happened in the operating theater. A new narrative, however, arose in the 1950s. Why? A large number of cases had been performed. Some people say that by 1950, between 40,000 and 60,000 cases had been performed in the United States. Certainly between 1949 and 1952, with much better statistics, about 18,000 had been done. There was a fuller appreciation of the statistical risk. This was considered, at first, a risk-free operation. I assure you, it was not. There was mortality, intellectual deterioration, and serious adverse events. Psychosurgery as an operation and as a procedure was subject to incoming fire. There were six important reasons and some others. The first was that Freeman was an unabashed showman. Here is his lobotomobile, and he went around the country telling mental institutions he was very prepared and very happy to do lobotomies any place, any time, line up the patients. He had the picks. He called this the burden of consciousness that he was able to fix. There were too many indications, and now I'm changing from the popular side to the scientific side. Initially, it was for violent psychosis, but it changed from violent psychosis to any time you didn't like behavior. Depression, personality disorders, schizophrenics with less obvious pathology, initially seen as an easy procedure, like minimally invasive surgery of some kinds, which was quite distinctive for its lack of harm. Do the operation, go walking around later in the afternoon. It solved problems. But soon it came to be questioned in the popular press. There were books that came out. The Lobotomist, My Lobotomy, Messing Around With My Head, Mind Control Operations, The Mind Stealers, One Flew Over the Cuckoo's Nest, Suddenly Last Summer, Francis. These are very famous books of the 1950s. People were terribly familiar with them. What happened was that the problem of daunting personality problems was actually publicized. There was a narrow clinical indication at first, so nobody minded the passivity and the flattened affect of somebody who was previously quite violent. But afterwards, intellectual changes were seen as an impediment, particularly in good families. And over time, they came to be seen not only as an impediment, but loss of personality was seen as reprehensible. You had pictures that were published, before on the left, after on the right. You had the story of the Kennedys and Rose Kennedy, who underwent a lobotomy gone wrong and probably should never have had one to begin with. And then you had the introduction of chlorpromazine, a psychotrophic. Phenothiazides had first been synthesized by the German dye industry. It was synthesized for psychiatric work. Only in 1952, it was formulated earlier as an antihistamine. It was introduced in 1954 by SmithKline French. And by 1955, over 2 million patients were given the drug. It was greeted with ambivalence. Many psychiatrists loved the idea of giving medication. This was called organic psychiatry. But others who were psychotherapists thought that this was wrong. That's not the way you treat patients. It was firmly emplaced in psychiatry by 1955. And it's interesting to actually look at the way in which this was advertised. So here's a woman and all you see is her shoes before and after. And then the idea of violence. Then the idea of having somebody quiet all day. Then more about violence and violence in the home. Then attacks of mania. Then Thorazine for behavior disorders in children note. And then even more about keeping the real in reality. This was a huge effort. Now good science, as we think about it, means good trial data. But nobody worried about trial data at first. But following the work of Austin Bradford Hill in England in the 1930s, clinically trials were newly recognized as the basis for good medicine. The first really good clinical trial with controls was 1946, very late, streptomycin for tuberculosis. It was not embraced by surgeons. But otherwise everybody demanded randomized control trials. There were very poor outcome data in psychosurgery. And surgeons were accused of selection bias, scientific misconduct, and poor reporting standards. I remember victim Adams looking at Dr. Ballantyne at the Massachusetts General who did singulotomies and saying to Dr. Ballantyne, Dr. Ballantyne, you are absolutely incompetent as a physician. Just like that. It was very bitter. There was a book written in 1952 by Freeman and Watts. If you look through it, you will be embarrassed. Mostly you have more pictures, very little in the way of data. But there are lots and lots of pictures. Now, there were unanticipated social apprehensions. And this is really getting to the nub of what we're talking about and to the end of this talk. People were afraid of communist influence, mind control after the Korean War, the loss of self and personality, problems with consent, and fears of political indoctrination through and by psychosurgery. So a wonderful story about Jose Delgado at Yale who implanted electrodes into a bull and stopped the bulls raging. That was seen as the danger of psychosurgery. You put protesters in a hospital, you put in electrodes, you stop them. And frankly, we believe the Soviets tried things like that. This is one of the best ones. The commie secret weapon is lobotomy. And there's a wonderful picture to show it. Then you have a book on how the CIA hid their alternate mind control program. And you have sort of the hippie conspiracy movement about taking out the brain. And that led to an anti-psychiatry movement that was actually organized by the Citizens Commission of Human Rights and actually followed a number of religious groups. So you had R.D. Lange and Thomas Shass questioning the existence of a mental illness. You'd had Eric Goffman, the sociologist, talking about St. Elizabeth's Hospital in D.C., a huge institution, but brainwashing the patients. And Thomas Sheff saying patients labeled as deviant or mentally ill because they have isolated social norms or their behavior is what society considers unacceptable behavior, these should not be considered mentally ill. In fact, he said that mental illness was a social role. A mental patients union was actually started in London in the 1970s. And there were demonstrations about keeping doctors and particularly surgeons away from mental illness. There's a coalition against psychiatric assault. But the final nail in the coffin was Peter Bregan in 1971, a psychiatric activist who couldn't get many of his things published but was able to get some of his work published in the congressional record. And starting in 1971, started talking about brain disabling treatments, including psychosurgery. By 1975-76, this attitude prevailed. And for all intents and purposes, psychosurgery had been defeated. Very little in medicine, very little in society is ever value neutral and certainly psychosurgery was not. Even in medicine, good ideas can suffer if the social milieu is not curated and psychosurgery was not. We have a second chance now. And the lessons of history are that very many well-meaning efforts have unpredictable and nonlinear repercussions and we need to study them before we decide on movements in medicine. And thank you very much for your attention. This picture, as many of you will know, is a picture of Evita after her lobotomy, her last public appearance. Thank you very much. applause

psychosurgery

history

frontal lobotomy

rise and fall

popularity