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Leucotomy: a qualified defence of ‘then’

J.S. Pippard
DOI: http://dx.doi.org/10.1093/qjmed/94.8.451 451 First published online: 1 August 2001

Leucotomy (known as lobotomy in the US) and electroconvulsive therapy (ECT) are the only physical treatments for mental illness devised in the 1930s that are still used today. Few drugs were available at this time, other than sedatives and amphetamines. The new treatments offered hope for patients with severe psychotic illness, the severely anxious, obsessional or depressed, and those exhibiting violently disturbed behaviour, all of whom were many in number.

In 1942, Freeman and Watts1 described a ‘standard’ leucotomy technique to divide all white matter in the coronal plane quickly and simply. This operative procedure was used in 84% of >10 000 patients given leucotomies in England and Wales from 1942 to 1954.2 The results were rather poor, especially in chronic schizophrenia. While standard leucotomy could alleviate suffering, it too often produced severe frontal lobe symptoms, with accompanying personality changes. Soon clinicians were trying ‘modified’ leucotomies targeted at more limited areas of the brain.

One such technique was the rostral leucotomy pioneered by Wylie McKissock. I became involved with this procedure in 1952, when as a research fellow at St George's Hospital, London, I began a follow‐up study of McKissock's first 240 patients.3,,4 In contrast to earlier reports on large series of mostly schizophrenic patients, many already seriously damaged by illness and institutionalization, some 75% of McKissock's patients had psychoneurotic or depressive disorders. I assessed the results as ‘good’ in 42%, and ‘worthwhile’ in a further 20%. Results were ‘good’ in 50% of the patients with affective disorders: personality changes were no more than slight in 95%. Had more intensive rehabilitation been available after the operation, the results might have been even better. These were patients unresponsive to other available treatments, and the results supported the continued use of this form of leucotomy. However, the all too frequent damage done by standard leucotomy coloured the perception of psychosurgery in general, including the more limited techniques, in the minds of doctors and patients alike. By the time the need for controlled trials was recognized, the damage had been done.

In the more paternalistic medical culture in which leucotomy was first proposed, questions of consent were considered less seriously than they are today. Leucotomy in the form, for example, of stereotactic tractotomy and cingulectomy is still used occasionally at a few neurosurgical centres, mainly for intractable depression (especially in the elderly) and for obsessional illness. However, the Mental Health Act (1983) forbids psychosurgery without the consent of both the patient and the Mental Health Act Commission (MHAC). MHAC approval is given only after thorough assessment by three Commission members, including a psychiatrist. I performed this function over three years in the 1980s, and found it much harder, more worrying and a more controversial task than making a clinical decision 20 or 30 years ago.

Past practice may only be judged fairly when its context is understood: simply applying current ethical standards and the wisdom of hindsight not only over‐denigrates the past, but underestimates the future. Consideration as to how much of our current best clinical practice will be deemed inadequate 50 years from now gives us a fairer standard by which to judge our past decisions.