Jrournal of medical ethics, I980, 6, 149-154 J Med Ethics: first published as 10.1136/jme.6.3.149 on 1 September 1980. Downloaded from Ethical considerations of psychosurgery: the unhappy legacy of the Ethcal considerations of psychosurgery: the unhappy legacy of the pre-frontal lobotomy

Larry 0 Gostin MIND (National Association for Mental Health)

Author's abstract by earlier research on animals by Professor John Fulton and Dr Carlyle Jacobsen of Yale University,7 There is no subject at the interface oflaw, psychiatry and used alcohol injections and later a 'leucotome' to pro- medical ethics which is more controversial than duce lesions in fibres connecting the subcortical areas psychosurgery. The divergent views ofthe treatment begin of the brain and the frontal lobes. This 'pre-frontal with its definition. The World Health Organisation' and leucotomy' was conceived as a method of treating others2 define psychosurgery as the selective surgical psychiatric illness by a generalised 'blunting' of the removal or destruction ofnerve pathways or normal brain emotions. Fulton, who helped form the theoretical tissue with a view to influencing behaviour. However, basis for the surgical intervention, reported that his proponents ofpsychosurgery demur on the basis that the most ferocious animals had been 'reduced to a state of 'modern' treatment is concerned predominantly with friendly docility'.2 In I949 Moniz received the Nobel emotional illness, without any specific effect upon Prize for his work. behaviour. The alternative definition offered is 'the Wider use ofpsychosurgery began when two Ameri- surgical treatment ofcertain psychiatric illnesses by means can surgeons, Drs Walter Freeman and James Watts, of localised lesions placed in specific cerebral sites.3 developed a form of psychosurgery similar to that It is difficult entirely to accept this definition because, as introduced by Moniz.8 The 'standard pre-frontal

examined below, scientificpsychiatry is notyet in aposition lobotomy' of Freeman and Watts involved the use ofcopyright. a to directly treat psychiatric illness solely through surgical blunt knife which was swept with a free hand in an arc intervention. There is no reliable theoretical relationship in the coronal plane and divided as much of the white between particular cerebral sites (which are normal and matter as possible. The procedure was carried out by healthy) and an identifiable psychiatric illness or making a burr hole in the side of the head. The opera- symptomatology. Given this state ofpsychiatric tion was repeated on both sides of the brain. The understanding, it is misleading to suggest fine distinctions pre-frontal lobotomy was considered to be most effec- between generalised alteration of behaviour or mood and tive in the treatment of depressive illness. However, treatment of an illness. Highly divergent practices and the surgery was used predominantly for schizophrenia theories (relating to the multiplicity ofconditions treated, where there was little evidence of its positive effect.http://jme.bmj.com/ surgical methods adopted and areas ofthe brain operated More importantly, there were potentially serious side- upon) further undermine exaggerated claims that effects which included intellectual and emotional psychosurgery can scientifically 'treat' specific illness impairment and personality change (a 'flattening' and a through precise surgical intervention. Nonetheless, 'withdrawal' effect which were sometimes character- contemporarypsychosurgery does not contain quite the same ised as 'vegetable states'), prolonged incontinence, 'broadbrush' approach ofits ancestors and it can lay some epilepsy and certain metabolic disorders.3

legitimate claim as an effective empirical treatment in It is estimated that there were approximately 50.000 on October 2, 2021 by guest. Protected narrowly limited circumstances. Major ethical problems such operations carried out in North America; there still, however, arise and these will be discussed in this were over I0 ooo in Great Britain between I942 and article. 1954. Two-thirds of the British patients were schizo- phrenic of whom only i8 per cent were considered to be recovered; up to 50 per cent of those with affective Historical antecedents disorders were reported to have socially recovered or Much of the controversy concerning psychosurgery is improved.9 based upon an ill-informed view of the nature of the The association of Freeman and Watts was discon- contemporary treatment. Psychosurgery, more than tinued when the former advocated a lesion produced any other psychiatric treatment, suffers from the leg- through the roof of the orbit, performed immediately acy of its rather crude predecessors. Psychosurgery on after two applications of unmodified electro- human subjects was first introduced by Dr Gottlieb convulsive therapy to act as an anaesthetic.'0 The end Burckhardt of Switzerland in I89I4 and Dr Ludwig of the decade of the I950S saw a diminishing in Puusepp of Russia in I9I0,5 but results were poor. enthusiasm for psychosurgery which was due in part to There was little further interest in psychosurgery until discontent with the severity of reported side-effects the work of the Portuguese neurologist, Dr Egaz and to the advent of the phenothiazines for the treat- Moniz, was published in 1936.6 Dr Moniz, encouraged ment and control of schizophrenia. iso Larry 0 Gostin J Med Ethics: first published as 10.1136/jme.6.3.149 on 1 September 1980. Downloaded from

The renaissance of psychosurgery (diathermy or radio-frequency), or by way of a cutting wire introduced via the probe. Alternatively, radio- THE NUMBER OF OPERATIONS PERFORMED IN THE active seeds, such as Yttrium-9o, may be placed in PREVIOUS TWO DECADES position and the centre destroyed over a period of The previous decade witnessed the 'renaissance of time'.' However, as indicated below, the older 'free psychosurgery'. This renaissance was no more clearly hand' methods are still very much in use in this country illustrated than by the Lancet in 1972 when it identified and, even with the stereotactic approach, there intractable psychotic depression as the 'indication par remains a wide range of cerebral target sites. excellence' for the 'modern' psychosurgery. The Lan- A survey of the 44 neurosurgical units in the British cet maintained that, if no more effective treatment Isles for the years 1974-76 showed marked variation in becomes available, 'it can be taken without further the preferred site for placing lesions and in lesion- argument that some form of lobotomy is here to stay. making techniques.'3 No less than i6 different types of The results are excellent, usually permanent, and on lesions were made in a minimum of 14 particular cere- occasion almost miraculous'. The Lancet concluded in bral sites. Free hand methods (eg using a leucotome or an incredulous manner, which was later characterised suction) were used in 26 (84 per cent) of the 31 units by Dr Raymond Levy of the Maudsley Hospital" as conducting neurosurgery. This represented approxi- not 'scientific' but 'revivalist' in tone: "This is no field mately 40 per cent of the patients, as those units doing for the euphoric novice; but the caustic advice to the fewest operations tended to use the older methods. beginners can be passed on to the whole profession - By contrast, stereotactic methods were used in i i units 'don't give it up, take it up' ".I2 More recently, Drs (35 per cent) on approximately 6o per cent of the Bridges and Bartlett of the Geoffrey Knight patients. Psychosurgical Unit at Brook Hospital advised, 'it is There was also great variation in the clinical indica- now unnecessary for an illness which fails to respond to tions for the use ofpsychosurgery. In three units which routine treatments to be left very long before operation were responsible for 248 ofthe operations, some 85 per (sic) is considered'.' cent of the diagnoses were related to mood - ie depres- There is a great deal of uncertainty concerning the sion, anxiety states, obsessive compulsive neuroses, number of operations which have been performed in schizo-affective psychoses and manic depressive this country. In 1970, Dr Geoffrey Knight then of the psychoses. It should be noted that several studies showcopyright. Brook Hospital, Britain's largest psychosurgical unit, good outcomes in respect of these medical indica- gave evidence of several hundred of his own cases, tions.'4 However, the Royal College survey showed most of which had been since i960.2 An enquiry spon- that there were numerous operations on patients with sored by the Royal College of Psychiatrists suggested diagnoses unrelated to mood disorder. These ranged that in the United Kingdom, I 58 operations were per- from repeated violence or aggression, anorexia ner- formed in 1974, 154 in 1975 and II9 in 1976."3 On 17 vosa, intractable pain, schizophrenia and self- January, I980, in a written Parliamentary Answer, Sir destructive behaviour. It is important to observe that George Young, Minister ofState, announced that there there is very little empirical or even theoretical evi- had been44 operations in both I977 and 1978, and that dence of the effectiveness of surgical intervention in http://jme.bmj.com/ the returns for 1979 were not yet available. Three respect of these clinical conditions.3 weeks later Sir George was obliged to retract his state- The multiplicity of existing psychosurgical tech- ment in a further Parliamentary Answer (8 February) niques and cerebral sites, together with the use ofsuch when Brook Hospital revealed that, at that hospital varied neurosurgical procedures on almost the entire alone, there had been 40 such operations in I974, 47 in range of psychiatric conditions raises valid lay objec- 1975, 37 in 1976, 33 in I977 and 35 in I978. Figures of tions to claims that 'contemporary psychosurgery' is an this magnitude in one hospital had clearly thrown established or specific 'treatment' for particular medi- on October 2, 2021 by guest. Protected doubt on the reliability of the national figures cal conditions. There does not appear to be anyreliable announced earlier. The government announced its theoretical position relating to psychosurgery;2 mark- intention to publish new figures later in the year. edly different interventions are used in similar cases, and similar interventions are used in respect of a wide The scientific justification for psychosurgery variety of clinical conditions. Psychosurgery is performed in cases (eg aggressivity) where it is even THE MULTIPLICITY OF PROCEDURES difficult to identify a medically accepted psychopath- The term 'contemporary' psychosurgery which is often ology. Rather, the operation appears to be performed used in psychiatric literature is somewhat misleading to modify behaviour when faced with continually as there is no single surgical intervention or cerebral unacceptable social conduct. site which theorists and practitioners agree upon. The procedure which is most often referred to as 'advanced' Clinical outcomes is the stereotactic approach which 'consists of a probe into the brain under X-ray guidance and control. As stated above, stereotactic psychosurgery has pro- When the tip of the probe is adjacent to the chosen duced improvement in patients with depressive target the destructive lesion is made. This may be illnesses, anxiety states and obsessional neuroses. achieved by electricity, cold (cryosurgery), heat However, these studies were based upon subjective Ethical considerations of psychosurgery '5' J Med Ethics: first published as 10.1136/jme.6.3.149 on 1 September 1980. Downloaded from assessments, often by the experimenter.'5 One cannot of highly diverse medical and social conditions. discount the fact that, in many of these studies, there Anorexia nervosa is treated by a potentially dangerous was intensive nursing and medical care before and after lesion made in the hypothalamus. Hypothalamotomy the surgical intervention (sometimes clinical has also been advocated to treat sexual deviation16 and improvement actually commenced before the opera- to correct obesity.'7 The thalamus has been the target tion), well designed rehabilitation programmes, and site for hyperresponsiveness.'8 Particularly controver- attendant psychotherapy and other therapeutic inter- sial and unestablished are lesions in the amygdala and ventions. These may well have contributed to the posterior hypothalamus to control aggressiveness and patients' improvement. Moreover, the elaborateness of antisocial behaviour.'9 The fact that these procedures the psychosurgical procedure may provide a poten- have been used in Britain on vulnerable severely men- tially significant placebo effect. To date, there has not tally handicapped people who cannot consent3 and on been a single controlled trial of psychosurgery. prisoners20 and, in the United States, on minority It must be acknowledged that virtually all groups and ghetto dwellers2l does not leave the outside psychiatric treatments - both physical and psychologi- observer confident in the purity of the medical objec- cal - are empirical and, accordingly, are based upon tives. There are distinct social and management impli- similar subjective assessments of clinical improve- cations associated with 'treatment' for the condition of ment. Given the empirical effectiveness of 'violence' or 'aggressivity'. There are, of course, the psychosurgery in narrowly defined circumstances, one vagaries of what is to be regarded as violent or poten- would be reluctant to ban the treatment in those pre- tially violent behaviour and the threshold of when cise circumstances and where the patient is giving brain surgery is to be performed and at what cost to the effective legal consent. Nonetheless, reservations relat- individual. Adoption of such social criteria for the use ing to the absence of a controlled trial need to be of brain surgery also raises serious questions about the expressed, particularly because of the uniqueness of limits placed on such treatment in hospitals, prisons neurosurgery in the psychiatric context. and the wider community. It may also be seen by some Psychosurgery seeks to destroy certain parts of the groups in society as a way to legitimise social objectives brain which, within the limits of current knowledge, under the guise of medicine, but without any reliable appear structurally intact and normal. The procedure identification of illness. Medical ethics are encoun- is, therefore, irreversible and may effect normal brain tered for there is genuine ambiguity about whethercopyright. functions. Our inadequate understanding of neuro- such procedures are individually therapeutic or logical processes and the absence of scientific evidence whether they are performed, at least in part, for the of its effectiveness or long-term side-effects, should benefit of others. subject psychosurgery to the strictest legal and ethical A nagging concern is that, to the extent that anorexia scrutiny. nervosa, hyperresponsiveness, abnormal sexuality or The most significant ethical and legal concern with aggressivity are exclusively psychiatric conditions, one psychosurgery occurs in cases where there is no evi- is mindful ofthe social influences, such as the patient's dence ofits effectiveness. Here, it would be imprudent background and experiences, as contributory factors. not to acknowledge the historical context. The stan- Psychosurgery presents a simplistic solution to com-http://jme.bmj.com/ dard pre-frontal lobotomy was observed from the plex problems relating to the aetiology and treatment beginning not to be effective in the treatment of ofmental illness. It is a purely physical and temporally schizophrenia and this finding was confirmed by the discrete procedure where results are expected to flow available research.3 However, it was estimated that from a single event, irrespective ofthe individual social some two-thirds of all operations in this country were circumstances of the patient. on patients who suffered from schizophrenia.9 Given There follow some case examples which illustrate the fact that the improvement rate for schizophrenics some of the reasons for the concern and controversy in on October 2, 2021 by guest. Protected was negligible and the side-effects so substantial it was this country. not to the credit of psychiatry or law that the procedure was not regulated either within the profession or by more formal independent methods. 'Contemporary' Case examples psychosurgery is also used in the treatment of schizo- THE LEUCOTOMIES AT RAMPTON HOSPITAL phrenia despite the fact that rarely is there any marked There is very little public knowledge that four clinical improvement. Drs Bridges and Bartlett con- leucotomies, through the use of suction, were per- cluded after a review of the evidence: 'At this stage of formed on young female patients at Rampton Hospital our knowledge schizophrenia is not a primary indica- between 1974 and I 976 without complete prior consul- tion for contemporary psychosurgery'. They observe tation and approval ofthe DHSS who are the managers that some schizophrenic patients were included in out- of the hospital. The clinical indication for the pro- come studies of stereotactic tractotomy, 'but in no case cedure was the sustained aggressivity or self-injurious was there marked clinical improvement, although behaviour of the patient. Each of the patients was in there was a useful degree of amelioration in some seclusion and dressed in a canvas suit for a period prior cases'.3 to the operations. Two of the patients are reported to There is also inconclusive evidence as to the effec- be discharged from Rampton; they are considered to tiveness of psychosurgery in the treatment ofa number be improved, more docile and manageable. A third 152 Larry 0 Gostin J Med Ethics: first published as 10.1136/jme.6.3.149 on 1 September 1980. Downloaded from patient committed suicide after the operation. The observed, 'such was the enormous pool of psychotic fourth patient did not have a significant reduction in patients vegetating as chronic sick in the closed wards aggressive behaviour despite two successive opera- of mental hospitals, without effective drug control and tions. There is no indication that any of these patients without hope, that when it became possible to help did give, or were capable of giving, effective legal them in any way, this new method was taken up with consent to the leucotomy. There are further ethical and more enthusiasm than caution and with more technical legal difficulties with the 'voluntariness' of consent, skill than psychiatric and neurophysiological under- even when properly given. InKaimowitz v Michigan22 a standing'.25 Nevertheless, what had occurred without United States court found that no detained patient significant regulation or active reservation was a surgi- could provide voluntary consent for experimental cally induced non-specific levelling or blunting effect psychosurgery performed to reduce aggressive which would occur regardless of the presence of par- behaviour: 'It is impossible for an involuntarily ticular identifiable disease. This should not properly detained mental patient to be free of ulterior forms of be regarded as within the acceptable boundaries or restraint or coercion when his very release from the competence of either psychiatry or law; it requires institution may depend upon his co-operation with the deeply personal value judgements. institutional authorities and giving consent to experi- Normal emotion, response and functioning (which mental surgery. . .. Involuntarily confined mental together comprise a unique human character) are the patients . . . are not able to voluntarily give informed essence and integrity of the individual. The intuitive consent because of the inherent inequality in their objection to the pre-frontal lobotomy was that it per- position'. This description when taken in the English manently and irreversibly affected or diminished nor- context may exaggerate the effect of the institutional mal human functioning ofthe individual by destroying process on a patient's ability to make independent healthy brain tissue in the most sensitive of organs. decisions.23 Nonetheless, the knowledge that The lessons for contemporary psychosurgery are dif- leucotomies have been given recently in a special hospi- ficult to evaluate. Certainly free hand and less selective tal in England without independent scrutiny, public methods of creating lesions are still employed and, to knowledge or protection for the patient is worrying. It this extent, the legacy of the pre-frontal lobotomy, suggests a deep sense ofcomplacency and deference to with its acknowledged side-effects and general blunt- clinical judgment on the part of the government and ing of emotional response, should remain a profoundcopyright. the profession. ethical concern. There are, however, emphatic claims that, with 'contemporary' (meaning stereotactic) oper- Psychosurgery in young children ations, normal emotional responsiveness is preserved. Lesions in the amygdala to reduce aggressive and dis- It should be noted that the evidence for this assertion ruptive behaviour have been performed on children appears to relate only to stereotactic subcaudate tract- aged eight and older at Edinburgh University. Similar otomy where an effect on personality was reported by amygdalotomies have been performed in Japan on relatives in only 7 per cent of the cases.'4 It is claimed that personality changes were for the better and

children aged five to thirteen who were characterised http://jme.bmj.com/ by unsteadiness, hyperactivity and poor concentra- included increased assertiveness, talkativeness and tion. Good results include 'satisfactory obedience' and outspokenness. There was also an increase in smoking 'constant steady mood'.24 In the United States or eating habits. These results are important and do psychosurgery is performed to reduce hyperactivity in allay some ethical concerns. However, given the fact children to levels which can be managed by their par- that there is little objective and reliable knowledge of ents. The principal ethical issue is that the profound the limbic system and the relationship between various and life-long effects of these operations are produced cerebral centres, the layman may view these claims during childhood when the person cannot understand with a certain sense ofincredulity. There is an intuiinve on October 2, 2021 by guest. Protected or decide for himself. Decisions taken by parents on feeling that, in altering or diminishing the experiemce behalf of children in this context cannot necessarily be of abnormal emotion, there may also be an effect on deemed to be in the best interests ofthe child, consider- healthy and normal functioning or feeling. Human ing the management objective of the procedure. emotion and character are difficult to measure; normal response may be affected, but our assessment is not Wider ethical issues: the ofthe individual sufficiently sensitive. Nor can we discount personality 'blunting' change because it is perceived to be 'for the better' The pre-frontal lobotomy caused a general pacifying or Alterations in character have important and subtle subduing effect on the individual, with patients some- consequences for an individual and any evaluation by times becoming more passive, shallow and lethargic, others ofthe desirability ofsuch changes is value laden. and losing spontaneity and the ability to introspect. Given the inadequate theoretical perspective and absence ofany controlled research, it was reasonable to The current legal position interpret any therapeutic effect or symptom relief as Despite the ethical concerns associated with part of a more general diminishing or 'blunting' of psychosurgery, there have never been any guidelines, emotional response. It would be improper to impute controls, regulations or monitoring arrangements bad faith to the practitioners ofthe day for as theLancet relating to its use in this country. Parliament, the Ethical considerations ofpsychosurgery '53 J Med Ethics: first published as 10.1136/jme.6.3.149 on 1 September 1980. Downloaded from relevant health authorities and the profession itself Future regulation of psychosurgery have been entirely silent on the circumstances when The imposition of any form of treatment without con- the operation could or should be performed. The sent is a serious intrusion on the dignity of an indi- practice of psychosurgery, then, is solely a matter of vidual; a person's will to protect his physical integrity professional discretion; there is complete respect for is an ultimate human concern. There are distinctive the sanctity of individual clinical judgement against ethical and legal issues associated with treatments any external interference. Further, there are no special which are intrusive, produce irreversible physiological legal requirements relating to consent to or psychological effects, carry significant risks, or are psychosurgery. The law of consent applies equally to unpredictable in effect. These categories of treatment all physical examinations and treatments, from the should be distinguished in law. most unobtrusive procedure to the most invasive. The White Paper on the Mental Health Act 195927 These are particularly important observations because proposes to incorporate into an amended Act special it is the essence of the argument of protagonists of legal arrangements for the administration of treat- psychosurgery that it is empirically effective in nar- ments which are 'hazardous, irreversible or not fully rowly limited circumstances. However, the absence of established'. The government appeared to address its any restriction or oversight of psychosurgery, together mind directly to psychosurgery in one of its defini- with the fact that its practice is not limited solely to tions: 'irreversible treatments are those which necessi- empirically indicated circumstances, suggests the need tissue or are to fetter clinical judgement. tate the removal or destruction of brain Currently, a patient who is informally resident in a designed to effect irreversible change in cerebral or psychiatric or general hospital may not be given any bodily functions'. physical examination or treatment without providing The White Paper underlines the need for review of legally effective consent. The elements which together the use ofpsychosurgery. However, the form ofreview comprise effective consent under the common law more than any other matter divided those who made voluntariness and recommendations to the government. Notably, the (information, competency, speci- Royal College of Psychiatrists proposed a concurring ficity) and the narrow justifications for proceeding medical opinion which it regarded only as advisory in without consent are discussed at length elsewhere.26 character; the ultimate clinical judgement of the

The question, however, which has vexed British copyright. lawyers is whether a compulsorily detained patient can psychiatrist, even relating to neurosurgery, would be treated without his consent. The difficulties oflegal remain unimpeded. construction, however, have not prevented successive The government accepted the broad basis of a pro- governments27 and the Royal College ofPsychiatrists28 posal made by MIND for a multi-disciplinary review. from advising practitioners that treatment may be However, the White Paper envisaged that these would imposed upon detained patients without their consent. be established under the auspices of Area Health The legal arrangements set out above raise in- Authorities. This raises critical issues concerning the triguing issues about the contemporary practice of independence of the decision-making process because psychosurgery. There are no statistics kept by AHAs have ultimate legislative authority for the treat-http://jme.bmj.com/ government as to the legal status of patients who have ment and detention of psychiatric patients. The cur- received psychosurgery or whether they have provided rent government, when in opposition, ,recorded its effective consent. However, the policy ofthe four large view that any external review would undermine the psychosurgery units in this country is that they will professional integrity of the consultant.29 It should be only rarely use formal compulsion. These units also remembered, however, that it is the patient's interests purport to treat only patients with severe emotional which are paramount; the nature of psychosurgery is disorder and claim marked success in cases of patients. such that strict and impartial protection for the patient who are gravely or totally impaired in their ability to is warranted even where the consultant purports to act on October 2, 2021 by guest. Protected communicate. This presents the paradoxical situation with consent. where practitioners purport to limit their interventions The following standards are suggested as minimally solely to cases ofgrave disablement but maintain, at the necessary for psychosurgery to be authorised: same time, that the patient is capable of sufficient (a) Psychosurgery must be the final therapeutic alter- understanding and competence to provide legally native -ze all reasonable efforts should have been made effective consent. There are cases, for example, with to treat the patient with reversible and less intrusive seriously obsessional people, where judgement and therapeutic procedures; reason are not necessarily affected by the illness; such (b) The patient must give full and effective consent; patients would be competent to provide meaningful (c) The patient must be suffering from a major identi- consent and should be allowed to do so, subject to fiable psychiatric illness and the efficacy and safety of independent safeguards. However, psychosurgery the particular neurosurgical intervention must be con- performed on a person with severe psychotic illness firmed by clinical research; and who is unable to give a meaningful consent might (d) The risk of adverse reaction or the severity of such be unlawful; an independent review ofthe propriety of reaction or the risk of personality or character change the treatment and competency ofthe patient to consent should not be disproportionate to the degree ofbenefit is warranted to protect consultant and patient. the treatment is likely to confer. '54 Larry 0 Gostin J Med Ethics: first published as 10.1136/jme.6.3.149 on 1 September 1980. Downloaded from

Neurosurgery in each individual case should be "Gostin, L (I979). The Merger ofIncompetency and Certifi- approved (according to the foregoing standards) by an cation: The Illustration of Unauthorised Medical Con- independent body which comprises a multi- tact in the Psychiatric Context. International journal of disciplinary legal and lay element. law and psychiatry, 2, 127-I68. 24Narabayashi, H and Gno, M (I966). Long Range Results of It is only by strict adherence to conditions such as Stereotaxic Amygdalotomy for Behaviour Disorders. those set out above that contemporary psychosurgery Confinia neurologica, 27, I68-I71. could reasonably distance itself from the unhappy leg- 25Psychosurgery on Trial. Lancet, 1975, i, 1175. acy left by its predecessors. 26 Gostin, L, op cit.; Gostin, L (I975). A human condition, vol. i, London, MIND. 27Department of Health and Social Security (1976). A review of the Mental Health Act I959. London, HMSO; H.M. References and notes Government (1978). Review of the Mental Health Act of human I959. Cmnd. 7320, London, HMSO. 'World Health Organisation (1976). Health aspects 28Royal College of Psychiatrists, The COHSE Report on the rights. Geneva, WHO. Management ofViolent Patients: Counsel's Opinion by 2Clare, A (1976). Psychiatry in dissent. London, Tavistock. C S C S Clark, QC (1979). The bulletin ofthe royal college 3Bridges, P K and Bartlett, J R (I977). Psychosurgery: Yes- ofpsychiatrists, February, 2I-25. terday and Today. British journal of psychiatry, 131, on 249-260. 29House of Commons Debate the White Paper, Hansard, 4Burckhardt, G (I89I). Ueber Rindenexcisionen, als Beittag February 22, I979, 642-755 . See also the written answer zur Operativen Therapie der Psychosen. Allegemeine Hansard, June 5, I980, 824-825. zeitschrift fur psychiatrie, 47, 463-548. 5Puusepp, L (I937). Alcune considerazioni sugli interventi chirurgici nelle malattie mentali. Giornale accademia di medicina di Torino, 100, 3-I6. Commentary 6Moniz, E (1936). Tentatives operatoires dans le traitement de certaines psychoses. Masson et Cie, Paris, Moniz, E (I937). Pre-frontal leucotomy in the treatment ofmental Paul Bridges The GeoffreyKnight Psychosurgwcal disorders.Americanjournalofpsychiatry, 93, 1379-I385. Brook 7Fulton, J F (I948). Surgical approach to mental disorder. Unit, General Hospital, London McGill medical journal, 17, I33-145. I am pleased to have the chance of commenting oncopyright. 8Freeman, W and Watts, J W (1950). Psychosurgery, 2nd Ed., Mr Gostin's paper because the Geoffrey Knight Illinois, Charles C Thomas. Unit has found Mr Gostin's previous papers on 9Tooth, G C and Newton, M P (I961). Leucotomy in England and Wales 1942-54. Reports on public health and medical ethical problems to be of considerable value. How- subjects no. 104. Ministry of Health, London, HMSO. ever, I feel rather less than enthusiastic about some "Freeman, W (1971). Frontal lobotomy in early schizo- aspects of this present review, and this perhaps phrenia: long follow-up in 415 cases. British journal of for three reasons. psychiatry, IuI9, 62i-624. The first part is a review of the development of

"Levy, R (1972). Psychosurgery. Lancet, July 22. psychosurgery which follows our paper' but therehttp://jme.bmj.com/ '2Psychosurgery (I972). Lancet, July 8. are quite a lot of additions and different vieW '3Barraclough, B M and Mitchell-Heggs, N A (1978). Use of points expressed not all easily acceptable. Foi neurosurgery for psychological disorder in British Isles example, 'scientific is not t during I974-6. British medical journal, 2, 1591-1593. psychiatry yet in '4Strom-Olsen, R and Carlisle, S (197I). Bifrontal stereotactic position to directly treat psychiatric illness solel tractotomy. British journal ofpsychiatry, II8, I4I-154; through surgical intervention'. But what is 'scientifi4 Goktepe, E 0, Young, L B and Bridges, P K (I975). A psychiatry' and what is the significance of 'solely'? further review of the results of stereotactic subcaudate In the next sentence we read 'cerebral sites (whichi tractotomy. British journal ofpsychiatry, 126, 270-280. are normal and healthy)'. But it is not at all certai4 on October 2, 2021 by guest. Protected '5Valenstein, E S (I973). Brain control. London, John Wiley. why a lesion in the ventromedial quadrant of the "Roeder, F, Orthner, H and Muller, P (I972). The stereotac- frontal lobe so successfully treats severe depression; tic treatment of pedophilic homosexuality and other Neither the abnormality nor its location are known; sexual deviations. InPsychosurgery (eds. E Hitchcock, L Laitinen and K Vaernet). Illinois, Charles C Thomas. So the question as to 'normal and healthy' tissu¢ '7Quaade, F (1974). Stereotaxy for obesity. Lancet, i, 267. is irrelevant. The lesion probably interrupts a nerv¢ 8Andy, 0 J and Jurko, M F (I972). Thalamotomy for hyper- pathway (possibly the fronto-thalamic radiation} responsive syndrome. In Psychosurgery (eds. E Hitch- in which case, while the structure of the site may b¢ cock, L Laitinen and K Vaernet). Illinois, Charles C normal, it is likely that its function is not. Mt Thomas. Gostin's next remark concerning 'fine distinctions "9Kiloh, L G, Gye, R S, Rushworth, P. G, Bell, D S and between generalised alteration of behaviour ot White, R T (I974). Stereotactic amygdaloidotomy for mood and treatment of an illness', suggests con- aggressive behaviour. Journal of neurology, neurosurgery as to normal or and psychiatry, 37, 437-444. fusion behaviour mood, as opposed to 20The Guardian, April 6, 1970. pathological behaviour or mood, the latter usuallyr 2'Breggin, P R (I972). U.S. Congressional record, February being regarded as an illness. No fine distinctions ar4 24, pp EI6o2-x6I2. needed. However, I would very much agree with 22Kaimowitz v. Michigan, 42 U.S. L.W. 2063, 1973. Mr Gostin that psychosurgery can now be seep