Continuing our mental health series, Philippa Martyr shares her research on the female experience of leucotomy in twentieth-century Western Australia.
Psychosurgery – especially leucotomy (called lobotomy in the US) – is probably one of the most misunderstood elements in twentieth century psychiatry. The gut reaction is usually one of horror: how could anyone think it was a good idea to go in blind to a person’s brain and deliberately cause damage as a therapeutic intervention?
It’s important to remember that leucotomy evolved from decades of apparently random physical experimentation on people with psychological disturbances. The experimental treatments from this era look chaotic: using malaria infection to treat neurosyphilis, narcosis treatment for mania and psychosis, insulin coma therapy, and induced epileptic seizures using drugs like cardiazol as well as electricity.
All these treatments stemmed from the same concept: the idea that mental and emotional disturbances originate in the body, and more specifically the brain. Early psychology argued that they came from the mind, spirit, soul, or consciousness – all largely untestable. But the biological hypothesis hasn’t done much better in terms of producing hard evidence. We still don’t know the physical causes or many of the mechanisms of major disorders like schizophrenia, and high-prevalence disorders like depression seem to have multiple origins and therefore multiple possible treatments.
Leucotomy promised calmer, quieter patients and a reduction in admissions to mental hospitals. To doctors in charge of overcrowded and dangerous facilities in the post-war era, the operation held appeal. Sadly, the promises of leucotomy were born of optimism rather than clinical results.
Women have generally not fared well under psychiatry in Australia, even though for much of the nineteenth and twentieth centuries they formed a minority of admissions to psychiatric hospitals. It was only after the 1940s that the numbers of women legally certified as insane (usually a pre-requisite for admission to a public mental hospital in Australia) began to outstrip the numbers of men. When deinstitutionalisation began in earnest from the late 1950s, women were ideally placed to benefit from early discharges, usually back to the family home, which was seen as a positive outcome. And yet, as we now know, the family home may have been the cause of the psychological disturbance that landed the woman in a mental hospital in the first place.
Recently Aleksandar (Sasha) Janca and I investigated the historical practice of leucotomy in Western Australia. Western Australia’s mental health records are just as hard to access as any other state, but they are also scant– even official records have large holes in them, which means that a study like this needs a lot of patient detective work. Australian neurosurgeons and psychiatrists also muddied the waters by publishing almost nothing in national and international medical journals on leucotomy in this period.
But we had a couple of advantages unique to our situation. The first advantage is that Western Australia had a tiny population and only one major public mental hospital for intractable cases (Claremont) and a busy reception home that managed less serious admissions (Heathcote). The second advantage is that I had been granted access to restricted mental health records as part of my broader historical research, under strict ethical and confidentiality requirements. This meant that I was able to access a single surviving file in the State Records Office of Western Australia which tracked payments for public-hospital leucotomy procedures in the Mental Hospitals Department.
This file provided me with details of over 100 individuals, who I could then cross-check against admissions records to Claremont and Heathcote to obtain as many diagnoses as I could. The rest of the study was made up of newspaper reports from Trove, a few fragmentary mentions in primary sources, and oral history interviews. Once I de-identified and organised the data on leucotomies, Sasha (who is a long-time academic and practising psychiatrist) was able to analyse it and suggest different ways of approaching it.
Very few writers on leucotomy have analysed its gendered administration, although Eileen Showalter, Joel Braslow, Jenell Johnson, and Thomas Schlich are notable exceptions. All of these historians agree that leucotomy was designed to change behaviour rather than cure an illness. We know that the first leucotomy in Australia was performed on a female patient in Adelaide in 1945. Normally in the history of medicine, the ‘first’ of any new procedure is well recorded, but in Western Australia we only know the patient who was operated on, and the date on which it happened (8 November 1947). It is not clear which hospital the procedure took place in, or who the surgeon was.
Our data shows that leucotomy was initially used in Western Australia to treat psychosis in men, usually war veterans. A shift took place in the 1950s, when leucotomy became used primarily to treat affective disorders – depressive conditions and mood disorders– in women. When we broke down the data further, we found that the majority of women who had leucotomies were married, aged 35 to 54 years of age, most of whom were admissions to Heathcote.
These women were short-term and less seriously unwell patients. Most had been admitted more than once to Heathcote, but at least five had a leucotomy during their first admission to Heathcote. The procedure for consenting patients at the time meant that each of these women would have had to give consent to the operation. So why were they subjected to such a dramatic procedure?
The answer has to do with international trends, especially in the UK, where leucotomy was routinely used to treat affective disorders in middle-aged women, some of whom had depression associated with menopause. By the mid-1950s, leucotomy was not fulfilling its early promise as a cure for psychosis, which mostly occurred in male patients. This might be one of the reasons for a shift to treating affective disorders instead, where women make up the majority of patients.
Was leucotomy more effective in treating mood disorders? At least seven patients in Western Australia had to return to hospital after their operation, some within a year of having had it. We found some other follow-up data which showed that the criteria for assessing a ‘successful’ leucotomy were impressionistic and arbitrary. For men, good results were measured by eventual workforce participation. But what about women? From the fragmentary evidence, we found that the operation’s success was measured by the extent to which a woman’s behavior could be controlled, with emotional qualities like pleasantness, relaxation, quietness, calmness and placidity serving as clinical indicators.
Case 006, a woman diagnosed with psychoneurotic depression, was ‘mildly confused and vague’ after her leucotomy, but ‘remained relaxed and pleasant’ and was discharged within a month of the operation. She was seen three months later and ‘appeared very well’. Case 007, a married 38 year old woman with depressed hysteria, became ‘restless and hilarious and difficult to manage’ after her operation on 25 February 1952. She relapsed and was given electroconvulsive treatment (ECT), and was then transferred from Heathcote to Claremont in September that year. Finally discharged in December, she was followed up in April 1953 when her ‘husband reported her as very good apart from some memory defect’.
The outcome for Case 018–a 47 year old married woman with obsessional neurosis– was ambivalent:
She seemed improved on return to Heathcote and was discharged on 29-1-55 but returned relapsed on 13-4-55. She has had Largactil and Serpasil and is still under treatment at Havelock Clinic at present. She is having 3-4 fits a year. She might benefit from further surgery. Result Fair– she is at least maintaining outside hospital.
This patient had to be given antipsychotic medication, was continuing to have outpatient treatment at Perth’s Havelock Clinic, and was having seizures, and yet the result was considered positive because ‘she is at least maintaining outside hospital’.
So if ‘good’ results were so ambivalent, what constituted a ‘poor’ result? Case 019, a married 37 year old woman with obsessional neurosis, was given two separate supraorbital leucotomies in 1955.
Following the second operation she still seemed tense and worried, but gradually improved. She had a setback in July 55 when a recurrence of a lumbar disc lesion enforced rest in bed with return of phobia etc. Largactil helped a little and she was discharged 20-8-55. When last seen 20-11-56 at Havelock [Clinic] there had been no progress, she ceased attending. Result: Poor (probably our fault for not recommending a more extensive operation – supraorbital [cutting] is seldom enough for chronic obsessionals).
Case 026, a woman at Claremont, was operated on in April 1956:
No improvement at all. In fact she has been more disturbed, more restless and antagonistic with a feeling that something had gone wrong in her head. Large doses of sedative and ECT have failed to give adequate control. Has to spend much time in solitary confinement: regarded as one of the worst patients in hospital.
Her October 1957 follow-up noted that she was ‘still very unstable and often noisy and violent. Records do not indicate much change. Very unlikely to be discharged.’ This may be the woman described by former Claremont nurse Evelyn Grove, who one day hit Evelyn so hard across the head that she saw stars. This patient was also one of a group of three female patients of whom it was noted, ‘Whether they are better or worse than they would have been if not leucotomised remains a matter for conjecture’.
Like so many other physical therapies, leucotomy did not deliver on its initial promise to empty significant numbers of beds in psychiatric hospitals, and by 1970, it had almost completely disappeared in Western Australia. The most usual explanation for this is the impact of cheaper and more effective antipsychotic medications, which had fewer permanent side-effects. However, the troubling lack of criteria for measuring leucotomy’s outcomes reminds us that the history of psychiatry is peppered with treatments that lacked a robust clinical evidence base.
Philippa Martyr’s broad historian-of-medicine remit includes mental health, women’s social history, histories of institutions, complementary and alternative medicines, epidemiology, health education, biography, the sociology of health and illness, and public health. She has researched, taught, and published widely in these areas, as well as in film and literary criticism, religion and ethics, sexualities, and Australian politics. She is currently a lecturer in the Discipline of Pharmacology at the University of Western Australia.
This blog piece is based on a recently published article co-authored with Professor Aleksandar Janca, ‘A matter for conjecture: leucotomy in Western Australia, 1947–70’, History of Psychiatry, June 2018.
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