Brendan Kelly: 'Lobotomy and malaria therapy - the strange history of treating mental illness'
In November 1941 in New York, Rosemary Kennedy, 23-year-old sister of Jack and Bobby, underwent lobotomy, a controversial surgical procedure involving cutting nerve connections in the front part of the brain. Her tragic story is the theme of a thought-provoking new piece of experimental music theatre, 'Least Like the Other, Searching for Rosemary Kennedy', presented at the Galway International Arts Festival last month.
It was a dramatic, sobering tale. Rosemary was intellectually disabled from birth and experienced seizures and mood swings throughout her life. This led her father to agree to the lobotomy operation without consulting her mother. The surgery was a disaster. It left Rosemary even more incapacitated and in need of institutional care for the rest of her life.
Why was the surgery performed? What were her father and doctors thinking? How could this happen?
Lobotomy was the single greatest mistake in the history of psychiatry. While brain surgery has a long history, frontal lobotomy for mental illness was developed in the early 1930s by Dr António Egas Moniz, a Portuguese neurologist who - incredibly - shared a Nobel prize for his work in 1949. The practice was adopted enthusiastically in the US by Dr Walter Freeman, who performed lobotomies on up to 3,500 people, including Rosemary.
In Ireland, lobotomy was introduced to patients of Grangegorman Mental Hospital (now TU Dublin) in April 1946, when Adams Andrew McConnell was engaged to perform the procedure at the nearby Richmond Surgical Hospital. While it appears some hundreds of lobotomies were performed, Professor John Dunne, a psychiatrist at Grangegorman, was keenly aware of its seriousness. He limited the surgery to patients with severe mental illness who had not improved with other treatments, had ongoing symptoms of a very impulsive, suicidal or homicidal nature or presented a constant threat to self, staff or others.
By June 1947, 23 lobotomies had been performed in Grangegorman with decidedly mixed results. While three patients became well enough to be discharged, others, who were less disturbed following the surgery, still had to be cared for within the hospital.
In 1950, Dunne reported that, out of 63 patients with schizophrenia and poor prognosis who underwent lobotomy, 19 recovered sufficiently to be discharged, 19 showed considerable improvements in behaviour, 18 showed no change, four worsened markedly and three died. Even among those who were discharged, problems remained. They were far from cured.
Lobotomy went into decline during the 1950s, owing chiefly to its negative effects and poor outcomes, as well as the arrival of safer alternative treatments such as antipsychotic medications. Systematically, the effects of lobotomy were overwhelmingly negative with many patients, like Rosemary Kennedy, ending up institutionalised for life.
From today's perspective, the story of lobotomy is one of therapeutic enthusiasm that went unchecked for too long. It found its roots in a deep desire to discharge people from large, toxic mental hospitals, but it is now clear the procedure was taken to an unacceptable extreme, used too widely and for too long, and often had tragic results. It is a humbling, haunting episode in the history of psychiatry, demonstrating the profound dangers of therapeutic enthusiasm that transitions into therapeutic desperation.
Lobotomy was not, however, the only novel treatment introduced with enormous drama in the early 20th century, only to be followed by a growing realisation the apparent benefits were not as great as initially thought, and that in some cases irreparable harm could result.
In the 1920s, malaria therapy was started at Grangegorman. This unlikely sounding treatment involved deliberately giving people malaria to treat mental illness caused by late-stage syphilis, which was often fatal. Dunne collected mosquitoes from customs men in Dublin but, when the mosquitoes wouldn't bite in Ireland's chilly climate, switched to using malaria- infected blood from London. Dr Julius Wagner-Jauregg, who pioneered this therapy, won a Nobel prize for it in 1927.
In the 1930s, insulin treatment was developed by Dr Manfred Sakel, an Austrian psychiatrist, and involved administering insulin (a hormone produced in the human pancreas) to induce a coma five or six mornings per week until such time as either a satisfactory therapeutic response was produced or 50 to 60 comas had been induced. The patient spent up to 15 minutes in deep coma on each occasion, although some patients were liable to develop convulsions. Each coma was terminated by the administration of glucose.
Insulin treatment, like lobotomy, went into decline in the 1950s. Today, malaria therapy, insulin treatment and lobotomy are no longer performed and our Mental Health Act 2001 has extensive regulations about treatment of patients involuntarily admitted to Irish psychiatric facilities.
But the stories of these treatments should not be forgotten. While the doctors who introduced them were motivated by a desire to empty the cavernous mental hospitals of the early 20th century, they neglected to address the factors which drove people there in the first place.
- Brendan Kelly is professor of psychiatry in Trinity College Dublin and author of 'Hearing Voices: The History of Psychiatry in Ireland', just published in paperback (Irish Academic Press, €24.95)