Tag Archives: psychosurgery

Surgery in the asylum II: The craniectomy controversy

In January 1895, The Strand Magazine published another instalment in its ‘Stories from the Diary of a Doctor’ series. The tales were written in a semi-fictional tone, ‘in collaboration with a medical man of large experience’ – ‘[m]any [were] founded on fact’. They presented a romantic vision of the doctor as saviour, accompanied by illustrations that echoed other Strand series such as Sherlock Holmes. January’s ‘Diary of a Doctor: Creating a Mind’, relates the situation of a titled family whose male head has been taken ill after an injury. The attending doctor, frequently present in the family’s castle, is there when the young male heir, Cyril, is brought to visit his grandfather on his sickbed.

Strand_Magazine_1891Two and a half years old, the boy is described as beautiful – almost angelic – yet the doctor relates that ‘one glance was enough to tell me that … the mind in that poor little casket was a sealed book. The beautiful boy was looking at no one: he was gazing straight out of the window…’ The grandfather is less poetic: “That boy’s an idiot,” said the Squire – “he’s a beautiful idiot – he’s no heir for me – don’t mention him again.” ‘Idiocy’ was a common term at this time used to refer to a condition present from an early age that made a person incapable of managing their own affairs; it was typically deemed incurable, and covered a range of conditions that are now generally referred to as learning difficulties.

The doctor, his curiosity aroused, examines the child and draws the family’s attention to

“how small his head is in proportion to the rest of his frame. That smallness is at the root of the mischief. The little fellow is suffering from premature ossification of the cranial bones. In short, his brain is imprisoned behind those hard bones and cannot grow. The bones I refer to should at his tender age, be open, to allow proper expansion of the growing brain.”

A little while later, he notes: “An idea has occurred to me – it is a daring one … I propose to open the casket where the child’s mind is now tightly bound up, and so to give the brain a chance of expansion.”

V0030048 Brain of someone described as an "idiot". Process print.

Brain of someone described as an ‘idiot’. © Wellcome Images

The parents of the child consent, and the operation is carried out. Lasting one and a half hours, the procedure is deemed a success. The tale ends triumphantly, with young Cyril like any ‘normal child’ by his third birthday, and presented to his grandfather (now recovered from his illness) with a dramatic flourish, eventually living in the castle and – presumably – a potential heir once more.

Whilst ‘Creating a Mind’ relied on fictional tropes for its effect, it raised very real concerns. T. Telford-Smith, Superintendent of the Royal Albert Asylum, described it as ‘a tale which I fear has given rise to exaggerated hopes in the minds of the parents of many idiot children’, suggesting that several had pursued the possibility of surgery after reading the piece. The procedure in question – craniectomy – involved removing bone from the skull to increase the space available for the brain. Telford-Smith estimated that over 200 such operations had been performed in Britain, America, and France since 1890. It was not something to be taken lightly, he emphasised, and was certainly not the miraculous cure that The Strand made it out to be. Similar concerns were voiced by G.E. Shuttleworth, who thought that craniectomy had ‘almost passed from the domain of science to the region of romance’ as a consequence of ‘Creating a Mind’.

This is not to say that medical practitioners deplored the operation completely. Telford-Smith had known it performed on several children who had been admitted to the Royal Albert. Relating the case of a six-year-old boy who had never spoken and often knocked his head violently against the wall – a practice that the parents found ‘most distressing’ – he said that the parents could see only limited difference after three procedures were performed in 1895. The child remained speechless, yet his parents said they would submit him to the operation again knowing the results, as his restlessness had decreased markedly and the head-knocking had ceased. The case was presented by Telford-Smith in direct response to ‘Creating a Mind’ – despite the slight improvements in the child, he said, ‘A mind has not been created’. His account, though, emphasised the need to look at each case individually, weighing up the risks and possible outcome. He also noted the need for dedicated education and training after surgery, reminding readers that a physical procedure was no substitute for love and attention.

Surgery on the brain (or that aims to affect the brain) is a highly emotive issue, especially when performed on children as in these cases. The Strand episode is an interesting example in which a popular representation of psychosurgery was positive – so much so that several doctors were moved to respond to it. ‘Creating a Mind’ sits in contrast to tales like Heart and Science (mentioned in this post) that portrayed surgery on the brain as a Gothic nightmare. It’s a reminder, then, that discussions about psychosurgery often extended beyond the asylum walls and that opinions on the matter were rarely straightforward: for some parents of the 1890s, a novel medical procedure such as craniectomy may have been perceived as a means of ‘cure’ for their children.

Further reading

L.T. Meade and Clifford Halifax, ‘Stories from the Diary of a Doctor: Creating a Mind’, The Strand Magazine (Jan. 1895).

G.E. Shuttleworth, ‘The Surgical Treatment of Idiocy‘, Journal of Mental Science (Jan. 1896).

T. Telford-Smith, ‘Craniectomy for Idiocy, with Notes of a Case‘, Journal of Mental Science (Jul. 1897).

T. Telford-Smith, ‘Craniectomy, with the After-History of Two Cases‘, Journal of Mental Science (Jan. 1896).

David Wright and Anne Digby (eds.), From Idiocy to Mental Deficiency: Historical Perspectives on People with Learning Disabilities (London: Routledge, 1996).

Forgotten histories of psychosurgery, and facing our fears

In 1890, T. Claye Shaw and Harrison Cripps related the case of a male patient at Banstead asylum who was suffering from general paralysis of the insane – a diagnosis now believed to refer to neurosyphilis. Post-mortem examinations of these patients often found large amounts of cerebro-spinal fluid (CSF) in the skull, and it was findings like these that could be used to inform treatment of the living patient. Under Cripps’s care, it was suggested that the patient had excess fluid in the skull that ‘was exercising considerable pressure’ and causing excruciating headaches. As a means of relieving this intra-cranial pressure, trepanation was performed – the removal of a small piece (or pieces) of bone from the skull.

A Bronze Age skull showing the marks of trepanation. © Wellcome Images.

In the historiography of psychosurgery, the use of trepanation in general paralysis is frequently absent. Searching index entries for ‘Psychosurgery’ often instructs one to ‘See Lobotomy’, reflecting our modern view of psychosurgery as those infamous methods instituted by Egas Moniz and Walter Freeman. Many accounts of psychosurgery’s development jump from ancient practices of trepanation to the early twentieth-century interventions of Moniz and Freeman, sometimes interrupted by reference to the work of Swiss alienist Gottlieb Burckhardt in the late nineteenth century. Burckhardt is then credited with the ‘discovery of psychosurgery’ – by his almost contemporaries and pioneers of lobotomy, Walter Freeman and James Watts, for example.

There was significant interest in the topic before Burckhardt’s work, however: Paul Broca examined a Peruvian skull that bore the marks of trepanation sent to him by an anthropologist acquaintance. That such findings would occasion a rejuvenation of interest in the topic amongst the alienist community appears an almost foregone conclusion, yet there are few references to the Shaw episode – or similar undertakings – within histories of psychiatry and psychosurgery. An exception is German Berrios’s work – in 150 Years of British Psychiatry (volume 1, 1991) and his 1997 article, ‘The Origins of Psychosurgery: Shaw, Burckhardt and Moniz’. Berrios places the work of Shaw alongside that of Burckhardt, and also addresses the moral implications of such invasive treatments. Though there is little evidence that it was a particularly common intervention, looking back on trepanation within the asylum appeals to our worst fears about the patient as experimental object. Berrios shows, though, that the use of trepanation in cases of general paralysis was not presented unproblematically by asylum doctors, and that its proponents ‘were aware of the potentially serious consequences of their treatment, and of the fact that they needed scientific, ethical and social warrants’.

Though logical considering contemporary understandings of the disease, Shaw’s surgical solution to general paralysis was not without controversy. In the British Medical Journal during the late 1880s and early 1890s, a number of articles and letters debated the appropriateness of trepanation for the asylum patient. Shaw and Cripps were enthusiastic about the operation, appealing to data that demonstrated the ‘increased arterial tension’ in the early stages of general paralysis. It was a surgical response that depended on early diagnosis, said Shaw and Cripps: they were convinced that the benefit for the patient was clear if trepanation was performed as soon as possible. One such case was presented as a resounding success: ‘The present state of the patient is a great improvement upon what it was; in fact he is no longer insane, and I propose to discharge him’, Shaw related triumphantly. The patient from Banstead, however, fared less well: though initially discharged when his headaches and delusions disappeared, his wife later wrote to say that he had been unable to retain his job and had become increasingly irritable. To Shaw and Cripps, the operation still had its merits, as the ‘painful urgent symptoms’ had been relieved.

Trephination set, 1771 – 1800. © Wellcome Images.

Trepanation was of course an extreme response to the symptoms of mental disease. For some commentators, the intractable nature of general paralysis merited such measures. Others displayed contempt for the practice. Prestwich Asylum’s George Revington wrote to the British Medical Journal in 1890, criticising Shaw: ‘I may mention the practical point’, he said, ‘that general paralytics are quite sufficiently apt to injure themselves, and to be injured by others without the additional facilities which a trephine hole in the skull would afford’.

Ultimately, trepanation could not cure general paralysis. In Berrios’s analysis, it was symptoms rather than cure that were foremost in contemporary doctors’ minds: Shaw and Burckhardt were able ‘to target individual (troublesome) mental symptoms without committing themselves to having to treat the entire disease’. Just how far doctors saw themselves as relieving symptoms – rather than precipitating cure – is unclear, however. At the time, the cause (or causes) of general paralysis remained obscure, so that any anomalies – such as the abundance of fluid on the brain – might hold out the promise of a solution.

Last week, a friend posted a link on Facebook to the Science in the Asylum conference. The first comment on the link read ‘It was terrible what they used to do people back then’. But as well as what was done, shouldn’t we also be asking why it was done? It’s very easy to look back at medical treatments of 100 years ago with horror from our present viewpoint, and to assume that interventions were doled out by sadistic doctors based on little more than poorly-informed medical speculation. The reality, however, was rarely so clearcut, and debates between doctors much richer and varied than we often give credit for, as demonstrated by the correspondence around the Shaw affair. Whilst we should never lose the patient from the history of psychiatry, we must take care not to lose the doctor too.

 - Jennifer Wallis

Further reading

Joel Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (Berkeley: University of California Press, 1997).

Stanley Finger et al, Trepanation: History, Discovery, Theory (Lisse: Swets & Zeitlinger, 2003).

Walter Freeman and James W. Watts, Psychosurgery: Intelligence, Emotion and Social Behavior following Prefrontal Lobotomy for Mental Disorders (Springfield, Illinois: Charles C. Thomas, 1942).

John Macpherson and David Wallace, ‘Remarks on the Surgical Treatment of General Paralysis of the Insane’, BMJ (23 Jul. 1892).

George A. Mashour et al, ‘Psychosurgery: Past, Present, and Future’, Brain Research Reviews 48 (2005).

Andrew Scull, ‘Somatic Treatments and the Historiography of Psychiatry’, History of Psychiatry 5 (1994).

T. Claye Shaw, ‘The Surgical Treatment of General Paralysis’, BMJ (16 Nov. 1889).