Psychosurgery in Sweden 1944 - 1958 : the practice, the professional and media discourse

Abstract: Background. The pioneering early experiments of prefrontal lobotomy were performed in 1944 by neurosurgeons in Stockholm in collaboration with psychiatrists. There was a rapid implementation of the new surgical approach. In 1946 and 1947 the two state mental hospitals, Umedalen and Sidsjön, introduced prefrontal lobotomy on a large scale. General surgeons now performed operations, a practice which was established all over Sweden. Prefrontal lobotomy was burdened, in certain city hospitals, by an initially high rate of postoperative mortality reaching more than 15 %. Pre-frontal lobotomy was phased out continuously already before 1950 and refined psychosurgical methods were introduced , but prefrontal lobotomy was still continued which lacked specialised neurosurgical units. The aims of the thesis were to contribute to and deepen the knowledge and understanding of the general and specific questions of early psychosurgery in its professional and social context. Specific aims: (Explore the practice of prefrontal lobotomy at the Umedalen State Mental hospital and plot the frequency of psychosurgery operations in Sweden. • Analyze the patients subjected to prefrontal lobotomy at the Umedalen State Mental Hospital 1947-1958, with respect to symptomatology and diagnosis, indications for the operation, gender distribution postoperative mortality, the practice of consent and other clinical factors. • Explore and analyze what was written on psychosurgery, when and how, and to identify differences, similarities and characteristics of the portrayal of psychosurgery in Swedish and American media 1936-1959. • Explore and analyze the confluence of the role of the State authority, The Swedish National Board of Health (Medicinalstyrelsen), the professional discourses on lobotomy and the media portrayal, in dealing with problems of implementation and mortality. Results. Paper I. At the Umedalen State Mental Hospital, 771 prefrontal lobotomies were performed 1947-1958 with an overall postoperative mortality of 7.4 %. Most of the patients operated on from Umedalen were women (61.2%) and most of the patients were diagnosed with schizophrenia. Of all the lobotomies performed in Sweden (approx. 4,500), 28% had been carried out at the Sidsjön and Umedalen State Mental Hospitals. Paper II. A sample of 105 patients, who were studied in detail from psychiatric records. It was found that 79% had been six years in primary school and only 3% had a higher education. In an analysis of the descriptions of behavioural problems stated in the medical records, it was found that the female candidate for prefrontal lobotomy was described as suffering from different problems more often than the male candidate. Disturbing behaviour, fluctuations of mood and violence against others were the most frequently described symptoms most often referred to with respect to the female lobotomy candidate. Paper III. In the comparative media study it was found that most of the articles on lobotomy in the Swedish and American media were positive or neutral towards psychosurgery, while very negative articles were least frequent. Neutral articles were more common in Swedish media (43%) while less common in the American media (19%). Articles being very negative towards lobotomy were considerably more often found in the American material (32%) than in the Swedish (14%). Paper IV. The implementation of lobotomy was rapid in Sweden and more than 4000 lobotomies were performed between 1944 and 1964. It was considered feasible for prefrontal lobotomies to be performed by general surgeons and, from 1951, it can be verified that most hospitals (12/20) had engaged general surgeons for the lobotomy operation while a minority (8/20) had engaged a neurosurgeon. The Swedish State, through the Swedish National Board of Health was responsible of the allocation and surveillance of mental care. With a system consisting of a Chief Inspector of Mental Care, State mental hospitals were inspected annually. Medical superintendents were given full autonomy to decide on the implementation and practice of lobotomy. No indications were found of any significant interference by the Swedish National Board of Health restricting lobotomy. Main conclusion. Medical superintendents were given full autonomy to decide on the clinical practice of lobotomy. Being left in the periphery of neurosurgical facilities, this led to their engaging general surgeons. Patients were operated on in surgical theatres lacking the sophisticated technical equipment of coping securely with haemorrhages, which were common in the early implementation of the operation. The practice of lobotomy in some mental hospitals was extensive and postoperative deaths were numerous but the Swedish National Board of Health took a defensive role and, even with the annual inspections, there was no important interference with the lobotomy question. Swedish media reported mostly positively on lobotomy, underlining the promising prospects of the new method submitted by the early proponents without critical questioning or independent investigations.