Ph.D. defence: Jesper V. Kragh on Danish psychosurgery, 1922-1983

Our own Jesper V. Kragh publicly defends his Ph.D. thesis “Det hvide snit: Psykokirurgi og dansk psykiatri 1922-1983″ [The White Cut: Psychosurgery and Danish Psychiatry, 1922-1983”] in the old auditorium of Medical Museion on June 1, 1-4 PM.
Based on close readings and statistical analysis of 50 years of patient records from one of the Danish national psychiatric hospitals, Jesper has described the introduction of methods such as malaria treatment, electroshock therapy and especially lobotomy in Danish psychiatric practice.
After some deliberations Jesper has chosen this photo of a stereotactical instrument as a web illustration — it was used in the 1960s and 1970s for precision brain surgery of psychiatric patients at Rigshospitalet [the National Hospital] in Copenhagen:

Thesis supervisor was Thomas Söderqvist, Medical Museion, University of Copenhagen, and the thesis was evaluated by Lene Koch, Dept of Public Health Services, University of Copenhagen (chairman) and external opponents Ingemar Nilsson, University of Gothenburg, and Roger Qvarsell, University of Linköping.
The defence starts at 13.00 and may continue for up to three hours. Come and listen — and join us for a glass of wine afterwards to congratulate Jesper to a very good thesis!
Here’s the summary of the thesis:
 The White Cut. Psychosurgery and Danish Psychiatry 1922-1983
This PhD-thesis is an examination of the introduction and utilization of somatic treatments in Danish psychiatry in the twentieth century. In 1922, the first of the somatic treatments, malaria fever therapy had been introduced in Danish mental hospitals. In 1937, convulsive therapies and in 1939, psychosurgery were introduced and raised the hopes for a decisive change within psychiatry, so that larger groups of patients could be discharged in future. To contemporary Danish psychia-trists, the new therapies augured well for a turning point in psychiatry, especially with regard to schizophrenia patients, who constituted the most pressing problem for the mental hospitals. However, Danish psychiatrists were also aware of the fact that all the new somatic treatments had adverse effects. Above all psychosurgery, invented in Portugal in 1935, was known to have a number of severe side effects. This fact also became quite clear to Danish psychiatrists, when they began to make wide use of psychosurgery in the 1940s.
Faced with the dilemma of whether to utilize an uncertain and unsafe treatment, Danish psychiatrists decided on an active course. Approximately 4.500 psychosurgical operations were carried out during the period 1939 to 1983. In no other country in the world did the number of operations reach such a high level compared to the size of the population and the number of in-patients. Consequently, the main question of this thesis is: What conditions contributed to this extensive use of psychosurgery in Denmark?
The thesis focuses on the use of lobotomy in Danish state mental hospitals. The state hospitals constituted the largest part of Danish psychiatry numerically, with approximately 7.500 of the 11.000 psychiatric beds, which were supposed to address the needs of a population of roughly 4.000.000 in the 1940s and 1950s. Large archives from the Directorate of the State Mental Hospitals and institutions like the Danish National Health Service offer a unique opportunity to investigate the negotiations regarding psychosurgery among the decision-makers. Patient records from various state mental hospitals are also an important source in this thesis. Especially the case notes from the State Mental Hospital in Vordingborg, a hospital with 850 beds in southern Zealand, give an insight into the doctors’ considerations, when they contemplated on using psychosurgery. In the archive in Vordingborg 336 patient records from lobotomized patients have been found and subjected to statistical analysis in this thesis.
The study of the various documents reveals that there was a very positive reception of psychosurgery among all the leading Danish psychiatrists. Most of these doctors had previously done research into other somatic treatments like malaria fever therapy and electroconvulsive therapy, and their favourable experiences with these therapies prepared the way for psychosurgery. The somatic treatments were also in harmony with biological psychiatry, which dominated Danish psychiatry in the 1940s. Moreover, the Directorate of the State Mental Hospitals was in favour of the somatic treatments and gave the hospitals grants to explore the new therapies. The prospect of economical advantages with the use of the new treatments and the hope that psychosurgery could align psychiatry with medicine played an important role for the decision-makers. Also a lack of critical voices in the medical literature, the health authorities, and institutions such as the Danish National Health Service, which supervised the mental hospitals, made the introduction of psycho-surgery unproblematic. Furthermore, extremely positive articles in the Danish press disseminated a rosy picture of the therapy to the public and raised the hopes among relatives to in-patients that psychosurgery could cure their family members in the mental hospitals. In the documents from the mental hospital in Vordingborg requests from relatives, asking doctors to lobotomize patients, can often be found.
The analysis of the patient records from Vordingborg and other state mental hospitals shows that the practise of lobotomy was a complex matter, and a number of different factors played a part in the wide use of the therapy. Especially the dire conditions of the mental hospitals in the 1940s and 1950s made doctors consider psychosurgery a solution for the many patients living a miserable life in the back wards of the hospitals. Patients, who had spent years of their lives in the hospital’s “disturbed wards”, were particularly exposed to psychosurgery. In the patients records the most common indications for psychosurgery were “unruly” and “aggressive” behaviour, but other factors such as the patient’s lengths of stay in the hospital, patients racked with pain, and lack of response to other somatic treatments could also prompt psychiatrists to employ lobotomy.
However, the social background of the patients did not have an effect on the decision to perform a lobotomy. Contrary to theories of the historiography of psychosurgery about a special selection of patients from the lowest strata of society, the Danish case shows no overrepresentation of patients from the working class, and wealthy and highly educated inmates were often among the lobotomy candidates. The social profile of the lobotomy patients in Vordingborg did not deviate from the Danish population in general. Yet, a gender difference can be found. Danish psychiatrists lobotomized women more often than men. For instance at the hospital in Vordingborg 68, 5 % of the 336 lobotomy patients were women and only 31, 5 % men. The sex distribution of all the resident patients in the hospital was in the same period 54 % women and 46 % men. There is no simple explanation to this gender difference, but the thesis argues that different conditions in the male wards and the female wards, and social factors such as different family patterns (which made it easier to discharge women) played a role; but also patterns of sex roles had an impact on the gender difference. The patient records from Vordingborg reveal that a greater amount of pressure and coercion were used when doctors wanted to lobotomize female patients. In contrast, force was seldom applied in cases with male patients. Doctors were also more willing to oblige to the wishes of the male patients, while they rarely complied with the female patients’ requests.
The special culture in the mental hospitals, where high risk was accepted and the question of the patients’ consent to a specific therapy played a minor role, also had an impact on the exten-sive use of psychosurgery in Denmark. Compared to the practise of lobotomy in many other countries, Danish psychiatrists allowed a broad selection of patients with diversified diagnosis. Patients at the age of 14 from the mental hospitals underwent a lobotomy, as well as inmates who had no previous treatment with other therapies and only had short-time stays in the hospitals. 6 and 8 year old children, from asylums for the feeble minded were also lobotomized. At least 20 children from these institutions were lobotomized. Many operations went wrong, and in the 1940s the hospitals often reported mortality rates of 6 to 10 %. The patient records from the hospital in Vordingborg show that more than 30 % of the lobotomy patients developed post-operative epilepsy and more than 50 % were later diagnosed with “lobotomia sequeal” (complication of lobotomy). A lot of the lobotomy patients were never discharged from the hospitals, and 40 % of the patients were still in the hospitals 10 to 40 years after the operation.
Despite the complications, there was no negative reception of the therapy in the following decades. The introduction of psychopharmacological therapies in Denmark in 1954 did not lead to a profound change in the attitude to psychosurgery among Danish psychiatrists, and the therapy was subsequently favourably described in the medical literature. Moreover, psychosurgery was still used to a lesser extent in the 1960s and 1970s. Only when the Danish Ombudsmand (Parliamentary Commissioner for Administration) intervened and critical reports on psychosurgery from young Danish psychiatrists and psychologists were published, the operations were finally terminated in 1983. The thesis examines this last phase of the history of psychosurgery, and a new calculation of the number of psychosurgery operations in Denmark is made, showing a much higher figure than in previous estimates.