Richard T White

Amygdaloid neurosurgery for aggressive behaviour, Sydney, 1967–1977: societal, scientific, ethical and other factors

Objectives: In 1967, despite escalating international hostility towards psychosurgery, a program of amygdaloid neurosurgery for the reduction of aggressive and self-harming behaviour commenced in Sydney. In this paper, the second of two articles on the Amygdaloid Neurosurgery Project (ANP), we analyse the relative contributions of seven nominated societal, ethical and other factors to the genesis and demise of the ANP, and consider implications of the history of the ANP for the future of neurosurgery for psychiatric disorders (NPD) in New South Wales (NSW) and elsewhere. Conclusions: Leadership and the availability of resources were crucial factors in the genesis of the project. Its scientific foundations were doubtful in 1967, and remain so in 2009. Ethical issues became the focus of hostile media and Government attention in 1977 and precipitated the projects demise. Lessons derived from an historical analysis of the ANP should assist the medical profession develop appropriate approaches to recent advances in NPD, including deep brain stimulation, new ablative procedures and stem cell implantation.

Amygdaloid neurosurgery for aggressive behaviour, Sydney, 1967–1977 : chronological narrative

Objective: The aim of this paper is to record an historical narrative of amygdaloid neurosurgery at Callan Park Mental Hospital, Sydney in the period 1967–1977. In this paper, this is denoted the Amygdaloid Neurosurgery Project (ANP). The goal of the project was to ameliorate aggressive or self-harming behaviour by selective ablative surgery on the amygdaloid nucleus. Conclusions: In 1964, Professor Leslie Gordon Kiloh became acting director of the newly built neurosurgical research facility at Callan Park Mental Hospital. In 1966, he advised bilateral amygdaloidotomy for the treatment of a 16-year-old aggressive and self-harming male patient. Following major improvement in that patients condition, a further 19 patients were treated by amygdaloid surgery. In 1974, Kilohs team reported that 39% of the first 18 patients treated had persisting improvement but one patient sustained persisting hemiplegia. The program was suspended in 1977 by the New South Wales (NSW) Government, following allegations by a senior nurse that patients at the neurosurgical unit had been mistreated. A Ministerial Committee of Inquiry proposed that stringent legislative controls should be applied to psychosurgery. The Committee expressed reservations about amygdaloid psychosurgery in particular. Psychosurgery referrals declined after that date. Since 2007, under the revised NSW Mental Health Act, all forms of neurosurgery for psychiatric disorder are prohibited.

The advent of psychosurgery in Australia—with particular attention to its introduction into Sydney:

Objective: The objective of this study was to describe the advent of prefrontal lobotomy in Sydney and, less comprehensively, its introduction into Australia. Method: Reference to journal articles, books, reports and archival data held at the Royal Prince Alfred Hospital and via internet searches, interviews and personal memory. Result: This paper describes the arrival of psychosurgery in Sydney in the mid-1940s, and less comprehensively, its arrival in other Australian cities. Conclusions: In New South Wales, from 1945 or 1946, prefrontal lobotomies were conducted in private clinics and in public hospitals but, because of legal and practical hurdles, it is unlikely that psychosurgery was performed in mental hospitals prior to December 1958. This paper gives some details regarding the participation of neurosurgeons and of the major public hospitals in psychosurgery, and touches on the attitudes within the Australian medical profession towards this dramatic new therapy.

Reflective accounts of psychiatry in Australasia, 1963–2000:

Objective: To provide reflective accounts of psychiatry through the first four decades of the existence of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Conclusions: The period from the 1960s to the end of the millennium saw significant changes in both the craft of psychiatry and the social and cultural context in which specialist training in psychiatry occurred.

A portrait of prefrontal lobotomy performed at the Royal Prince Alfred Hospital in Sydney by Dr Rex Money

Objective: The objective of this article is to provide a portrait of prefrontal lobotomy performed at the Royal Prince Alfred Hospital, Sydney by the Head of Neurosurgery Dr Rex Money and to describe Dr Money’s role in the promotion of psychosurgery in Sydney. Methods: We draw attention to an oral presentation by Dr Rex Money in 1951, a journal article written by Money, archival information held at the Royal Prince Alfred Hospital, including Dr Money’s accounts of his travels and his reports regarding neurosurgery – both internationally and in Australia. Results: Dr Rex Money performed a series of 13 prefrontal lobotomies between 1945 and 1951, and presented the theoretical basis for his series, his operative procedures and the outcomes at the annual meeting of its medical officers’ association. Conclusion: Notwithstanding various deficiencies in his clinical research, Money’s descriptions give a relatively comprehensive account of one of the first series of prefrontal lobotomies performed in Australia. The current article also describes Dr Money’s contributions to the promotion of psychosurgery in Sydney, and illustrates the participation of a senior neurosurgeon and of a major Sydney teaching hospital during the psychosurgery saga.

Obstacles to a randomised controlled trial of intensive dynamic psychotherapy: an account of the New South Wales Section of Psychotherapy outcomes project

Objective: This paper examines the obstacles to a randomised controlled trial (RCT) of intensive dynamic psychotherapy (IDP) by reference to the fate of the New South Wales Section of Psychotherapy outcomes project. Method: Planning was complete and the final research protocol was about to be implemented when funding difficulties led to suspension of the project. The opinions of the research subcommittee regarding the main obstacles to the ultimate success of the project are now analysed in the expectation that better research strategies will follow. Results: With hindsight, six of the eight members of the research subcommittee reported that the project was not feasible. By choice of questionnaire items they identified the greatest threats to a successful trial as: standardisation of the procedures, termination at 24 months, the availability of funding and the choice of treatment procedures. The most frequently volunteered concerns related to the enlistment and cooperation of the trial therapists (5), standardisation of the experimental therapy (3), probable shortfall in trial subjects (3) and the availability of funding (2). Conclusions: The most powerful general obstacles to success of the project related to the standardisation of procedures and the failure to maintain sufficient cooperation of trial therapists. The protocol required IDP therapists to terminate procedures at 24 months, which contradicted their usual practices and led to some alienation from the project. Amendments to the protocol might improve the possibility of a successful trial. However, one might also conclude that it is premature to attempt a naturalistic RCT of IDP.

Sir John Macpherson, the first but sometimes overlooked Professor of Psychiatry at the University of Sydney

Objective: To chronicle the creation of the Chair of Psychiatry at the University of Sydney, and the career and legacy, in New South Wales, of the first incumbent, Professor Sir John Macpherson CB MD FRCPE. Conclusions: The creation of the Chair, Macpherson’s appointment, and his contributions to psychiatry in Sydney during the 52 months of his tenure, are well documented in contemporaneous sources and demonstrate that he was a very worthy Foundation Professor of Psychiatry at the University of Sydney. There are several possible reasons why Macpherson has been overlooked, including an erroneous statement in The World History of Psychiatry (1975) that William Siegfried Dawson, his successor from 1927 to 1952, was the first Professor of Psychiatry.