Cruel adjustments

Last Resort
June 26, 1998

Former medical therapies lend themselves to historical sensationalism: the discarded cure-alls of yesterday's psychiatry are dead easy to debunk. Critics have waxed indignant at malaria therapy (for treating GPI, or general paralysis of the insane), insulin coma therapy, metrazol convulsion, BEST (Blitz Electro-Shock Therapy) and all the other seemingly grotesque, quackish, brutal or over-hyped interventions that rose and fell before the psycho-pharmacological breakthroughs of the 1950s.

Among these, lobotomies and leucotomies have come in for particular censure. In Great and Desperate Cures, Elliot Valenstein devastatingly exposed the appallingly hit-and-miss quality of early psycho-surgery. A corer or spatula would be inserted and waggled about to sever fibres in the frontal lobe: it was barely better than a stab in the dark.

This history of lobotomy by Jack Pressman has been eagerly awaited. On the evidence of his 1986 PhD dissertation, it has been anticipated that a rather revisionist reading would emerge. Historians of psychiatry will be glad to know that the wait has not been in vain - except it is terrible to have to note that the author died last year, tragically young.

Pressman comes neither to bury psychosurgery nor to praise it, but to explain why a procedure that is now not only obsolete but widely reviled should have enjoyed such popularity, particularly in the United States, between its introduction in 1936 and the mid-1950s. The explanatory framework he offers is rich and rewarding. On the positive side, it had come to seem probable that modification of the behaviour of the mentally ill should be possible through direct intervention into the brain. Nineteenth-century advances in neurophysiology had made it clear that specific cortical centres controlled particular aspects of cognition and affect. The front brain remained somewhat of a mystery: was it not likely that it was somehow implicated in mental balance and mental disease? Animal experiments seemed to point in that direction.

Furthermore, surgery had spectacularly established itself as the cutting edge of medicine. From the humble tonsillectomy upwards, myriad operations had become routine, reasonably safe, and even fashionable. Surgeons, The New York Times said in 1936, "now think no more of operations on the brain than they do of removing an appendix".

And lobotomies held out hopes not just for the mentally ill but for psychiatry itself. That speciality was bumping along the bottom in the early 20th century, having become utterly bemired with the unsavoury associations of huge, squalid public institutions for the mad poor. Psycho-surgery promised to change that: to turn those no-hope asylums into true hospitals, to bathe psychiatry with the prestige of surgery and of physiological lab research, and thus to provide that lifeline back into mainstream general medicine that had been demanded by the great prophet of modern US psychiatry, Adolf Meyer.

More negatively, one could say that psychosurgery had a great appeal faute de mieux. What else was to be done with the half a million lost souls festering in America's asylums in concentration-camp conditions? Any attempt at cure seemed better than none, and it was an old medical aphorism that desperate conditions required desperate remedies. There is no reason to doubt, Pressman insists, that the pioneers of psycho-surgery were genuinely affected by the plight of sufferers and fired by the prospect of "cure" rather than the "care" that too often meant neglect.

Of course we now "know" that psychosurgery did not work. But Pressman properly emphasises that this is just the kind of wise-after-the-event judgement that politically correct scholars so often denounce in others yet go on practising when it suits their own prejudices. There is, in any case, substantial evidence from mid-century of individual lobotomised patients recovering from crippling agitational states, being discharged from institutions and going on to hold down jobs and family roles - even if today it seems shocking that almost no attempt was made at the outset to monitor recovery rates, define what "recovery" amounted to or conduct proper clinical trials.

If we are now inclined to be leery of all those "cures" (if they were so real, why was lobotomy abandoned?), Pressman sensibly historicises that term for us. Within the mental hygiene agenda developed by Meyer and others, mental health was understood above all in terms of "adjustment". Lobotomy achieved just that - it was particularly effective at turning cases who were depressed, demanding, troublesome or suicidal into "quiet, placid, uncomplaining persons who showed little concern about their troubles" - submissive souls who, even if they never achieved institutional discharge, would nevertheless thereafter be model patients.

Last Resort has impressive strengths. It is impeccably researched, and Pressman has an ear for the telling quotation: Walter Freeman to patient undergoing lobotomy under local anaesthetic: "What's going through your head?" Patient: "A knife." It effectively contextualises psycho-surgery in respect of medicine, science and wider American values; and it transcends simplistic One Flew over the Cuckoo's Nest caricatures to offer a balanced counter to the anti-psychiatry onslaught, seeking to understand the psycho-surgeons without providing an apologia for them.

The book, however, is not without its weaknesses. By way of a control, I would have welcomed at least a passing glance at psychosurgery in the Old World - one imagines European surgeons were on the whole less gung-ho. It is occasionally repetitive and too long; and its historiographical discussions, however thoughtful, are sometimes laboured.

It is also a pity that Pressman chose not to probe the personalities, or the psyches, of psycho-surgery's champions. Valenstein drew a devastating portrait of "the dean of lobotomy", Walter Freeman, as a perpetrator of cruel and unnatural therapies, implying, convincingly, that he was unfit to practise and barely sound of mind. Like his English contemporary, William Sargant, Freeman swung from grandiosity to nervous breakdowns.

Pressman certainly fills in the details: often using an ordinary cocktail-cabinet ice-pick, inserted, via the eye-socket, sometimes with a carpenter's hammer, Freeman at one point was getting through 100 trans-orbital lobotomies a week. The point finally came when his erstwhile supporter, Yale's eminent John Fulton, scathingly suggested he might try a shotgun, since that would be faster. By way of interpretation, however, Pressman contents himself with remarking rather coyly that his protagonist devoted himself to the operation "with a level of drive that surely bordered on the pathologically obsessive". It is as though in trying so hard to avoid judgment he has shied away from confronting big issues of psychiatric power and surgical abuse.

The consequence is that Last Resort manages to make an irreversible technique, inflicted upon tens of thousands - a technique from which psychiatrists themselves were soon to recoil - seem all very sensible. Perhaps the truly shocking thing is that, according to the standards of psychiatry less than half a century ago, it was precisely that.

Roy Porter is professor in the social history of medicine, Wellcome Institute.

Last Resort: Psychosurgery and the Limits of Medicine

Author - Jack Pressman
ISBN - 0 521 35371 8
Publisher - Cambridge University Press
Price - £40.00
Pages - 555

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