Needing treatment like a hole in the head

Last Resort: Psychosurgery and the Limits of Medicine

Cambridge University Press: 1998. PP.555 £40.00, $49.95
Saw head: surgeons cut into the brain of this patient from the 1989 film Brain Dead. Credit: KOBAL COLLECTION

The history of psychiatry has been punctuated by the enthusiastic use of unpleasant, bizarre and dubiously helpful ‘treatments’, each of which has eventually been discarded. To those who question the whole legitimacy of psychiatry as a branch of medical practice, or who deny that mental illness really is an illness, it all seems to confirm their lowest opinions. In the twentieth century, replacing the revolving chairs and cold showers of previous eras, two treatment methods have figured most prominently in this demonology: electroconvulsive therapy (ECT) and, worst of all, leucotomy, also known as psychosurgery or lobotomy. To cut into a person's brain on rather dubious scientific grounds seems like the ultimate in medical imperialism.

But, as the late Jack Pressman shows in this impressive but flawed work, the story is much more complex. The generally accepted view, which is over-simplified, is that the idea stemmed from the experimental work in the early 1930s of John Fulton, professor of physiology at Yale University in New Haven, Connecticut, who had been a pupil of Sir Charles Sherrington. Fulton showed that cutting nerve tracts under the frontal lobes of monkeys relieved ‘experimental neuroses’. He reported these results at a conference in London in 1935, where the audience included Egas Moniz, who was not only an academic neurosurgeon (then a rare bird) but had also been Foreign Minister of Portugal. Moniz was inspired to apply the procedure to human subjects suffering from severe mental illness, and the first few cases suggested that this was a promising, perhaps revolutionary, method of treatment. He also invented X-ray examination of the cerebral circulation, and was eventually to be rewarded in 1949 with the Nobel prize for physiology or medicine.

Pressman emphasizes that the introduction of leucotomy can be evaluated only against the actual circumstances of psychiatry at that time; it is easy with hindsight to be critical. The first specific treatment method in psychiatry — artificial malaria to treat tertiary syphilis — had been introduced only a few years before by Wagner von Jauregg in Vienna. This procedure was also unpleasant and uncertain in its effects. Insulin coma and convulsions induced by injected drugs were then in their early stages of development. Apart from these treatments there was nothing but sedatives (each with its own problems) and psychotherapy, which was ineffective as a treatment for severe mental illness. As a result, countless people suffered for years from distressing symptoms or disturbed behaviour for which nothing helpful could be done.

As with many innovations, the United States took up with enthusiasm what began elsewhere. Apart from the humanitarian need for effective new treatments, the state mental hospitals were full and, in the aftermath of the Depression, were desperately underfunded; anything that could make patients well enough for discharge would be of enormous value to them. Pressman suggests that there was a divergence between clinical and administrative aims, and this has been one of the many regular criticisms of leucotomy, but a patient who became well enough to leave the generally awful conditions of an overcrowded and understaffed state hospital was clearly benefiting as much as the institution.

The US pioneers of leucotomy were James Watts and Walter Freeman (no relation, but I met him towards the end of his career). Their early cases were mostly of agitated depression or obsessive-compulsive disorder, and the results were sometimes miraculous. But the operation became really widespread when it was extended to people with chronic schizophrenia, most of whom were in state hospitals. From early on there were warnings that the benefits were not gained without a price: intellect as such did not seem to be impaired, but there might be a blunting of the more sensitive aspects of the personality. Because of this, many variations were tried on the original ‘standard’ operation to try to relieve symptoms without causing such damage, with some success.

Leucotomy remained in vogue for about a decade in the United States, Britain and some other countries, but the discovery of major tranquillizers in the mid-1950s and the widespread use of electroconvulsive therapy largely removed the need for such an invasive and potentially flawed procedure. Pressman's main point is that much of the condemnation of leucotomy has taken no account of its history, in that it ignores the clinical and administrative problems faced by those who used it and has an unreal view of the actual process of medical advance. This cannot always be on the basis of scientific deduction. But when Pressman finally asks “Did it work?”, the issue is evaded.

From reading this work, one would conclude that the leucotomy story ended in about 1955, but this is not so. ‘Modified’ operations, with much more limited effects, continued to be used in Europe for intractable cases of depression and obsessive-compulsive disorder until they were largely replaced by more recent drugs. Sometimes they really did save lives. But Pressman makes hardly any reference to work outside the United States, giving only a passing mention to a British 1947 survey of 1,000 cases, which was at the time the largest and most systematic research carried out. He tells us how to read the story, but not how it ended, even though the text is long and repetitious.

Regrettably, Pressman died shortly after finishing this work. Had he lived, he would undoubtedly have made further important contributions to medical history.

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Freeman, H. Needing treatment like a hole in the head. Nature 393, 428–429 (1998).

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