GREAT AND DESPERATE CURES: THE RISE AND DECLINE OF PSYCHOSURGERY AND OTHER RADICAL TREATMENTS FOR MENTAL ILLNESS by Elliot Valenstein (Basic: $19.95; 306 pp., illustrated)
In this authoritative and disturbing book, Elliot Valenstein, a professor of psychology and neuroscience at the University of Michigan, deals primarily with the history of prefrontal lobotomy--the psychosurgical procedure that aimed to alleviate severe symptoms of mental illness by cutting and crushing nerve fibers and other matter in the prefrontal lobes of the human brain. Pioneered in 1935 by the prominent Portuguese neurologist Egas Moniz, the procedure was accomplished with a thin cutting instrument called a “leucotome,” which was inserted into the brain through holes drilled in the skull. Lobotomy quickly found an evangel in the United States in Walter Jackson Freeman, a neurologist at the George Washington University Medical School in Washington, D.C. In 1946, Freeman, simplifying Moniz’s original method, did the first transorbital lobotomy, forcing an ice pick--he later used a leucotome--into the brain through the orbital cavity that houses the eyeball, then maneuvering it through vertical and horizontal arcs to sever the nerve fibers in the frontal lobes.
Lobotomy was said to relieve some of the symptoms of schizophrenia but was especially touted for acute anxiety and depression, reportedly rendering even highly agitated patients calm and good-tempered. According to Freeman and his longtime collaborator James Watts, lobotomy accomplished these results because the intensity of emotions invested in particular ideas was regulated by the anatomical pathways known to exist between the prefrontal lobes and the thalamus.
After World War II, lobotomy caught on in the United States. By 1946, it was estimated that 2,000 of the operations had been performed; by 1949, more than 10,000. Between 1949 and 1952, the American lobotomy rate ran 5,000 per year, and tens of thousands more were performed elsewhere in the world. Lobotomy was celebrated in the press and was endorsed by distinguished psychiatrists, neurologists and neurosurgeons. Church groups generally declared it ethically justifiable (a conclave of French Catholics decided that a lobotomized priest could not hear confession but could teach at a university). Lobotomy received the ultimate accolade when, in 1949, Egas Moniz shared the Nobel Prize for physiology or medicine.
Prof. Valenstein argues convincingly that the enthusiasm for lobotomy was thoroughly unwarranted. The theory on which it was based rested, as a critic of Moniz’s vague ideas said in 1937, on “pure cerebral mythology.” Then, too, although in many cases lobotomy did in fact produce striking relief from acute agitation, in a number of others it resulted in permanent incontinence and, in many more, a zombie-like placidity that included the loss of motivation, foresight and intellectual capacity. No reliable balance was taken of its impact--no systematic specificity given to its degree or type of therapeutic effectiveness, no rigorous assessments made of how patients who underwent the procedure fared in comparison with those with the same disorders who did not. Valenstein supplies ample evidence that from the days of Moniz’s first reports, lobotomy was attacked by physicians for unfounded claims and shoddy methods. Indeed, the lobotomy rate declined precipitously in the early 1950s partly as a result of the mounting criticism, but also because of the new availability of drugs such as chlorpromazine and the increasing popularity of psychoanalytic therapy.
Valenstein ventures several reasons for the ascendancy of lobotomy. Among them were the ferocious professional ambitions and salesmanship of Moniz and Freeman, as well as the press’ uncritical popularizations of assertions by lobotomy enthusiasts ( Life reported the false claim that after lobotomy, 30% of otherwise “hopeless patients” were able to resume normal, productive lives). There was also, he argues, a professional self-interest on the part of physicians committed to somatic--as distinct from psychoanalytic--theories of mental disease and, by extension, to somatic therapies. The propensity to resort to lobotomy went together with a willingness to rely on electroconvulsive shock, metrazol and insulin-coma treatments. Finally, pressure to perform lobotomies often arose from patients’ families and from the superintendents of mental institutions, who saw in the procedure a chance to save money by making patients releasable.
Prof. Valenstein, who in 1976 wrote a report on psychosurgery for the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, set out to write a “cautionary tale from which there is much to learn that applies to current practice not only in psychiatry but in all of medicine.” He has succeeded handsomely, and has also produced a wholly accessible, compelling and authoritative work of history.