Last Resort: Psychosurgery and the Limits of Medicine

Professor Pressman’s death during the production of this book was a great loss to historical scholarship. He spent a decade revising his dissertation, which, itself, represented the best account of the American crusade for prefrontal lobotomies from the mid-1930s to the early 1950s; the result was a brilliant exposition of the ways in which psychiatrists and other medical practitioners approached illness. Pressman rejected a long-standing pattern in medical history through which practitioners have been judged by the degree to which they adhered to high scientific standards. Those standards tended to invoke a view of scientific efficacy held by the historian and esteemed medical professionals; implicitly, at least, this became the evaluative framework for an earlier era despite the actual standards and conditions of practice in that era. For an alternative, Pressman urged historians to focus on the social process of medical change in a particular time and place. Historians needed to describe how specific clinicians, always plagued by incomplete data and overwhelming uncertainty, guessed and stumbled and decided to proceed. Those whose perspectives gained recognition never adhered to pure scientific ideals: through personal rapport, often rushed clinical judgments, and other social and cultural variables, they persuaded their colleagues to deploy specific courses of therapeutic action under very imperfect conditions. Another era with a different cast of characters and circumstances would often characterize their work as unscientific.

With this as his perspective, Pressman told a story of the twenty thousand lobotomies performed in America, primarily during the 1940s, that differed greatly from important predecessor studies such as Elliot Valenstein’s Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (1986). Adolf Meyer’s psychobiology, formulated earlier in the century, provided Pressman’s point of departure. Meyer was not out to cure disease so much as to facilitate better adjustments by mental patients to their environments. In doing so, Meyer focused on a wide array of organic and social factors pertinent to the patient. This holistic approach considerably enlarged the map for mental health interventions of diverse sorts from practitioners with very different orientations.

Neurophysiologist John Fulton and neuropathologist Walter Freeman found places for themselves on this broad Meyerite map: they seized on the new lobotomy operations of Portuguese neurologist Egas Moniz. Fulton, excited by reports from Moniz and by his own subsequent laboratory and other investigations, established a story line that underscored how Moniz had applied prior clinical work on chimpanzees to the surgical treatment of human psychoses. Fulton’s narrative grossly exaggerated the clinical basis for Moniz’s procedure but gave American psychiatrists hope that they could cure their most hopeless chronic psychotic patients. Lobotomies promised “last resort” cures for the sickest patients, saving wasted human lives and freeing overcrowded state mental hospitals from some of the tedious, difficult, and often unrewarding work with these patients. As Fulton told his story, Freeman conducted large numbers of operations all over the country and emboldened other neurosurgeons, many of whom had become disillusioned with electroshock (ECT), a rather substantial organic intervention that they had hoped would improve “last resort” cases. In the mid and late 1930s, these surgeons began to perform lobotomies. The results seemed spectacular: in no few cases, the lobotomized patient no longer screamed and destroyed things, but appeared far more content, became neat, ate regularly, put on needed weight, interacted pleasantly with others, and performed elementary work tasks in the hospital. Some (fewer than one-third) were even released into the community. Thus, the operation was perceived as exceedingly successful. In the Meyerite perspective of the era, many patients had become much better adjusted to their environments.

The psychosurgery era peaked in the late 1940s, and then abruptly tapered off with the introduction of chloropromazine in 1954. This and successor psychotropic drugs promoted a post-Fulton narrative of how new medications promised “miraculous cures”—how they interacted with the human body less drastically, and were more effective...