Beyond the "Two Psychiatries": Jack Pressman's Last Resort and the History of Twentieth-Century American Psychiatry: Introduction

After Jack Pressman's death in June 1997, friends and colleagues sought various ways to honor his memory. With the help of Guenter Risse, Jack's colleague at the University of California at San Francisco, I organized one such event for the 1998 annual meeting of the American Association for the History of Medicine in Toronto, Canada: a lunchtime symposium titled "Beyond the 'Two Psychiatries': A Roundtable Discussion of the History of Twentieth-Century American Psychiatry." Guenter Risse chaired the session, and shared his own personal reflections on Jack's career at the University of California at San Francisco. In preparing their presentations, the other participants--John Burnham, Ellen Dwyer, and Joel Braslow--were asked to comment on two related questions: first, what problems does writing the history of twentieth-century psychiatry pose for scholars; and second, how does Jack's work point to directions that future work should take? The papers in this Bulletin collection are revised versions of the talks that they gave at the Toronto meeting.

As we all realized in organizing this symposium, Jack's death could not help but affect the way his colleagues read what turned out to be his final piece of scholarship. Jack died shortly after finishing Last Resort: Psychosurgery and the Limits of Medicine, which was published posthumously in the spring of 1998. But even had Last Resort's publication not been marked by such sadness, these papers confirm its status as a landmark contribution to the history of psychiatry. In writing this book, Jack sought nothing less than to reshape the contours of the field. He did so by taking on one of the most celebrated, indeed notorious, instances of changing therapeutic standards in twentieth-century medicine: the rise and fall of psychosurgery in the 1940s and 1950s.

As Jack notes in his introduction, psychosurgery seems a "peculiarly wrongheaded, if not perverse" subject to use to understand the trajectory of medical progress. ¹ Yet "exclusive attention devoted to the best-case exemplars of medical science," he argues, provides a very misleading view of medical innovation. ² Using case records, professional correspondence, and scientific writings, Jack shows that at the high point of its popularity, psychosurgery met all the criteria for a legitimate therapeutic procedure: it had the backing of the best scientists and most concerned clinicians, and it seemed to offer hope to people otherwise doomed to a lifetime of misery. Understanding why psychosurgery achieved and then lost this legitimacy provides invaluable insights into the complexity of medical "progress." As Jack summed up in the epilogue, psychosurgery's history reminds us that "there is no sure shield against future advances in knowledge, no bulwark that can stand against the changing circumstances of the world in which medical practices are judged." ³

In what follows, three historians of psychiatry comment on where that insight might lead us in thinking about both the past and the future of American psychiatry. Representing the variety of traditions in the field, they approached this task from different perspectives. The most senior of the three scholars, John Burnham, has written extensively on the psychodynamic tradition in American psychiatry. His scholarship on the history of psychoanalysis, psychiatry, and psychology remains the standard work on those subjects. Ellen Dwyer's prominence rests on a different tradition, that of institutional social history deeply grounded in patient case histories and asylum records. Her perceptive history of the nineteenth-century asylum, as well as her research-in-progress on epilepsy, exemplify the value of the "behaviorist approach" to medical history that Erwin Ackerknecht called for in 1967. Finally, Joel Braslow brings the insights of the clinician-historian to the twentieth-century history of psychiatry. His recent book on somatic treatments in California mental hospitals during the 1950s is an excellent companion...