Book Review

Last Resort: Psychosurgery and the limits of medicine

N Engl J Med 1998; 339:1719-1720December 3, 1998

Article

Last Resort: Psychosurgery and the limits of medicine
(Cambridge History of Medicine.) By Jack D. Pressman. 555 pp., illustrated. New York, Cambridge University Press, 1998. $49.95. ISBN: 0-521-35371-8

Last Resort is medical history at its best. No exercise in antiquarianism, it illuminates the meaning of a misguided therapeutic innovation so as to shed light on the dilemmas medicine continues to face in assessing therapeutic options. Pressman has conducted a close, careful, and thoroughly documented examination of original sources. Notes occupy 78 pages at the end of the book; they need not weigh down readers persuaded by the logic of the author's analysis, but they will be invaluable for the scholar who wants to review the evidence. This book is much more than an important contribution to medical history (as if that were not enough). Every student and practitioner in psychiatry, psychology, and social work — in short, any student who wants to understand contemporary psychiatry and medicine — will find Last Resort extremely rewarding. It should become required reading for all psychiatric house officers. Last Resort exemplifies the uses Joseph Needham ascribed to medical history in his History of Embryology (2nd ed. New York: Abelard–Schuman, 1959):

The history of science is the guarantee of its freedom. The mistakes of our predecessors remind us that we may be mistaken; their wisdom prevents us from assuming that wisdom was born with us; and by studying the processes of their thought, we may hope to have a better understanding, and hence a better organization, of our own. . . . Scientific men do not live in a vacuum; on the contrary, the directions of their interest are ever conditioned by the structure of the world they live in.

In November 1935, Egas Moniz, a Portuguese neurosurgeon, began a series of 20 leukotomies (procedures that partially destroy small areas in the frontal lobes). The procedure was carried out on 13 patients with agitated depression, of whom a majority were reported to be “clearly improved,” and on 7 patients with schizophrenia, of whom only 2 improved. Moniz's report of his success with psychosurgery led Walter Freeman, chief of neurology, and James Watts, chief of neurosurgery, both at George Washington University, to undertake what soon became the largest series of such operations in the world. So widely was the procedure hailed that a Nobel prize was awarded to Moniz in 1949.

Some 20,000 psychiatric patients in the United States had undergone psychosurgery by 1951. Although most of the procedures were done in state hospitals (where the majority of patients resided), university medical centers, private asylums, and Veterans Administration hospitals also performed them. Yet today, frontal lobotomy as such is no longer done. The entire episode has become an embarrassment to psychiatrists and neurologists, who prefer to dismiss it as a one-time aberration.

How did this painful episode come about? Were its advocates marginal practitioners? Why were errors that are so visible in retrospect not self-evident at the time? Pressman agrees that lobotomy was “a crude and reckless procedure devoid of any scientific justification,” but he is unwilling to settle for calling it “a medical mishap of epic proportions.” Those who ascribe the fad for psychosurgery to the moral and scientific failings of our predecessors miss its real lesson. The important question is how a therapy so highly valued at one point in time came later to be considered entirely useless. By raising and trying to answer that question, the author reminds us that the usefulness of a therapy is contingent on the era in which it is applied, that what is judged to work is specific to place, patient, and doctor, and that we are no less vulnerable to error than those who came before us.

Were the proponents of psychosurgery marginal? To the contrary, their intellectual lineage was illustrious. The most highly regarded American neurophysiologist of the middle third of this century, John Fulton of Yale, himself a pupil of Sir Charles Sherrington and Harvey Cushing, claimed credit for having inspired Moniz to try the operation because of the behavioral change Fulton reported after he made frontal-lobe lesions in chimpanzees. Watts, the neurosurgeon who first used the procedure in this country, trained with Percival Bailey in Chicago, Henry Viets and William Mixter at Massachusetts General Hospital, Fulton at Yale, and Francis Grant in Philadelphia, names to conjure with. Adolf Meyer, Richard Brickner, Kurt Goldstein, and Harry Solomon, leading authorities, commented favorably on the first reports of success. Edward Strecker, chairman of psychiatry at the University of Pennsylvania, called for it to be extended to patients with chronic schizophrenia. The procedure had many critics. They included such formidable figures as Smith Ely Jelliffe, Roy Grinker, William A. White, and Gregory Zilboorg. Their protests, however, were without avail.

Psychosurgery was introduced at a time when overcrowded and understaffed public hospitals were, as captured in the title of Albert Deutsch's book, The Shame of the States (New York: Harcourt, Brace, 1948). It was a time of despair among professionals and of readiness to attempt drastic remedies for desperate circumstances. The few psychiatric treatments thought to be effective for psychotic patients were electroconvulsive therapy, metrazol-induced convulsions, and insulin-induced coma, all of which carried a serious risk of injury, were unpleasant to experience, and were of uncertain efficacy. The changes in symptoms and behavior after psychosurgery left most observers in no doubt about its benefit. A 1943 review article in the American Journal of Psychiatry analyzed the results of the 618 lobotomies reported in the literature and found 31 percent of the patients described as “improved” and 35 percent as “recovered” — at the cost of 12 deaths resulting from the operation, 2 suicides, and 8 patients “made worse.” As to the psychic cost (some said lobotomized patients had lost their souls), Walter Freeman dismissed that concern with this statement: “Even if a patient is no longer able to paint pictures, write poetry, or compose music, he is, on the other hand, no longer ashamed to fetch and carry, to wait on tables or make beds or empty cans.” Freeman, it is important to add, was persuaded that the procedure converted “taxeaters” into taxpayers.

Fulton, along with others, began to have second thoughts about the increasing resort to psychosurgery without careful research on neuroanatomy. He arranged the 1947 meeting of the Association for Research in Nervous and Mental Disease as a challenge to Freeman before a distinguished audience. Unchastened, Freeman went on to introduce a new procedure, “transorbital lobotomy.” After using electroconvulsive therapy to produce unconsciousness in the patient, Freeman used an ice pick (literally) to crush through the bony orbit above each eye to produce brain lesions (the ice pick was later replaced by a specially built instrument). Frustrated by the slow pace at which the benefits of psychosurgery were being made available to patients in need, Freeman toured the country like a traveling evangelist. Between 1948 and 1957, he alone lobotomized 2400 patients in the last wave of psychosurgery. A man who had earlier distinguished himself as director of the research laboratories of St. Elizabeth's Hospital and as the founding secretary of the American Board of Psychiatry and Neurology, he ended his career as a self-righteous therapeutic zealot.

In the 1930s and 1940s, psychiatry lacked a method adequate to the challenge of evaluating therapy. Diagnostic categories had not been validated; existing psychometric measures failed to identify cognitive defects after lobotomy. Indeed, systematic evaluations of treatment were uncommon in medicine in general. The first published randomized, controlled trial was the Medical Research Council's trial of streptomycin for tuberculosis in 1948. Awareness of the inadequacy of existing research methods led the National Institute of Mental Health to convene a series of conferences between 1950 and 1953, but the actual quietus to psychosurgery was given in 1954 with the introduction of chlorpromazine, the first of a series of effective psychotropic drugs. Surgery had become redundant by the end of the decade.

Although better methods were on their way and moral sensitivities became keener, what ended lobotomy was new, more effective, and safer treatments. Randomized, controlled trials, institutional review boards, and Food and Drug Administration regulations were important steps forward. Have they made therapeutic decisions in medicine cut and dried? Not at all, as Last Resort makes clear, and as recent events affirm. Lidocaine “prophylaxis” continued to be prescribed for acute myocardial infarction long after controlled trials revealed consistently negative results; it is only a year since the widespread use of fenfluramine and phentermine for appetite suppression was interdicted after valvular lesions became apparent. Life is short, art long, opportunity fleeting, experience treacherous, and judgment difficult.

We owe Jack Pressman an enormous debt for Last Resort. Sadly, it is a debt we cannot repay except by honoring his memory. Just after sending the copy-edited manuscript to the press, he died suddenly and unexpectedly of cardiac causes, ending a short but brilliant career.

Leon Eisenberg, M.D.
Harvard Medical School, Boston, MA 02115