Thursday, January 1, 2009

Review: Jack D Pressman, Last resort: psychosurgery and the limits of medicine, Cambridge History of Medicine series, Cambridge University Press, 1998

With the introduction of chlorpromazine in 1954, the reputation of lobotomy as a psychiatric treatment plummeted, becoming, by the time of the film One Flew Over the Cuckoo’s Nest, a symbol of psychiatric barbarity. In seriously attempting to put the history of this recently failed treatment, as opposed to a more remote example such as bloodletting, in its social as well as medical context, the late Jack Pressman took the risk of being called an apologist for psychiatry’s abuses. He has however, wonderfully avoided both bashing psychiatry and whitewashing the historical record by writing both “an intensive case study of the rise and fall of” of a treatment and “an extended musing on how we tell our stories of triumph and failure in science.”

One could give numerous examples of Pressman’s “musings on how we tell our stories.” Consider for one the priority dispute between John Fulton, the influential Yale physiologist, who claimed that his work on lobotomies on chimpanzees critically influenced Egas Moniz, the Portuguese neurologist, who won the Nobel Prize in 1949 for introducing lobotomy as a treatment for psychiatric patients. For Pressman the story of this priority dispute emphasizes a traditional narrative of scientific discovery. Pressman accepts the view that Fulton did not deserve recognition for priority. What makes his chapter on priority interesting, however, is that Pressman retells the story to show how Fulton’s insistence on the importance of his work on chimpanzees contributed enormously to legitimizing lobotomy by giving the procedure a veneer of scientific credibility as well as the imprimatur of Yale science.
Many of the chapters in this book attempt similar reworkings of accepted versions of the lobotomy story. Perhaps the most significant of these is Pressman’s detailed study of the records of patients who underwent lobotomies at McLean Hospital in Massachusetts. Since I was familiar with the story of Walter Freeman taking an ice pick to the brains of many indigent patients in state hospitals, reading Pressman’s account of thoughtful psychiatrists deciding which affluent patients in this elite hospital would receive the benefit of lobotomy made it easier to see a parallel between the practice of lobotomy and the treatment of severely ill psychiatric patients in the 1990s. Far from whitewashing lobotomy, Pressman’s approach provided an historical lens through which to see my own work more critically.
In addition to reconstructing clinical decision making practices at a single hospital, Pressman also puts the lobotomy story in the context of the evolution of the treatment of severely mentally ill patients in the United States in the twentieth century. One limitation of this is that he has nothing to say about treatment in other countries. Limiting himself to one national context is, however, a wise choice because it allows him to demonstrate social and intellectual synergies that otherwise would have gotten blurred. Of particular interest is his demonstration of how Adolf Meyer’s notion of psychobiology, the most influential psychiatric philosophy in the United States in the first half of this century, provided an intellectual rationale for the practice of lobotomy. Given psychobiology’s previous reputation as providing fertile soil for the growth of psychoanalysis, Pressman’s observation of its role in supporting the ultimate biological treatment gives the reader a new understanding of just how eclectic psychiatry was in the mid-twentieth century.
Last Resort is a fine book that deserves a wide readership. Unfortunately the author’s penchant for repeating his arguments again and again makes the book longer than it needed to be and will probably put off one group who would benefit from reading it--clinical psychiatrists. For historians, however, it is, as the author hoped it would be, both a detailed case study and a fascinating musing on how we tell stories.
Gerald Grob’s introduction spells out how much we have lost by the untimely death of this talented historian.

reviewed by Edward M. Brown, History of Medicine,

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