Jack D Pressman
Cambridge University Press, £40, pp 572 
ISBN 0 521 35371 8
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Rating: ★★★★
Psychosurgery forms an intriguing chapter in 20th century medicine that involved an alliance between psychiatrists, neurosurgeons, and neuroscientists in an attempt to help a desperate group of patients. Its rise and fall is an exemplary tale that reveals the scientific and intellectual status of clinical science. For that reason it is of interest far beyond the bounds of the specialties concerned. Jack Pressman tells this tale with a blend of historical ability and acumen that preserves him from the simplistic thinking of scientists attempting to write the history of medicine.
Pressman traces the course of psychosurgery in a way that rings true for any clinician, bringing out the complex factors involved in the acceptance of any medical innovation. He identifies a convergence between a theoretical bias toward hard biological science, suggestive experiments favouring a certain conclusion, and then a bold and dramatic clinical venture that initially seemed to have beneficial effects. He carefully charts the way in which “the procedure’s fate also became wrapped up in the currents driving psychiatry.” Among these were the revisioning of psychiatric disorder as maladjustment, the need to have some positive treatments to offer a hopeless remnant of patients, and the growing numbers of these chronic patients in state psychiatric hospitals. This, after some early and dramatic successes, made the lobotomy rate an indicator of the extent to which an institution was keeping up with modern trends in the care of patients.
Pressman discusses the difficulties of assessing outcomes and therapeutic effectiveness in psychiatry and the entwined intellectual, pragmatic, and social content in any medical advance. He distils a deep lesson for clinical science in general. We tend to see medicine as a smooth progress of the scientific method in which we discern and transcend the ignorance and therapeutic limitations of the past, but this is not so. In every age we are pushed and pulled by theoretical and therapeutic fashions, and what may seem like an exciting and innovative treatment at some point may later be viewed as not only obsolete but also barbaric.
Clinicians must somehow retain both scientific objectivity and an attitude of care for their patients in the face of this uncertainty. Healthy scepticism can be indiscernible from reactionary entrenchment in soon-to-be-outmoded ideas, and yet enthusiastic adoption of the new can lead to tragedy and suffering. Nevertheless, we go on into uncharted territory, where the waywardness of our path may be revealed only by a map drawn with the benefit of hindsight. Seen in this way, the story of lobotomy is the story of clinical medicine as we know it.