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Unkind Cuts

Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness

by Elliot S. Valenstein
Basic Books, 338 pp., $19.95

This is the book which for some length of time I have been awaiting. Not without trepidation, having lived through those lamentable years that made up what the author calls “the rise and decline of psychosurgery.” Professor Valenstein deals particularly with the mutilating brain operation known as a leucotomy—or, in the US, lobotomy—which was performed on tens of thousands of people before its decline in popularity during the 1950s. Most of the principals who developed this procedure were known to me and although I was little more than a disapproving onlooker, I was never an active protestor, I regret to say.

As Professor Valenstein points out in his scholarly account, the operation of leucotomy did not appear upon the psychiatric scene unheralded. The failure of conservative measures to alleviate the symptoms and behavior of a large and captive population of psychotics encouraged the introduction of procedures some of which were reckless, drastic, traumatic, and crude. As in frustration one kicks or thumps into action a faulty radio, the alienist resorted to measures that in every sense of the word were shocking. During the first thirty years of this century dangerous methods inducing states of hypoglycemia, smothering, suffocation, hypothermia, electroshock, or convulsant drug-intoxication were deliberately employed in cases where mental illness was intractable, distressing, or socially unacceptable. The author quotes the apt remarks of my friend the late Dr. Maurice Partridge.

Bizarre illnesses may require bizarre treatment, and in psychiatry they often get it. They show so often a stubbornness and resistiveness to treatment, they expose so clearly the ignorance of their pathology and aetiology that they arouse aggressive reactions in the baffled and frustrated therapist.

Disapproving of long-winded metaphysical attempts to solve the intrapsychic conflicts of the insane as practiced by analysts, those who were in charge of psychotic patients resorted either to desperate and ill-considered steps or else to studied inactivity.

Those of us whose professional lives had been devoted to helping vicitms of structural disease of the brain were horrified by these somatic treatments, which seemed to create the very problems we were trying to cure. A grim homeopathy, indeed. But, strange to say and reluctant to admit, occasionally such violent interventions seemed to work; or, at any rate, distressing symptoms lessened or even disappeared. No obvious explanation was available or even sought. Res ipsa loquitor, as lawyers say.

Neurological sensitivities had in fact already been blunted by the apparent success during the 1920s of treating cases of general paresis by a malaria-induced fever. Such patients had traditionally come within the province of neurologists and not that of psychiatrists or alienists. A few neurologists, like the distinguished Foster Kennedy, even welcomed the advent of insulin coma in schizophrenia as an offset to Freudian analysis. In his preface to the American edition of Sakel’s monograph on insulin shock therapy, he had written, in 1938, that the scholarship of his time was being “blown away by a new wind” and that “we shall not again be content to minister to a mind diseased merely by philosophy and words.”

All this, and much besides, Professor Valenstein tells us in his recital of the tangled story of the physical approaches to mental illness. It was in such a climate of uncritical complacency that Egas Moniz of Portugal introduced in 1935 a surgical attack upon the psychoses by way of a deliberate destruction of the white matter of the frontal lobes of the brain.

Who was this innovator Egas Moniz? And how did it happen that he, a respected neurologist, allowed himself to become involved in the care of the chronically in sane? The author’s answers to these questions are interesting. Since 1911, Egas Moniz had occupied the chair of neurology at the University of Lisbon. Highly unconventional, well-born, versatile, a thwarted politician, he received his medical training at Coimbra University, with postgraduate study in Paris at the feet of such prominent neurologists as Pierre Marie, Jules Dejerine, Josef Babinski, and, particularly, Jean Sicard. Already he had attained fame through his invention of cerebral arteriography, which demonstrated graphically the pattern of the arteries of the brain—a valuable diagnostic aid. This discovery led to flattery from Babinski, who proclaimed that Moniz had set forth on the enterprise as courageously as his compatriots of the fifteenth century, the explorers Bartholomeu Diaz and Vasco da Gama. He was being extravagant in his praise, for to design a clinical device entails ingenuity rather than inspiration.

From the evidence available, it seems likely that the stimulus to his venture into a surgical treatment of the insane was the Second International Congress of Neurology held in London in the summer of 1935. One entire day’s deliberation was devoted to the topic of the frontal lobes of the human brain. The contributions set off in his mind ideas that he debated with his young colleague, Pedro Almeida Lima. They had been hearing at the congress—as I well recall—how surgical “ablation,” or removal, of the frontal lobe in tumor patients was sometimes followed by an unempected change for the better in their mental symptoms. Could it be that deliberate destruction might, therefore, prove an effective remedy for psychotics whose behavior was uninhibited and unmanageable? Such dangerous thinking was unusual for a neurological physician whose responsibility did not ordinarily entail the care of schizophrenics and “cyclothymes,” i.e., people suffering from manic-depressive psychosis.

Back home in Lisbon, Moniz could not rid his mind of these notions and sought an opportunity for putting them to the test. Without delay he secured the transfer to his service of a few mentally deranged patients from the local lunatic asylum. Within a couple of months he was able to publish in several medical journals the results of the destruction of the frontal lobes in twenty patients. In the first seven, he instilled absolute alcohol into the substance of the brain, but afterward he rejected this procedure in favor of a blind sectioning of the white matter with a narrow knife or “leucotome” introduced by way of six trephine holes bored into the most forward part of the skull. This intervention he called a “leucotomy,” the first step in “psychosurgery,” as Moniz put it.

Not only was Moniz no psychiatrist, he was no surgeon. Because of chronic gout his hands were crippled and deformed; he therefore instructed his colleague, Almeida Lima, to act as a technician working under his direction.

Moniz claimed he had been pondering over psychosurgery for several years previously, though there is no written evidence to support this contention, either from him or from any of his colleagues in Portugal. Valenstein is critical of Moniz—and rightly so—on several counts: the haste with which he embarked upon these drastic measures; the lack of careful case selection; an inadequacy in documentation; and the paucity of follow-up studies. Certainly publication was far too precipitous. We may also add the element of imprudence, a trait which sometimes masquerades as courage or boldness.

The author stresses that the hypothesis behind psychosurgery was based upon the flimsiest of reasoning. On the assumption that thoughts and ideas are somehow stored in the frontal lobes among the fibers that connect nerve cells, serious mental disorders were attributed to “fixed thoughts” that had become established to an abnormal degree, and could not be dealt with except by their destruction.

In the interesting biographical account of Egas Moniz written by Antonio Damasio, one-time neurologist in Lisbon, we learn rather more about the personality of Moniz.* He was a lifelong gambler, something that implies an innate recklessness. As to his views on frontal lobe function, Damasio wrote:

Moniz was the organicist par excellence and he clearly conceived psychiatry as a kind of desert soon to be invaded by neurology. Although his approach was sometimes crudely mechanistic, it was not unlike that of a present day cybernetician. He thought, for instance, that ideas were linked to a certain circuit or set of circuits which tended to become fixed by conditioning.

Thus Moniz rationalized his experimental surgery. With the minimum of preparation, with no animal studies to test the safety or otherwise of the procedure, Moniz went on further to justify his undertaking. His admirers generally claimed that creative genius enabled him to see beyond all the possible risks and opposing arguments. Valenstein asserts that there was nothing about any of his arguments that should have persuaded a prudent man to attempt psychosurgery. “It was not genius that enabled Moniz to see beyond the risks; rather, it was his willingness to take these risks.”

Of the twenty patients who were leucotomized, he claimed that seven “recovered,” seven “improved,” while six were “unchanged.” Four of the twenty patients had been referred to him by his friend Sobral Cid, the professor of psychiatry at the University of Lisbon. Dr. Cid, however, soon betrayed a disapproval of his colleague’s venture, and thereafter refused to cooperate. Neither did Moniz secure the backing of the other outstanding neurologists in Lisbon—Dr. António Flores and Dr. Diogo Furtado. After an initial period of cooperation, serious hostility developed between the latter and Professor Moniz.

The patients who were said to have improved were those suffering not from mental derangement but from anxiety and depression. Chronic schizophrenics with marked thought disorders benefited little, if at all. The statement that seven of the patients were “cured” does not convince Valenstein, who considers the accounts that were made available of their postoperative state as being wholly inadequate. The most glaring deficiency, in his opinion, was the brevity of the follow-up period.

Moniz claimed that his operation neither interfered with intelligence nor impaired memory, without, however, giving any data in support. In June 1936 when his monograph was published in Paris it was nonetheless acclaimed widely. Thereafter the operation of leucotomy was practiced on a considerable scale.

From Professor Valenstein’s book we cannot determine how long Moniz and Lima continued to perform leucotomies in Portugal. Moniz retired from his university post in 1944 when he reached the age of seventy, and his chair devolved upon the gifted and scholarly António Flores, who was “critical of Moniz’s venture into the unknown” (Damasio). Moniz continued to write until his death in 1955.

Psychiatrists and neurosurgeons in other parts of the world were not slow to adopt the procedures of leucotomy. Cases were reported in Brazil, Cuba, Romania, and Great Britain, but the majority of operations took place in Italy. Various modifications in technique came about, according to the whims of the surgeons involved.

In pursuance of this grisly saga, we find the center of activity moving from Lisbon to Washington, DC, where, in 1936, the neurologist Walter Freeman read with excitement the accounts of what Moniz had been doing. Although not a surgeon, he determined to adopt the technique immediately after his return from vacation. Perhaps it would not be inappropriate to speak of him as jumping on the bandwagon. He enlisted the interest of his neighbor James Watts, a neurosurgeon, while ordering from a Paris firm of instrument makers two “leucotomes” as devised by Moniz. He also sent Moniz a congratulatory letter, to which came a friendly reply as well as a signed copy of the monograph on leucotomy.

  1. *

    Egas Moniz, Pioneer of Angiography and Leucotomy,” Mt. Sinai Journal of Medicine (1975), pp. 500–513.

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