Between the ego and the icepick: Psychosurgery, psychoanalysis, and psychiatric discourse

Bulletin of the History of Medicine

Volumn 82, Issue 2, 2008, Pages 387-420

  Raz, Mical ^a  

^a TEL AVIV SOURASKY MEDICAL CENTER   (Israel)

Author keywords

American psychiatry; Psychiatric discourse; Psychoanalysis; Psychosurgery; United States; Walter Freeman

Indexed keywords

ARTICLE; EGO; HISTORY; HUMAN; PSYCHIATRIC TREATMENT; PSYCHIATRY; PSYCHOANALYSIS; PSYCHOSIS; PSYCHOSURGERY;

EGO; HISTORY, 20TH CENTURY; HUMANS; PSYCHIATRIC SOMATIC THERAPIES; PSYCHIATRY; PSYCHOANALYSIS; PSYCHOSURGERY; PSYCHOTIC DISORDERS;

EID: 47749149237     PISSN: 00075140     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (131)

1. For a comprehensive account of the history of psychosurgery in the United States, see Jack D. Pressman, Last Resort: Psychosurgery and the Limits of Medicine (Cambridge: Cambridge University Press, 1998).
2. See also Elliot Valenstein, Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (New York, Basic Books, 1986)
3. for a less balanced but highly readable version, and Joel T. Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (Berkeley: University of California Press, 1997), to place lobotomy within the context of additional somatic treatments in psychiatry.
4. All of the archive material cited in this essay is taken from the Walter Freeman/James Watts Collection, the George Washington University, the Melvin Gelman Library, University Archives. It is listed only in box and folder format. Walter Freeman is hereafter referred to as W.F.
5. For example, Valenstein claims that "not one group took an effective stance against psychosurgery," despite the fact that many individuals opposed the practice: Valenstein, Great and Desperate (n. 1), p. 187. Stepansky writes of "the context of this cautious receptiveness to somatic intervention as a treatment option" within which prefrontal lobotomy was introduced: Paul E. Stepansky, Freud, Surgery and the Surgeons (Hillsdale: Analytic Press, 1999), p. 196.
6. Stepansky's book, Freud, Surgery (n. 3), follows the surgical metaphor in Freud's writings and Freud's relations with surgery and surgeons. His final chapters depict the psychoanalytical response to somatic therapies and, especially, to psychosurgery.
7. Ibid., p. 206.
8. Ibid., p. 197.
9. Stepansky describes his presentation of an early version of this chapter before the section on the psychiatric history of the department of psychiatry at Cornell University Medical College on 7 October 1998: ibid., p. 197.
10. Ibid.
11. Valenstein, Great and Desperate (n. 1), p. 183.
12. Ibid., p. 185.
13. Ibid., p. 183.
14. According to the book's index, Pressman refers to Freud on five different occasions, and dedicates six pages throughout the book to the dispute between psychoanalysts and psychosurgeons: Pressman, Last Resort (n. 1).
15. Ibid., p. 366.
16. For example, Pressman cites the suggestion given by psychoanalyst Smith ElyJelliffe, upon hearing of the development of psychosurgery, to excise solely the anal areas in the brain: Ibid., p. 84.
17. Ibid., p. 367.
18. Ibid., pp. 367-75.
19. Ibid., p. 385;
20. Group for the Advancement of Psychiatry (GAP), "Research on Prefrontal Lobotomy" (Report no. 6), June 1948, p. 1.
21. Pressman, Last Resort (n. 1), p. 372.
22. GAP Report (n. 17), p. 2.
23. Ibid.
24. Ibid., p. 1.
25. For an account of these developments, see Pressman, Last Resort (n. 1), p. 385.
26. Ibid.
27. Gerald N. Grob, "Psychiatry and Social Activism: The Politics of a Specialty in Postwar America," Bull. Hist. Med., 1986, 60: 477-501, on p. 486.
28. Pressman, Last Resort (n. 1), p. 377.
29. Ibid.
30. Jonathan Sadowsky, "Beyond the Metaphor of the Pendulum: Electroconvulsive Therapy, Psychoanalysis, and the Styles of American Psychiatry," J. Hist. Med. All. Sci., 2006, 61: 1-25, on p. 6.
31. See also Harry Stack Sullivan, Conceptions of Modern Psychiatry: The First William Alanson White Memorial Lectures (Washington, D.C.: The William Alanson White Psychiatric Foundation, 1947), p. 73.
32. Sadowsky, "Beyond" (n. 27), p. 21.
33. Ibid., p. 7 (n. 18).
34. Ibid., p. 14.
35. Valenstein, Great and Desperate (n. 1), p. 184.
36. Pressman refers to the same reference as does Sadowsky, while Valenstein and Stepansky both refer to the editorial in Psychiatry. Pressman, Last Resort (n. 1 ), p. 366;
37. Sadowsky, "Beyond" (n. 27), p. 6; Valenstein, Great and Desperate (n. 1 ), p. 180;
38. Stepansky, Freud, Surgery (n. 3), p. 198.
39. Harry Stack Sullivan, "Editorial," Psychiatry, 6 May 1943, pp. 227-29.
40. Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York: J. Wiley, 1997), p. vii.
41. Gerald Grob, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac, by Edward Shorter, Bull. Hist. Med., 1998, 72: 153-55.
42. Shorter, A History (n. 34), pp. 326-27.
43. Ibid., p. 225.
44. Additional works, such as anthropologist Tanya Luhrmann's study of the theory and practice of American psychiatry, have addressed the relations between psychotherapy and biological treatments in psychiatry following the advent of psychopharmacological therapies. Authors including Jonathan Metzl and David Healy have written of the impact of psychopharmaceuticals on the shaping of American psychiatry. Metzl, through a gender-focused analysis, demonstrates that in many ways, the psychoanalytic discourse was, in fact, continued within the "scientific" pharmacological discourse, and Healy has focused on the conceptual changes in psychiatric discourse following the advent of psychopharmacology. See Tanya M. Luhrmann, Of Two Minds: The Growing Disorder in American Psychiatry (New York: Alfred A. Knopf, 2000);
45. Jonathan M. Metzl, Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs (Durham: Duke University Press, 2003);
46. and David Healy, The Creation of Psychopharmacology (Cambridge: Harvard University Press, 2002).
47. Nathan G. Hale, The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917-1985 (New York: Oxford University Press, 1995), p. 250.
48. Ian R. Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada 1880-1940 (Ithaca: Cornell University Press, 1997), p. 86.
49. On Jelliffe, see John C. Bumham's biographical account and edited correspondence. John C. Bumham, Jeffiffe: American Psychoanalyst and Physician and His Correspondence with Sigmund Freud and C. G. Jung, ed. William McGuire (Chicago: University of Chicago Press, 1983).
50. Letter from William A. White to Smith ElyJelliffe, 7 August 1936, in The Inner World of American Psychiatry, 1890-1940: Selected Correspondence, ed. Gerald N. Grob (New Brunswick, N.J.: Rutgers University Press, 1985), pp. 125-26.
51. American neurologist and pathologist Walter Freeman (1895-1972) had a cardinal role in the development and active promotion of the lobotomy procedure in the United States. For a complete biography of Freeman, see Jack El-hai, The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness (Hoboken: J. Wiley, 2005).
52. "Some Observations of Obsessive Tendencies Following Interruption of the Frontal Association Pathways (Proceedings of the New York Neurological Society)," J. Nerv. & Ment. Dis., 1938, 88: 225-34, on p. 230.
53. Valenstein, Great and Desperate (n. 1), p. 184.
54. "Origin and Nature of Hypoglycemic Therapy of the Psychoses (Proceedings of the New York Neurological Society)," Arch. Neurol. Psych., 1937, 38: 200.
55. On Kurt Goldstein and the development of his holistic neurology, see Anne Harrington, Reenchanted Science: Holism in German Culture From Wilhelm II to Hitler (Princeton: Princeton University Press, 1996).
56. New York Neurological Society, "Some Observations" (n. 44), p. 228.
57. The invited participants were Walter Freeman, M. A. Tarumianz, Theodore Erickson, J. G. Lyerly, H. D. Palmer, and Roy Grinker. The moderator was Paul Bucy. A condensed version was published as "Neurosurgical Treatment of Certain Abnormal Mental States" in JAMA, 1941, 117: 517-26, and the entire typescript of the discussion is conserved in the Freeman/Watts archives, box 16, folder 23 (referred to hereafter as "typescript" for brevity). The citations that were not published in the JAMA version will be quoted from this reference.
58. In the original typescript (n. 49), Grinker states that "although I was not informed, I am apparently here to criticize the procedure as best I may and at least to indicate some words of caution" (p. 87).
59. "Neurosurgical Treatment" (n. 49), p. 521.
60. Typescript (n. 49), p. 87.
61. Freeman responds to Grinker's claims and notes that throughout the discussion, instead of saying "'I think' or 'I know' or 'I believe,'" Grinker said "'I feel.'" Freeman takes this as an indication of a lack of rational approach: ibid., 112-13.
62. "Neurosurgical Treatment" (n. 49), p. 527.
63. Typescript (n. 49), p. 117.
64. Walter Freeman and James W. Watts, "The Frontal Lobes in Their Relationship to the Ego and the Future," N.C. Med. J., 1941, 2: 288.
65. "Psychosurgery: An Evaluation of 200 Cases Over Seven Years," Baltimore, 22 October 1943. Freeman/Watts archives, box 16, folder 17.
66. Walter Freeman and James W. Watts, "Behavior and the Frontal Lobes," T. New York Acad. Sci., 2nd ser., 1944, 6: 310.
67. "In memoriam-S. Bernard Wortis, 1904-1969," Am. J Psychiatry, 1970, 126: 1037-38.
68. A. P. Solomon to W.F., Freeman/Watts archives, box 1, folder 3, 9 August 1947.
69. Bernard Glueck, "The Effects of the Hypoglycemic Therapy on the Psychotic Process," Am. J. Psychiatry, 1937, 94: 171-73.
70. William Menninger, "The Results with Metrazol as an Adjunct Therapy in Schizophrenia and Depressions," B. Menninger Clin., 1938, 2: 129-41.
71. Jan Frank, "Some Aspects of Lobotomy (Prefrontal Leucotomy) Under Psychoanalytic Scrutiny," Psychiatry, 1950, 13: 42.
72. Elizabeth Zetzel, "Psychoanalytic Observation Regarding the Dynamic Effects of Frontal Lobe Surgery," in Frontal Lobes and Schizophrenia, ed. Milton Greenblatt and Harry C. Solomon, (NewYork: Springer, 1953), pp. 185-94.
73. Ibid., p. 185.
74. Ibid.
75. Ibid., p. 193.
76. Pressman refers to Kalinowsky as the "American pioneer of electroshock therapy": Pressman, Last Resort (n. 1), p. 174.
77. For Kalinowsky's work, see for example, Lothar Kalinowsky and Paul H. Hoch, Shock Treatments and Other Somatic Procedures in Psychiatry [1946] (New York: Grune and Stratton, 1949)
78. or Lothar Kalinowsky and Paul H. Hoch, Somatic Treatments in Psychiatry (New York: Grune and Stratton, 1961).
79. Lothar Kalinowsky, "Problems of Psychotherapy and Transference in Shock Treatments and Psychosurgery," Psychosom. Med., 1956, 18: 399-403, on p. 399.
80. Ibid., p. 402.
81. In 1953, Eugene Brody published an article on the responses of lobotomy patients to comic cartoons in which he correlates the ability "to gain pleasure and to respond to the cartoon humor" with "regression in the service of the ego." Eugene Brody, "The Response of Schizophrenic Patients to Comic Cartoons Before and After Prefrontal Lobotomy," Folia psychiatrica, neurologica et neurochirurgica Neerlandica, 1953, 56: 623-35.
82. Eugene Brody, "Superego, Introjected Mother, and Energy Discharge in Schizophrenia: Contribution from the Study of Anterior Lobotomy," J. Amer. Psychoanal. Ass., 1958, 6: 481-501, on p. 499.
83. Ibid., p. 498.
84. Topectomy is a psychosurgical procedure which consists of the ablation of a smaller amount of the frontal lobe cortex than would be ablated in a lobotomy. It was performed for the same indications, mainly by neurosurgeons, as it was a more complex procedure than transorbital lobotomy.
85. James P. Cattell, "The Alterations of Ego Functioning after Topectomy," Psychoanal. Rev., 1954, 41: 117-18.
86. Paul H. Hoch, J. Lawrence Pool, Joseph Ransohoff, James P. Cattell, and Harry H. Pennes, "The Psychosurgical Treatment of Pseudoneurotic Schizophrenia," Am. J. Psychiatry, 1955, 11: 653-58.
87. Martin J. Schwarz, "Lobotomy, A 6-Year Follow-Up of 45 Patients," Am. J. Psychiatry, 1956, 43: 224-27.
88. Patient M.A. to W.F., 5 February 1956, Freeman/Watts archives, box 1, folder 7.
89. "Psychosurgery," Life, 3 March 1947, pp. 93-96.
90. Valenstein refers to this same article and reproduces the caricature within his book. He refers to its usage of psychoanalytic terminology and its claim that the lobotomy destroys the superego, and compares this to a similar article published in Time, which, he claims, "implied that the operation created a superego where apparently there had been none before," hence, in fact, supplying the very psychoanalytic terminology he found lacking in the Life article: Valenstein, Great and Desperate (n. 1), p. 180.
91. In his unpublished biography, Freeman writes: "Of the four assistants I employed while getting them started, only Bob Groh stayed in the general practice of neurology and psychiatry. The others, Zigmond Lebensohn, Paul Chodoff and Oscar Legault took their G.I. funds to pay for personal psychoanalyses, and became so deeply immersed that I lost them. I believe they sacrificed more than they earned, except possibly in the realm of inner satisfaction with the intellectual agility they developed." Freeman, unpublished autobiography, Freeman/Watts archives, box 9, folder 1, chapter 17, p. 1.
92. Oscar Legault, "Denial as a Complex Process in Post Lobotomy," Psychiatry: Journal for the Study of Interpersonal Processes, 1954, 17: 153-61.
93. Oscar Legault to W.F., 25 June 1954, Freeman/Watts archives, box 40, folder 1.
94. Zigmond M. Lebensohn, "In Memoriam - Winfred Overholser," Am. J. Psychiatry, 1965, 121: 832.
95. "George Washington University School of Medicine Proceedings of the First Post-Graduate Course in Psychosurgery," Digest Neurol. Psychiatr., 1949, 17: 407-54, on p. 429.
96. Ibid., p. 425.
97. John N. Rosen to W.F., 18 October 1958, Freeman/Watts archives, box 5, folder 7.
98. William A. White and Smith E. Jelliffe, Diseases of the Nervous System: A Textbook of Neurology and Psychiatry (Philadelphia: Lea & Febiger, 1935), p. 143.
99. Freeman, unpublished autobiography (n. 81), Freeman/Watts archives, box 9, folder 1, chapter 2, p. 11.
100. Walter Freeman, "Adolescents in Distress: Therapeutic Possibilities of Lobotomy," Dis. Nerv. Syst., 1961, 22: 555.
101. Walter Freeman, "With Camera and Ice-Pick in Search of the Super Ego" (unpublished manuscript), 22 April 1960, Freeman/Watts archives, box 10, folder 6.
102. Kenneth P. Rothfield, M.D., who wrote his bachelor's thesis on lobotomy in 1984 at Harvard University, interviewed James Watts and asked him, in a subsequent letter, the following question concerning this manuscript: "In this address, Dr. Freeman directly compared the effects of lobotomy to a Freudian model of mental illness. This is the first document I have found so far which makes this comparison explicit. I have enclosed a copy of the speech for you to read, and would appreciate any comments you might have. I am especially curious about whether Dr. Freeman ever compared the frontal lobes to the super ego during your association." No answer is conserved in the Freeman/Watts archives, and Rothfield does not recall receiving one. However, in his thesis, Rothfield states that Watts does not remember any such comparison: Kenneth P. Rothfield, "The Theory and Practice of Psychosurgery: Dr. Walter Freeman and the Lobotomy Era" (unpublished thesis), Harvard University, 1984; Kenneth P. Rothfield to James Watts, 25 January 1984, Freeman/Watts archives, box 10, folder 5; Kenneth P. Rothfield, personal communication, 18 October 2005.
103. Howard J. Faulkner and Virginia D. Pruit, Dear Dr. Menninger: Women's Voices from the Thirties (Columbia: University of Missouri Press, 1997).
104. Abraham Myerson, "The Attitude of Neurologists, Psychiatrists and Psychologists toward Psychoanalysis" [1939], Am. J. Psychiatry, 1994, 151(Suppl. 6): 48-54.
105. Ibid., p. 53.
106. Karl M. Bowman and Milton Rose, "Do Our Medical Colleagues Know What to Expect From Psychotherapy?" Am. J. Psychiatry, 1954, 111: 401-9, on p. 401.
107. Ibid., pp. 406-7.
108. Brody, "Superego" (n. 72), p. 499.
109. Bowman and Rose, "Do Our Colleagues" (n. 96), p. 401.
110. Braslow, Mental Ills (n. 1), p. 169.
111. Vernon Kinross-Wright, "Chlorpromazine Treatment of Mental Disorders" [1955], Am. J. Psychiatry, 1994, 151(Suppl. 6): 271.
112. Hale, Rise and Crisis (n. 39), p. 338.
113. On the treatment orientation of North American academic psychiatrists, see for example, J. Alexander Bodkin, Robert L. Klitzman, and Harrison G. Pope Jr., "Treatment Orientation and Associated Characteristics of Nordi American Academic Psychiatrists," J. Nerv. & Ment. Dis., 1995, 183: 729-35.
114. See, for example, such a letter from 22 December 1945, in which psychoanalyst Donald Winnicott warned: "are we to see our countryside littered with 'cured' mental hospital patients with permanently deformed brains?": Donald W. Winnicott, The Spontaneous Gesture: Selected Letters of D. W. Winnicott, ed. F. Robert Rodman (London: Harvard University Press, 1987), p. 7.
115. See also Donald W. Winnicott, "Leucotomy," in Psychoanalytic Explorations, ed. Clare Winnicott, Ray Shepherd, and Madeline Davis (Cambridge: Harvard University Press, 1989), pp. 534-41.
116. On the public images of psychoanalysis in the United States, see Hale, Rise and Crisis (n. 39), pp. 290-91.
117. On psychosurgery and the popular press, see Gretchen Diefenbach, Donald Diefenbach, Alan Baumeister, and Mark West, "Portrayal of Lobotomy in the Popular Press, 1935-1960," J. Hist. Neurosci., 1999, 8: 60-69.
118. On the state of American psychiatry in the first decades of the twentieth century, see Shorter, A History (n. 34), pp. 190-92
119. and Pressman, Last Resort (n. 1), pp. 146-57.
120. Jack Pressman makes a compelling argument for how, following his contexualized approach to the history of psychiatry, "at multiple levels, psychosurgery worked-then": Pressman, Last Resort (n. 1), p. 428.
121. For a contemporary historical view on the development and acceptance of somatic treatments in psychiatry, see Oskar Diethelm, "An Historical View of Somatic Treatment in Psychiatry," Am. J. Psychiatry, 1939, 95: 1165-79.
122. Garfield Tourney describes the change in attitude from "pessimism" to "tremendous early enthusiasm" with the appearance of somatic treatments for the "functional psychoses." Garfield Tourney, "History of Biological Psychiatry in America," Am. J. Psychiatry, 1969, 126: 29-42, on p. 35.
123. John J. Leveille describes the dominance of analysts in American psychiatry during the postwar period, writing that "analysts took over the most prestigious chairs and university departments in the 1940s," held leading positions in the American Psychiatric Association, and set the tone in the psychiatric curriculum in medical school: John J. Leveille, "Jurisdictional Competition and the Psychoanalytic Dominance of American Psychiatry," J. Hist. Sociol., 2002, 15: 252-80, on p. 252.
124. John Sadowsky points out that most of the biological treatments "were developed during the period when psychodynamic theory was at its peak of influence," Sadowsky, "Beyond" (n. 27), p. 25.
125. Hale, Rise and Crisis (n. 39), p. 214.
126. Ibid., p. 215.
127. Leveille, "Jurisdictional Competition" (n. 109), p. 275.
128. In fact, Paul Stepansky has claimed that American analysts "always fell back on their professional status as medical men" and hence could "ill afford to ignore an invasive procedure that . . . was emblematic of scientific medical psychiatry": Stepansky, Freud, Surgery (n. 3), p. 194.
129. Pressman claims that psychosurgery "was damned" from the psychoanalysts' perspective, while noting that the "polarization between the two camps" was not a necessary event: Pressman, Last Resort (n. 1), p. 367. In this article I have attempted to develop and present a different perception.
130. For a concise definition of psychoanalysis, see Jean Laplanche and Jean-Bertrand Pontalis, The Language of Psychoanalysis, trans. Donald Nicholson-Smith (London: Karnac Books, 1988), p. 367.
131. The eclectic trend in American psychiatry has been described by Hale, Rise and Crisis (n. 39), pp. 160, 343-44, 358.