Book review

By Jack El-Hai. Hoboken, New Jersey, John Wiley & Sons, 2005, 362pp

Surgery may not be the most obvious treatment for mental illness. Surgeons are people who find it extremely rewarding to act and see the impact of their actions on their patients. However, operating on the body may not have very specific effects on a disordered mind. This fact has not hindered enthusiasts intervening surgically believing their outcomes to be positive.

Two recent biographical histories of eminent and notorious American psychiatrists are revealing about the tragedy of such excesses. Madhouse by Andrew Scull recounts the story of Henry Cotton (1876-1933), who believed that the cause of mental illness was the systemic effects of largely hidden chronic infections. Septic foci, therefore, must be searched for and eradicated. Even if many people were sceptical about the causal connection, Cotton argued that detoxification was nonetheless beneficial, and patients were relieved when they found that their mental condition was due to poisoning by infection.

The lobotomist by Jack El-Hai describes the life of Walter Freeman (1895-1972). Freeman thought that Cotton's theory of focal infection met its demise because of the drastic, and not infrequently fatal, operation of colectomy. The occasional satisfactory, if temporary, results from visceral surgery could be explained through the effects of shock, like other "shock" remedies, such as insulin coma, metrazol convulsions and electroshock. Nonetheless, Freeman believed in surgery for mental disorder. And anyway, "if the trouble is in the head, why work on the belly?". Partial separation of the frontal lobes from the rest of the brain, Freeman argued, draws the "sting" of mental disorder and gives relief to patienta by banishing the fear that so disabled them.

These books are both well written. They emphasise the extent to which it is misleading to view these men as essentially mavericks. They received considerable support from the psychiatric profession. For example, they were not opposed by Adolf Meyer, regarded as the dean of American psychiatry in the first half of the 20^th century. Meyer wrote Cotton's obituary, concluding that he had "an extraordinary record of achievement". He suppressed a report of the poor outcome of Cotton's work in the forlorn hope that he could persuade Cotton to accept the reality of his results. Perhaps because of what he had learnt through the excesses of Cotton, Meyer encouraged Freeman to follow up scrupulously the experience with each of his cases, which Freeman vigorously pursued during his life with cross-country trips to visit patients.

The entanglement of Meyer in these tales is significant as his psychobiological approach in theory stands in contrast to biomedical psychiatry. The lesson is that a psychosocial understanding of mental illness needs also to have a strong ethical foundation to be influential. The simplistic and biologically reductionist accounts of mental disorder which underpinned the work of Cotton and Freeman still enjoy widespread currency in modern psychiatry, particularly to sustain pharmacotherapy. These theories require as much faith and self-deception as those of Cotton and Freeman, even though we now wonder how the outrageous events described in these books could have occurred.