Eric J. Engstrom, Department of History, Humboldt University of Berlin
Marietta Meier’s book tells a story of the rise and fall of lobotomy in post-World War II Europe. The geographic and temporal focus of the study is Switzerland and especially Zurich in the 1940s and 1950s. But it also incorporates larger perspectives by situating itself historiographically within the context of other studies of twentieth century “societal, subject, gender, and knowledge regimes [Ordnungen]” (p. 14).
As a research strategy, Meier draws on Michel Foucault’s notion of problematization. In particular, she explores what specific problems the advocates of psychosurgery were responding to, the means deployed in order to resolve those problems, and the multifaceted implications of the psychosurgical ‘solutions’. Meier also invokes a cultural history approach that stresses the structural and symbolic meanings that historical actors attributed to their work by 1) examining various kinds of socio-medical interaction and, as the need arises, 2) shifting her own narrative perspective and analytical tools in the spirit of Jacques Revel’s ‘Jeux d’échelles’.
The book is organized chrono-thematically. It generally narrates the rise and fall of lobotomy, but also uses each chapter to open up new perspectives on psychosurgery. In addition, Meier draws repeatedly on medical records to track the hospital ‘careers’ of a few individual patients, using the continuity of their medical biographies to examine different themes as she moves from one chapter to the next. The result is a deeply layered and sophisticated historiographic reckoning with one of twentieth-century psychiatry’s most hotly disputed heroic cures.
After surveying so-called ‘active’ somatic therapies in the early twentieth century, Meier examines the conceptual underpinnings and practical technique of lobotomy. Advocates argued that lobotomy interrupted structures in the brain that regulated “affective tension” (p. 60) and thus reduced the intensity or took the “sting” out of the “emotional nucleus” (p. 15) of the psychosis. Meier interprets the notion of ‘affective tension’ as a boundary concept that enhanced its plausibility across several domains: it resonated with current thinking about the physiology of emotions, it seemed to confirm clinical findings, and it played to long-standing convictions that affective dysregulation was a significant aspect of many mental disorders.
Meier then turns to the rapid spread (and criticism) of lobotomy in Europe after World War II. She explores the circulation of medical knowledge and its permeation through global, national, and regional knowledge networks and cultures. Unsurprisingly, she finds considerable diversity in terms of whether and how lobotomies were used in different settings. She also examines the criteria used to determine the procedure’s effectiveness. Significantly, she finds that changes in patients’ personalities were deemed a price worth paying in order to reap the benefits of better social integration, reduced aggressiveness, and emotional relief. Advocates in Europe tended to insist that the procedure only be used as a last resort, mainly in the treatment of chronic schizophrenia, whereas in the United States it was used in the treatment of a broader spectrum of disorders.
Meier then examines patient records from the Burghölzi psychiatric hospital in Zurich, using them to reconstruct how patients became candidates for lobotomy and how doctors interacted with patients and relatives. Disruptive behavior, resistance to therapy, and a diagnosis of chronic schizophrenia were common characteristics. Ultimately, however, specific situative factors and the discretion of doctors had a major role to play in determining who was subject to the procedure. Meier is also able to demonstrate that lobotomy was first used mainly on women. She stresses that this was primarily because of a “double standard of mental health” (p. 209) whereby disruptive, loud, and aggressive women were more likely to clash with contemporary gender norms than men, whose violent behavior was less likely to be interpreted as a symptom of a treatable mental illness.
The book’s final chapter explores the decline of lobotomy and the introduction of new forms of treatment in the 1950s and 1960s. Meier argues that the decline was not simply the result of the introduction of new neuroleptic drugs or what many critics called “chemical lobotomies” (p. 275). Instead, it was due to a new psychoanalytic style of thought or ‘Denkstil’ that spawned efforts to treat schizophrenia psychodynamically. This new style of thought “shook the foundational assumptions of psychosurgery” (p. 262).
In her conclusion Meier posits four hypotheses that help to explain the significance of psychosurgery. First, she draws on Ian Hacking’s notion of ‘making up people’ to contend that psychosurgery produced new forms of subjectivity. Touted as the first therapeutic procedure that could produce a quick and lasting transformation of patients’ personalities, the success of psychosurgery relied upon and reinforced a new understanding of human personality not as a culturally formed and qualitative given, but rather as a malleable, surgically ‘treatable’, and biological attribute. Second, psychosurgery at once profited from and reinforced a collectivist ‘Subjektordnung’ that privileged the social conformity of patients over and above their individuality. Third, to explain the delay in the popularity of lobotomy, Meier emphasizes the importance of the Second World War. Citing Nikolas Rose, she points to the expanded role that psychiatrists and psychologists played not just in treating mental illnesses, but also in optimizing the governance of citizen-subjects. The war also facilitated a ‘can-do’ mentality that privileged quick and effective forms of treatment like lobotomy over more laborious and time-consuming cures. And fourth, Meier cites the persistent and growing criticism of lobotomy to argue that the very ‘Subjektordnung’ that psychosurgery had nourished and relied upon for its success was already being significantly undercut during the 1950s.
Overall, Meier has produced an authoritative and convincing account of mid-twentieth century psychosurgery. But there nevertheless remain a few problems with her study. For one, Meier is surprisingly reticent about patient consent. To date, much of the historical research on lobotomy has been driven by the looming ethical issue of whether psychiatric patients are and were able to consent to their treatment. Although Meier devotes considerable space to doctors’ interaction with relatives and guardians, she directs relatively fewer analytical resources toward patient consent.
In the book’s introduction, Meier is right to distinguish between neuro- and psychosurgery. But in doing so she has underestimated the importance of neurosurgery and its significantly better reputation as the ‘epitome’ of mid-twentieth century scientific medicine. More so than Meier appreciates, psychosurgery benefited from that reputation and used it to more effectively piggy-back its way to ‘success’ in psychiatry.
Furthermore, Meier’s stark juxtaposition of psychosurgery and psychoanalysis is somewhat misplaced. According to Meier, a new psychotherapeutic ‘Denkstil’ was the most important factor in the decline of psychosurgery. But this claim likely says more about the specific constellation of forces in Switzerland and Zurich under Manfred Bleuler than about developments generally. In the United States, where psychoanalytic theories and practices had made greater inroads, psychoanalysis and psychosurgery seem not to have been as antithetical as Meier implies: indeed, psychoanalysts sometimes agreed that lobotomies were effective and even interpreted their results in psychoanalytic terms as resolving ‘fixations’ or effecting ‘catharsis’. Furthermore, the foremost advocate of lobotomy in the United States, Walter Freeman, himself deployed psychoanalytic terminology in the promotion of his therapy, claiming that: “If a person had a strangulated hernia the only cure was surgical. What these psychotic patients were suffering from was a strangulated Oedipus complex”. In other words, Freeman and his acolytes had already co-opted the new ‘Denkstil’ of psychoanalysis in the promotion of their surgical technique. Meier ignores this, which is a problem because it helps to explain some of the early acceptance of lobotomy. In narrating her historical drama, Meier should have had psychoanalysis on-stage for lobotomy’s rise and not just for its downfall.
This also points more generally to the pitfalls of using ‘Denkstile’ to explain historical change. Not only is the concept fraught with difficulties when it comes to distinguishing which actors are in or out of any given ‘Denkstil’, but too often it also fails to grasp the resilient human ability to truck and hold contradictory viewpoints.
All of these criticisms aside, Meier’s account is far and away the best history we have of psychosurgery in continental Europe. For years to come it will remain an impressive standard against which future scholars will have to measure their work.
 Ian Hacking, Making up People, in: Thomas C. Heller / Morton Sosna / David E. Wellbery (Hrsg.), Reconstructing Individualism. Autonomy, Individuality, and the Self in Western Thought, Stanford 1986, S. 222–236
 See Elliot S. Valenstein, Great and Desperate Cures. The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness, New York 1986, pp. 180–187; Mical Raz, Between the Ego and the Icepick: Psychosurgery, Psychoanalysis, and Psychiatric Discourse, in: Bulletin for the History of Medicine 82,2 (2008), pp. 387–420; Katja Guenther, Localization and its Discontents. A Genealogy of Psychoanalysis and the Neuro-Disciplines, Chicago 2015, pp. 185–186.
 Valenstein, Great and Desperate Cures, p. 218.