This study joins a slew of in-depth monographs about twentieth century somatic therapies dating back to the vanguard publications of Elliot S. Valenstein and Jack D. Pressman.1 In his preface, Kragh contends that more lobotomies per capita were performed in Denmark than in any other country. And so he sets out to explain why Danish psychiatrists embraced the surgical procedure so enthusiastically. The book’s narrative is organized as a tripartite story of the treatment’s rise, heyday, and fall. It admirably underscores the panoply of factors involved in the mid-twentieth century practice of lobotomy, giving due consideration to institutional practices, medical debates, public health policy, legal statutes, public perceptions, doctors’ authority, and patients’ consent.

Kragh’s monograph is more than a history of lobotomy. The first five chapters present a valuable English-language overview of developments in twentieth century Danish psychiatry following the establishment of the Directorate for State Mental Hospitals in 1922. Kragh tracks the evolution of psychiatric hospitals and services through the 1950s. The Directorate’s role in supervising, centralizing, and expanding these facilities was augmented by national sterilization legislation in 1929 (and subsequent amendments in 1935), which generally legitimized and broadened the scope of surgical interventions. But that legislation also regulated the use of compulsory treatment and set limits on acceptable side-effects. For example, soon after these heroic somatic therapies were introduced, asylum doctors were required to obtain patient and family consent for the procedures.

Kragh argues that the expansion of psychiatric hospitals was accompanied and even promoted by promising new somatic therapies, especially Wagner-Jauregg’s malaria therapy for the treatment of syphilis in the 1920s (chapter 2), and then insulin coma and cardiazol shock therapies for the treatment of schizophrenia in the later 1930s (chapter 3). However, the heyday of these therapies proved to be short-lived: a nationwide study of the coma and shock treatments found them to be mostly ineffective, and too often even harmful. Nevertheless, their use helped to establish attitudes and practices that eventually influenced how later, after World War II, lobotomies were performed in public mental asylums. Far from being deterred by the relative inefficacy of somatic therapies, Kragh suggests that psychiatrists’ dashed hopes made them yet more receptive to lobotomies a few years later. In a profession still wanting for the kinds of spectacular advances enjoyed by other branches of mid-century medical science, these therapies further primed the pump for the introduction of lobotomies. Psychiatric interest in Denmark was further spurred by the 1939 meeting of the International Neurologist Congress in Copenhagen, where Walter Freeman, Ugo Cerletti, and Lucio Bini presented results of their psychosurgical and electro-convulsive treatments.

The promise of somatic therapies also influenced efforts to modernize psychiatric hospitals in the 1940s and enhance the profession’s public image. But Kragh notes an important distinction: whereas in the US psychosurgical treatments were sold as a means for reducing institutional overcrowding, this was not the case in Denmark, where overcrowding was not a serious problem. Instead, so-called “apostles of the knife” (p. 171) put forth other arguments that helped enhance lobotomy’s popularity among doctors and the general public.

In chapter 9, Kragh examines the selection of the “motley group” (p. 231) of prospective lobotomy patients. He finds that socioeconomic background was not a relevant selection criterion. Far more important was patient behavior on the hospital wards. Case records from the Vordingborg asylum show that nearly three quarters of all lobotomy patients came from wards for unruly and aggressive patients, while the medical criteria for their treatment was “highly diffuse” (p. 238). For patients from quieter wards, however, diagnosis, prognosis, and patient well-being were indeed relevant selection criteria. Significantly, in the overall majority of cases, the treatment was not viewed as a “last resort” (p. 249-256), as has sometimes been assumed in the historical literature. Although patient suffering and the failure of other therapeutic options were often also relevant indicators, they were subordinate ones. In other words, Kragh finds that lobotomies were performed on patients not primarily because they were either long-term chronic cases or because all other therapeutic options had been exhausted.

Kragh’s findings echo those of Jack Pressman and Joel Braslow for the US, and Marietta Meier for Switzerland, that women were far more likely than men to be subject to lobotomies. Hoping to explain these findings, Kragh devotes an entire chapter to female psychopaths at the Vordingborg asylum. In contrast to other studies, however, Kragh finds that dominant gender stereotypes of the time do not suffice in explaining the difference. Other factors, such as the hospital staff’s attitudes about aggressiveness, or patients’ prospects for discharge and their familial relationships, also influenced the therapeutic decision-making. For example, the stronger pressure to discharge women as opposed to men had doctors more likely to perform lobotomies on women. That said, elsewhere Kragh confirms that “an authoritarian attitude” (p. 323) among psychiatrists and gender “stereotypes of the day” (p. 324) substantially influenced whether doctors could obtain consent for the procedure. Kragh notes that at the time it seemed “legitimate for men to take decisions on women’s behalf” (p. 324). More robust consent rules evolved only later, in the wake of the Helsinki Declaration (1964), and were not codified in statute until the 1990s.

The book’s penultimate twelfth chapter turns to the demise of psychosurgery, beginning in the mid-1950s. The lobotomy shared much the same fate of other mid-century somatic therapies: its medical efficacy came to be seen as ephemeral, an artifact of professional hopes and ambitions that was unable to deliver comprehensive and lasting relief to suffering patients. Kragh attributes this shift less to any medical qualms about lobotomy’s effects than to changing social attitudes towards psychiatry and medicine. If anything, Danish psychiatrists were simply moving on to new therapies – either to psychotropic drugs, or less so to psychotherapy, or later to social psychiatry – rather than outright abandoning lobotomies. Indeed, medical faith in psychosurgery continued well into the 1970s. But from the mid-1950s, psychiatrists administered it more conservatively, eventually coming to see it as a therapy of last resort, especially after drugs had failed. It took a critical report by the Danish Board of Health in 1982 to effectively put an end to the practice.

The monograph is not without its faults. The book’s focus on lobotomy is at once both its strength and weakness. Telling the history of lobotomy lends itself to a narrative of rise and fall, but it also risks simultaneously eliding other continuities, as well as downplaying the wider dynamics and diversity of therapeutic repertoires. Most patients in psychiatric institutions were not lobotomized. What remains under-explored in Kragh’s account are the continuities of older therapeutic regimes, as well as the emergence of new alternatives. This reviewer often found himself asking where lobotomy stood in relation to other alternatives (work-therapy, psychotherapy, drugs), and indeed even to other more heroic options (surgical or chemical castration, endocrine therapies). Granted, these alternatives are sometimes touched upon, but the relationships could have been explored in greater detail. Recent research has underscored how different therapeutic arrangements could overlap and/or be sequenced with one another. This is especially relevant in psychiatry because, more so than in other medical specialties, therapeutic strategies often involved a substantial degree of trial and error, of “groping in the dark” (p. 56), in search of viable paths to recovery.

Kragh’s account can sometimes also seem repetitive. Time and again he reiterates that somatic treatments were favorably assessed by doctors, the press, and other observers. But this kind of repetition has nothing to do with a naïve faith in biological psychiatry. In fact, it is as much a historiographic artifact as anything else. Kragh’s narrative must struggle to overcome our own relentlessly pejorative view of mid-twentieth century asylums. And so what can sometimes read as repetitive overkill in fact challenges us to reflect upon the enormous divide separating our views about asylums from those of earlier contemporaries.

Overall, Kragh is in impressive command of his source material, advancing his arguments forcefully and effectively. The book is well organized and clearly written, refreshingly free of the self-indulgent jargon that so often blights other studies. Eschewing simplistic conclusions, Kragh has chosen to take the hard road of carefully analyzing psychiatric practices and contexts. As a result, his study stands head and shoulders above many lesser works. Future scholars will have no choice but to reckon with his conclusions.

Note:
1 See Elliot S. Valenstein, Great and Desperate Cures. The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness, New York 1986; Jack D. Pressman, Last Resort. Psychosurgery and the Limits of Medicine, Cambridge 1998; Joel Braslow, Mental Ills and Bodily Cures. Psychiatric Treatment in the First Half of the Twentieth Century, Berkeley 1997; Andrew Scull, Madhouse. A Tragic Tale of Megalomania and Modern Medicine, New Haven 2005; Mical Raz, The Lobotomy Letters. The Making of American Psychosurgery, Rochester 2013; Marietta Meier, Spannungsherde. Psychochirurgie nach dem Zweiten Weltkrieg, Göttingen 2015; Jonathan Sadowsky, Electroconvulsive Therapy in America. The Anatomy of a Medical Controversy, New York 2017.