THE SCENE IS AN OPERATING THEATER at the George Washington University Medical School in Washington, DC, in the mid-1940s. A number of support staff are present in the room, but there are three main actors: a masked figure, who is performing the surgery; another medical man, who sits holding the hand of the patient, talking in measured tones, asking the questions; and the patient himself, a twenty-four-year-old railroad brakeman named Frank, who has been given a local anesthetic to dull pain at the site of the initial surgical incision, and a dose of morphine to calm him, but not so strong as to prevent him from taking part in the conversation that follows. The site of the incision has been shaved, wiped down with soap and water, cleansed with ether, and marked with gentian violet. The patient’s head is supported by a sandbag, and his hands and feet are strapped to the operating table. A rubber dam has been placed to direct the flow of blood that accompanies the start of the operation, and towels screen off the site of the incision.
What follows is a transcript provided by one of the principals, who made a point of recording many of the operations he took part in. The conversation takes place against the background of the usual sound effects of surgery: the rattling of instruments, the hissing of the suction used to clean the wound, the crunch of the chisel, and the grinding of the drilling machine used to cut through bone:
Doctor: Are you scared?
Frank: Yeh.
Doctor: What of?
Frank: I don’t know, doctor.
Doctor: What do you want?
Frank: Not a lot. I just want friends. That’s all. How long’s this going on?
Doctor: Two hours.
Frank: Two hours? I can’t last that long. (Squeezes hand)
Doctor: How do you feel?
Frank: I don’t feel anything, but they’re cutting me now.
Doctor: You wanted it?
Frank: Yes, but I didn’t think you would do it awake. Oh. Gee whiz, I’m dying. Oh, doctor. Please stop. Oh, God, I’m goin’ again. Oh, oh, oh. Ow. (Chisel) Oh, this is awful. Ow. (he grabs my hand and sinks his nails into it) Oh, God, I’m goin’, please stop.
Doctor: Frank?
Frank: Yeh?
Doctor: What work have you done?
Frank: A little bit of everything.
Doctor: Such as what?
Frank: Brakeman on a railroad. That was a good job. Ow … and a material checker.… Ow … stop, unh, unh, uhn. [The doctor records that at this point the patient is scarcely controllable, even though fastened down to the operating table.] I liked that one, too. Hey, listen, cut it out for God’s sake. Oh, quit, I’m goin’. What’s goin’ on? … Hey, give me some air. (The towels have slipped a bit) Hey, what’s goin’ on? Oh, please stop.
Doctor: Relax!
Frank: I can’t relax. Oh, what’s going on here? (Rongeur [a device for removing bone]) (Admits he feels no pain) Hey this is … oh, you know I can’t go on. Oh, I’m having trouble breathing. Oh, stop experimenting.
Doctor: Stop what?
Frank: I don’t know. How long’s this goin’ on? Fix it up. I’m having trouble breathing.
Doctor: Feel better now?
Frank: No, I’m getting worse. I’m goin’. Oh, come on, will you?
Doctor: How much is a hundred minus seven?
Frank: Ninety-three, unh, unh, ow! (Tapping) eighty-six, seventy-nine, seventy-two, sixty five (Drilling) Ow! I don’t know. Give me some air. Air, Air. Ow! Hey, Cut it out. Cut it out! (Trembling hands still cold. He is quick to grab my hand when I try to take it away.)
Doctor: How do you feel?
Frank: Yes, sir. Click.
Doctor: What’s it like?
Frank: Oh, a pickle puffle phi, hey, stop it, will ya?
Doctor: You’re grabbing me awful tight.
Frank: Am I? I can’t help it. How long does this go on?
(Right lower cuts)
Doctor: Glad you’re being operated?
Frank: Yes, it makes me feel better.
Doctor: Why all the fuss?
Frank: Oh, I can’t help it. I can’t breathe. Hey, what are you doing there?
(Right upper cuts)
Doctor: Feel all right now?
Frank: Yeh, I can’t breathe. Hey, when is this thing over?
Doctor: What will you do when you are well?
Frank: Oh, go back to work. Oh, I can’t stand it.
Doctor: What job?
Frank: Oh, it’s a good job, brakeman with a railroad.
Doctor: Scared?
Frank: Yeh.
Doctor: Sing God Bless America.
Frank: (He starts rather high and does a couple of lines, then grunts and continues his chatter) Ow! That’s hot. What’s going on here? (Warm saline) (Left lower cut) (Left upper cut) (Stabs left)
Doctor: Was that hot?
Frank: No, it wasn’t hot.
Doctor: How do you feel?
Frank: Yes, yes.
(10.15 a.m. He is moving his head about during the stabs) (Stabs right) (Voice suddenly becomes muffled)
Doctor: Who’s operating?
Frank: I dunno.
Doctor: Are you uncomfortable?
Frank: No.
Doctor: Why do you jerk around?
Frank: I don’t know.
Doctor: Can you breathe?
Frank: Yes. (He thumps with his hands which are now quite warm and pink.)1
The silent surgeon is Dr. James Watts. The figure holding the patient’s hand and talking him through his ordeal is Walter Freeman, and the operation is a standard lobotomy, one that would be performed by the tens of thousands in the 1940s and would win for its inventor, the Portuguese neurologist Egas Moniz, the 1949 Nobel Prize for Medicine.
Freeman and Watts initially performed this surgery under local anesthetic, though Freeman adopted a different approach after the war, using a series of electroshocks to induce a coma before inserting an ice pick through each eye socket into the brain. They used a series of stock questions to elicit conversation from those whose frontal lobes they were severing. By a process of trial and error, they had concluded that the signal to stop cutting was when the patient began to be confused. Cease before that, and the patient would most likely remain as psychotic as before. Cut further and the brain damage would be too severe. It was a rough-and-ready standard but sufficient in their eyes to term this a “precision” lobotomy. On occasion, the conversations were more macabre than the one recorded here, as when Patient 53 responded, after a long pause, to Freeman’s stock question “What’s going through your mind?” with what under other circumstances might be regarded as remarkable sang-froid, “A knife.” (The outcome of the operations, in both cases, is unrecorded.)
Freeman was quite aware of the existential agonies his patients suffered during the surgery but the need to know when to cease severing brain tissue meant that this unfortunate side effect was unavoidable. As he explained in an article he co-published with Watts in 1950: “An operation under local anesthesia is always a somewhat trying experience to the patient. This must be doubly so when the patient knows his brain is being operated upon.… [A] number of patients have informed us, both before and after the operation, that they accepted the operation in the hope that it would kill them.… Apprehension becomes a little more marked when the holes are drilled, probably because of the actual pressure on the skull and the grinding sound that is as distressing, or more so, than the drilling of a tooth.”2
Once the skull had been opened, the cutting of the frontal lobes proceeded quite quickly; whatever protests the patient mounted generally died away as the operation drew toward a close.
IN JULY 1935, five years or so before he sat talking Frank through his lobotomy, Freeman sailed for England to attend the Second International Neurological Congress. By a stroke of good fortune (for Freeman, if not for his future patients), he made the acquaintance there of an eminent Portuguese neurologist, Egas Moniz.
Freeman had by then established himself as one of the up-and-coming neurologists of his generation in America, helped by the fact that he was the grandson of one of the founders of the field, William W. Keen, who, along with Silas Weir Mitchell and George Morehouse, had written a classic text, Gunshot Wounds of the Nervous System, based on their experiences in the Civil War. Later, Keen had attempted some pioneering brain surgery, and in the opening decades of the twentieth century he was widely recognized as one of the grand old men of American medicine. His eminence was something Freeman aspired to emulate, and his grandfather’s influence had helped Walter secure training in Paris in the 1920s under the eminent neurologist Pierre Marie, eventually paving the way for a post at the George Washington School of Medicine, a position he took up in 1926. His professorship at George Washington was less impressive than it sounded. Neither that medical school nor its rival Georgetown had much in the way of resources, and neither had been very successful in meeting the heightened standards for medical education that the Rockefeller Foundation had been heavily involved in promoting in the first three decades of the twentieth century. Indeed, in 1931, both medical schools briefly faced the threat of loss of accreditation and closure.3
Two years before he joined the faculty at George Washington, his grandfather’s influence had won Walter a well-paid job at the federal mental hospital St. Elizabeths. He was seeking (like many before him) to uncover a physical cause for schizophrenia, and this position, which lasted nine years, had given him the chance to perform hundreds of autopsies. In 1934 he had parlayed his professional connections into an appointment as secretary to the newly formed American Board of Psychiatry and Neurology, a powerful position he would occupy for more than a decade. The publication of a well-received text on neuropathology further burnished his credentials, though the process of writing the book almost derailed his career.
Prone to insomnia, Freeman slept little while completing the manuscript, working at a manic pace. He collapsed on completion, suffering from what he himself called a “nervous breakdown,” which was in reality a full-blown manic episode, accompanied by the delusion that he was dying of cancer. Travel to Europe brought some relief, as did taking the barbiturate Nembutal to secure regular sleep. From this point forward, Freeman was addicted to (or as he preferred to put it, dependent on) the drug to function, using a cold shower in the morning to restore some semblance of normal mental functioning if his senses were still numbed.
Freeman arrived in London eager to connect with European neurologists and psychiatrists. One of the features of these medical meetings was the setting up of booths outside the meeting rooms where the participants could present versions of their work. Moniz and Freeman found themselves next to one another and struck up a conversation. Surgery on the brain had long been hampered by the absence of imaging technology that could capture soft tissues. X-rays, which had revolutionized orthopedic surgery, were of little use to neurosurgeons, and this was a problem Moniz had tackled in the late 1920s. He experimented with the injections of strontium and lithium bromide, hoping to visually capture the arterial circulation of the brain to help locate brain tumors, hematomas, and aneurysms. The technique was a failure, and one of the three patients he injected died. But he persisted, injecting another three patients with a 25 percent solution of sodium iodide, and this time got positive results.
Freeman’s own exhibit featured a modified version of this technique using thorotrast, a radioactive contrast medium that was opaque to X-rays with few apparent side effects. (Unfortunately, it lingered in the body and was later found to have powerful carcinogenic effects.) Freeman found the Portuguese “a kindly old gentleman, who had made a great discovery and could now rest on his laurels.”4
Both men subsequently attended a full day of presentations on the frontal lobes of the brain. Wilder Penfield of McGill University, renowned for his surgical treatment of epilepsy, reported that he had operated to remove an enormous brain tumor from a patient (who was, in fact, his sister) and had been forced, in the process, to remove much of the frontal lobes. Richard Brickner, a New York neurologist, spoke about a stockbroker, Patient A, with a large frontal meningioma, who had been operated on by the neurosurgeon Walter Dandy at Johns Hopkins.5 A’s intellect had survived the operation, but his personality had been transformed. Formerly shy and introverted, he had become vivacious and boastful, lost all sense of self-restraint, threw tantrums, and grew uninterested in his appearance or personal hygiene. Brickner noted that in a casual setting, the patient could appear to be normal, but his peculiarities “rapidly became manifest” when closer attention was paid. The patient showed impaired judgment and restraint, pathetic attempts to assert superiority, emotional lability, and generally infantile behavior. His capacity for complex thinking and his initiative seemed to have disappeared.
Following Brickner, Spafford Ackerly, a neurosurgeon at the University of Louisville, reported a similar set of findings in 1935 with respect to a female patient he had operated on for a brain tumor in Louisville in 1933. Putting the best possible face on the results, he nonetheless found she exhibited slowness and perseverance postoperatively. Initially her husband said that she would not do as she was told, but he reported later that she was more docile and cooperative.6
These presentations reflected an emerging consensus on the importance and role of the frontal lobes among the nascent neurosurgical community. The battlefield casualties of the First World War had presented the medical establishment with a number of cases of patients with brain damage, often to the frontal lobes, and they were known to exhibit a pattern of euphoria and childlike behavior, particularly evident when the brain damage extended bilaterally. To the study of these military casualties, neurosurgeons could add reports of cases involving tumors or accidental damage to the frontal lobes. Taken together, there was now a growing and consistent set of findings about the effects of lesions of this sort.
The Chicago neurosurgeon Percival Bailey, who had served at the front in the First World War, worked at Harvard on return under the tutelage of the leading neurosurgeon of the age, Harvey Cushing. Cushing, who trained at Johns Hopkins and in Switzerland and England and spent most of his career at Harvard, was the first surgeon to have even a modicum of success operating on the brain. To be sure, his patients with malignant brain tumors generally died within a year or fifteen months, as such patients still do today. But those with benign tumors or traumatic brain injuries for the first time had some chance of survival, and the flamboyant Cushing became a famous figure.7
In the decade that followed Bailey’s time at Harvard, he and Cushing pioneered the classification of brain tumors, and he developed more effective techniques to operate on them. Their work stood in stark contrast with earlier surgery of this sort. Lacking imaging technology to locate the tumors, and without adequate lighting in the operating theater, successful interventions were previously rare. The sessions on the frontal lobes at the 1935 Congress reflected recent advances in surgical techniques, and the emergence of a still-small but growing number of specialists willing to operate on the brain.
With far more experience than most of his fellow neurosurgeons, Bailey spoke with authority about his hesitations about “amputating a frontal lobe. This procedure is always followed by a more or less great alteration in character and defects in judgment,” he warned, “when the patient is a professional businessman, who must make decisions affecting many people, the results may be disastrous.” With housewives and “washerwomen” he had fewer qualms about operating, reasoning that they could manage with less need to exercise judgment and initiative.8 Men’s brains mattered more.
Seen in this context, Penfield’s, Brickner’s, and Ackerly’s papers could be read either as a sobering commentary on the deficits that followed frontal lobe surgery or, alternatively, as documenting the ability to survive and function even following such trauma.9 Their reports added further weight to the remarks of the distinguished French neurologist Henri Claude, whose wide-ranging survey of the field had opened the session. All available evidence, Claude pointed out, suggested that “altering the frontal lobes profoundly modifies the personality of subjects.”10
Later in the day, John Fulton moderated a separate session on the physiology of the frontal lobes. Fulton had studied under the eminent Charles Sherrington at Oxford and then took a position at Harvard, where, like Percival Bailey, he befriended Harvey Cushing. In 1927, at thirty, he had become the youngest-ever Sterling Professor of Neurophysiology at Yale.
At the Congress, one of his young associates, Carlyle Jacobsen, reported on work on memory he had been doing with primates, most notably with two chimpanzees, Becky and Lucy. If the chimpanzees remembered the tasks they had been presented with, they were rewarded. As the experiments grew more complicated, Becky failed the tests. She grew increasingly frustrated, rolling on the floor, raging, defecating, and throwing her feces at her tormentors. Jacobsen arranged for Fulton to remove the frontal lobes of both chimpanzees, and the change in Becky was startling. It was as if, he commented, she had joined a “happiness cult” or “placed [her] burdens on the Lord.” Her failures no longer concerned her. She was tamer and easier to manage, but also, as he would subsequently reveal, “severely deteriorated.”11 The full extent of her deterioration was only revealed some twelve years later, when Jacobsen and other members of the laboratory confirmed how badly damaged Becky and Lucy had been postoperatively, exhibiting “erratic” performance across a wide variety of tasks and “profound behavioral deficit.” Becky had lost the ability to groom or care for herself, something that would have been a fatal defect in the wild.12
Fulton would later claim that it was listening to his and Jacobsen’s paper that prompted the Portuguese neurologist to start operating on psychiatric patients, though Moniz strenuously denied it. More than a decade later, Fulton went so far as to claim that Moniz had approached him at the end of the talk to ask if he had thought about operating on human beings. It is difficult, after all this time, to know whom to believe, but the most thorough historian of lobotomy, Jack Pressman, was skeptical of Fulton’s claims, going so far as to call them “fabrications,” a conclusion my own work in the archives supports.13
WHATEVER THE CASE, on November 12, 1935, Moniz began to perform operations on the frontal lobes of patients at the Santa Marta Hospital in Lisbon. To be more precise, since Moniz was crippled by gout and arthritis, he had the Oxford-trained neurosurgeon Almeida Lima undertake the surgery for him. At first, Moniz had Lima drill holes into the skull and inject alcohol into the brain, but he soon decided the destructive effects of this technique were too unpredictable. Instead, he had Lima “crush white matter” and cut a half-dozen cores out of the frontal lobes with a device he dubbed a leucotome. Moniz instantly pronounced the procedures, which he referred to as leucotomies, a grand success, “simple, [and] always safe.” His initial announcement, in a French medical periodical, was rapidly followed by a monograph, Tentatives operatoires dans le traitement de certaines psychoses, and several more papers trumpeting his discovery and asserting that “it’s by adopting an organic orientation that [psychiatry] will make real progress.”14
Remarkably, Moniz’s longest postsurgical follow-up was a mere eleven days. Later, he would concede that “deteriorated patients obtain slight or no benefit from the treatment”—a concession that accords awkwardly with his claimed success in his first twenty patients, since these were allegedly chronic patients from the back wards of Portuguese mental hospitals.15 We know that Moniz’s first patient, whom he proclaimed “a great success,” was an agitated depressive who spent the rest of her days confined at the Bombarda mental hospital, and she was followed by a series of patients described as suffering from agitated depression or paranoid schizophrenia.16 Sobral Cid, the superintendent of the Bombarda mental hospital in Lisbon, who had supplied the first dozen patients Moniz experimented on, refused to supply any more (presumably having observed the results), and Moniz was forced to scramble to secure his last eight patients from other hospitals.
The extravagant claims Moniz made for his new operation rested on the slenderest of empirical foundations. Their theoretical justification was flimsier yet. Moniz asserted that in compulsive psychoses and melancholia, the mental life of patients was “constricted to a very small circle of thoughts, which master all others, recurring again and again in the sick brain.” The “anatomico-pathological explanation” of the psychoses, he deduced, must be that the connections between the neurons making up the brain had become stuck, and “after two years’ deliberation, I determined to sever the connecting fibers of the neurons in question.”17
The Harvard neuropsychiatrist Stanley Cobb pronounced himself singularly unimpressed. “The reports are so meager,” he wrote, “that one cannot judge of the work.”18 But Walter Freeman was of a different mind. He immediately wrote to Moniz, congratulating him on his daring, and indicated that he planned to introduce psychosurgery to the United States. There was a small obstacle, however: Freeman was a neurologist, with no training as a surgeon. Thus, like Moniz (though for different reasons), he was forced to find a partner who could perform the operations.
Fortunately, George Washington Medical School had just hired a young neurosurgeon eager to build his practice, James Watts. Though the field of neurosurgery was relatively novel and thinly populated, Watts had an impressive résumé. He had trained under Harvey Cushing at the Peter Brigham Hospital and at Harvard, and he had subsequently worked with John Fulton at Yale (encountering Becky the chimpanzee) before taking up an appointment in Freeman’s department. Watts had accepted the position even though “my salary will be negligible, a few hundred a year” and “the budget for neurology and neurosurgery will be small”—a measure of how little demand there was for neurosurgeons in the mid-1930s. His hope was that over time his university connections would help him to build up a lucrative practice.19 He was just the partner that Freeman needed.20
Though the heat of a Washington summer in the years before air-conditioning delayed their first surgery, Freeman and Watts managed to perform their first lobotomy in September 1936. Their patient, sixty-three-year-old Alice Hammatt, had not been hospitalized prior to the procedure, despite her husband’s report of suicidal tendencies, years of agitation and depression, and episodes where she periodically exposed herself and urinated on the floor. He (and perhaps she) had had enough of this terrible situation. “The patient,” Freeman and Watts later wrote, “was a past master at bitching and really led her husband a dog’s life.”21
Guided by Freeman, Watts cut out several conical sections from her brain. When she recovered from the surgery, they noted that she was calmer and less agitated in the hospital. “In a month,” they reported, “[she] was managing the essentials, although her husband and her maid did most of the work.” A success, they intimated, though they proceeded to describe her as shrewish, unselfconscious, lacking in initiative, indolent, and abusive.22 Both her husband and the patient herself pronounced themselves satisfied, though Mrs. Hammatt was prone to repeated epileptic seizures brought on by the scar tissue from the operation, and she died from pneumonia five years later.
Three weeks later, Freeman and Watts operated on a fifty-nine-year-old bookkeeper, also a victim of agitated depression, again using Moniz’s leucotome. Other operations followed more rapidly, most of which they claimed were highly successful. Six weeks after they started to operate, however, Freeman sent a note to John Fulton that hints at considerable doubts: “This matter of prefrontal lobotomy has me all hot and bothered and I want a little conversation with you and Jacobsen on the subject.” He indicated that he planned to be in New Haven on November 10 and asked Fulton to set aside “a couple of hours to discuss things with me.”23 A decade and a half later came an indirect admission that outcomes had been rather different from the ones they were publicly proclaiming. They buried these poor results when they published the first edition of their textbook on psychosurgery in 1942, but in the second edition, they acknowledged that “the number of failures was considerable.” Indeed, “we had so many failures with the original Egas Moniz technique that we tried to obtain better results.”24 To do so, they developed an alternative technique.
JUST AS HENRY COTTON had interpreted his patients’ failure to recover their wits not as evidence that his theory was mistaken but that he had been insufficiently bold in his incisions, so Freeman and Watts saw themselves as failing because they had not done enough. “It seemed to us that [an] insufficient number of fibers had been sectioned,” and that more brain tissue needed to be removed.25 Accordingly, they developed a new technique that they referred to, with no sense of irony, as a standard or “precision” lobotomy. Instead of taking out conical cores of brain tissue, they now used an instrument akin to a butter knife to make sweeping cuts in the frontal lobes bilaterally. When patients failed to recover, they often resorted to a second or even a third lobotomy before giving up the case as hopeless. These decisions were often taken within days of the first operation. As they explained, “Since we carry out our work at a general hospital, and disturbed patients require private rooms and special day and night nurses, prolonged hospitalization is out of the question. The family cannot bear the expense and the hospital will not tolerate the noise. Therefore, as soon as it becomes apparent the prefrontal lobotomy is a failure, we immediately consider a second operation.”26
Other interventions were sometimes employed before a second operation was performed. At a session on lobotomy’s “successes” put on for student physicians at George Washington University in 1949, Freeman recounted how he dealt with one of his lobotomized cases who remained difficult postoperatively. The woman was given forty electroshock treatments in the space of two and a half days. When she still hallucinated, he performed a second transorbital lobotomy, after which he reported she was “alert and cheerful and dignified.” Unfortunately, two weeks after she was presented as an advertisement for psychosurgery to the medical students, she relapsed and had to be institutionalized.27
Of their first twenty cases, one died within days of the operation from a massive brain hemorrhage, eight were submitted to a second lobotomy, and two were subjected to a third operation, with uniformly disastrous results. Among these patients, as Freeman and Watts revealed in a brief appendix to a paper published a decade later, were the following outcomes:
- A suicide, an attempted suicide, and two other deaths within three months of the operation
- A patient rendered “tactless and disagreeable”
- Another who was left with “extreme flattening of emotional life … extreme indolence, petulance and puerility … [and] a sterile intellectual life”
- A seventh who was subject to “frequent convulsions and incontinence”
- A patient who “emerged permanently relieved of his depression, but with a boisterous, arrogant and extravagant nature that required institutionalization”
- A woman who became “fat, jolly and outspoken”
- Another characterized as “indolent and sarcastic and was subject to outbursts of anger, which made it necessary to confine her in an institution for eighteen months”
- A woman who, postsurgery, was “greatly deteriorated, fat and inaccessible” (Freeman and Watts lamented that “her family refused permission for further operation”)
- And another female patient who was “indolent and talkative in a silly, vapid way”
More positive results were reported in a handful of cases:
- Their second case, a bookkeeper, was reported to have returned to work within three months of the operation and had worked for eight years before retiring and living comfortably at home
- A cement finisher was “euphoric but soon relapsed” after surgery, but some years later it was reported that he had “been steadily employed as a janitor at a school, where he is highly thought of”
- A housewife who initially “made an erratic adjustment and was in and out of hospitals for four years” after which she divorced and remarried “and writes enthusiastically of her new life”
- Finally, a bookbinder who had been a lifetime hypochondriac “has been employed for the past seven years at her old job. She still complains when asked about her symptoms but never mentions them otherwise.”
Though Freeman and Watts passed over the matter in silence, seventeen of these twenty patients were women, eleven of them housewives.28 The overrepresentation of women was rarely so extreme, but virtually all the later reports on lobotomies noted that female patients were greatly in the majority.29 Morton Kramer of the National Institute of Health’s Biometry Branch found that 12,296 lobotomies were conducted in the United States in the eighteen months ending on June 30, 1951. A majority of the patients in the wards were male, yet nearly 60 percent of the psychosurgery had been performed on women.30 A study conducted by Charles Limburg in 1949 had found an even larger gender discrepancy: women were lobotomized twice as often as males.31
The predominance of female patients was also notable in the surgical treatment for focal sepsis, and in the administration of electroshock therapy right down to the present. Why were female bowels and brains uniquely attractive to those bent on discovering a physical remedy for mental disorders? Gender biases of this sort can be traced back to the vogue for clitoridectomies and surgical excision of the ovaries as a remedy for psychosis, reflective of male physicians’ attitudes to female bodies that were widely embraced in the nineteenth century, with roots in Western medicine extending back to Hippocrates and Galen.32 The persistence of these gendered prejudices in what was still a heavily male-dominated profession unquestionably played a major role. And the existence within the larger culture of assumptions about women’s roles and capacities fed into this narrative in some obvious ways. Women’s minds, so medical men continued to believe, were much more closely linked to their peculiar biological natures.
Freeman quite openly spoke of how these concerns fed into the decisions he and Watts made about whom to operate on: “We have based our work more on social than on the psychiatric findings,” he explained, and, in deciding on whether to perform a lobotomy, “we have performed operations when the patient faced prolonged or permanent disability and where the type of occupation did not require much constructive imagination.”33 Being a housewife (or, in the case of richer women, a decorative fixture in a gilded domestic environment) required in the eyes of their doctors much less intelligence than was required of most men, and readjustment to these roles was more readily accomplished than returning to the workaday world.
There are other possible explanations for the greater use of these physical therapies on women. Perhaps psychotic women on the wards acted out more frequently than their male counterparts, or perhaps (and this strikes me as more likely) disobedient and violent female patients were simply perceived as more deviant and problematic. Either way, these women were perceived as more eligible candidates for surgical solutions. At Pilgrim State Hospital on Long Island, the largest mental hospital in the country, the neurosurgeon H. S. Barahal laid out the basic calculus that many followed: “One of the criteria for surgery on chronically ill patients has been disturbed behavior; and female patients are generally more disturbed on a behavioral level.”34
Joel Braslow has examined the records of all 241 lobotomies performed at the Stockton State Hospital in California to see whether the marked discrepancy along gender lines (85 percent of the psychosurgeries performed there were on women) can be explained by other factors. Was it that women were disproportionately clustered in particular diagnostic categories thought to warrant lobotomies? No. Nor did they outnumber men on the wards during the period he examined. To the contrary, male patients were consistently in the majority. “The inescapable conclusion,” Braslow writes, “is that Stockton physicians, to a highly significant degree, preferred to lobotomize women.” In this decision they were at one with their counterparts elsewhere. Braslow also found a marked propensity to discipline women more severely. “Men,” he discovered, “were nearly thirty times less likely than women to be bound in camisoles, straitjackets, belts and cuffs or mittens, or lashed to chairs or beds.”35
The great majority of those whom Freeman and Watts operated on in the early months and years of psychosurgery were ambulatory patients whose mental illnesses had not been so severe as to require hospitalization. Only a dozen of the eighty patients they had operated on by the time they published the first edition of Psychosurgery in 1942 had been diagnosed as schizophrenic.36 The assertion that lobotomy was a treatment of “last resort,” as some have claimed, was frequently a fiction.37 Moniz had found that deteriorated patients were generally left worse off after psychosurgery, and some American psychiatrists urged that lobotomies be performed on much less disturbed patients. As early as 1942, the prominent British psychiatrist T. P. Rees claimed that “it is unfair both to the patient and the surgeon to defer the operation.… [N]o-one should be in a mental hospital for longer than twelve months without the possibility of his being relieved by prefrontal leucotomy being considered.”38 Toward the end of the decade, more and more psychiatrists began to act on such views.
At the outset, seeking patients to experiment on, Freeman had approached William Alanson White, superintendent of the enormous St. Elizabeths Hospital in Washington, DC, asking if he could operate on some of its inmates. White dismissed the suggestion out of hand, saying, as Freeman later recalled, “It will be a hell of a long while before I let you operate on any of my patients.”39 White wrote about the encounter to his friend Smith Ely Jelliffe, with whom he edited the Journal of Nervous and Mental Disease, “I am asked to subject my patients to this operation as a legitimate experiment in therapy. I do not very often trouble you with the various propositions that are handed up to me, but here is one which I would like to have you tell me what you think of in as few words as possible. I could express the whole matter in one word, but I do not want to do that because it would be unmailable.”40
Undeterred by this forcible rejection and by reports of postoperative complications and deterioration, Freeman and Watts relied on outpatient referrals. By November 1936, they had accumulated enough experience to present their results to their colleagues. Freeman, more comfortable in front of an audience, took the lead. On the whole, it did not go well.
IN BALTIMORE, MARYLAND, before a meeting of the Southern Medical Society, Freeman’s presentation was met with astonishment and anger. Dexter Bullard, the proprietor of Chestnut Lodge, a private asylum for mental patients run along psychoanalytic lines, tried to shout him down. He was scarcely alone. The Baltimore Sun reported that Freeman’s presentation was greeted with “cries of alarm” and for much of the discussion period “one man after another … joined in the chorus of hostile cross-examiners.” Benjamin Wortis, a psychiatrist on the faculty at New York University, pointedly demanded to know “where Dr. Freeman obtained his evidence that obsessions are located three or four centimeters deep in the frontal lobes.” Dismissively alluding to Cotton’s surgical interventions on the digestive tract, he added, “I can only hope this report will not start an epidemic of progressive evisceration experiments.”41
The official publication of the paper itself in the Southern Medical Journal was accompanied by a heavily sanitized version of the discussion, giving no hint of the disorder following its delivery. Mercifully for Freeman, Adolf Meyer was in the audience, and just as things threatened to get out of hand, the Johns Hopkins professor intervened. “I am not antagonistic to this work,” he informed his assembled colleagues, “but find it very interesting.” Though it was important not to promise miracles, he was convinced that experiments along these lines should continue. Certainly, he concluded, “the available facts are sufficient to justify the new procedures in the hands of responsible persons.”42
Three decades later, in an unpublished autobiography written for his children, Freeman vividly recalled that “the reaction of most of the discussors was … unfavorable.” His gratitude for the intervention that saved the day was palpable: “Adolf Meyer, bless him, wrote out a judicious statement indicating that this method had possibilities, that it was based on some of the information we were gaining about the frontal lobes, and he adjured us ‘to follow each case’ ”—a classic Meyerian formulation—“with a view to determining the eventual results. Had it not been for his sympathetic and helpful discussion, the advance of lobotomy would probably have been much slower than it was.”43 Absent Meyer’s intervention, the whole program might have come to a halt.
Now past seventy, and clinging to his post at Hopkins long after the official retirement age, Meyer continued to lend his considerable authority to the support of lobotomy until he stepped down in 1941. He provided private encouragement to Freeman and met with him on a number of occasions to examine the brains of lobotomized patients who had died during or shortly after an operation.44
Still, Freeman continued to encounter sharp criticism from both psychiatrists and neurologists whenever he ventured to talk to them. In February 1937, he traveled to Chicago, where he reported on twenty lobotomy cases to the Chicago Neurological Society. In the discussion period, his methodology was roundly critiqued. Why, one participant asked, had Freeman not used a control group, opening up the skulls of a second group of patients without proceeding to damage their brains? Harry Paskin went further, raising the question of “why the operation had been done on the brain?” After all, it was well known that psychiatric patients had been found to show temporary signs of improvement in the aftermath of “trauma, intercurrent disease or surgical operation, only to relapse later.” Lewis Pollock of Northwestern University challenged the “anatomic basis” of lobotomy and the locationalist model of the brain it rested on, and he called lobotomy “not an operation but a mutilation.” He was outdone by the outspoken neurosurgeon Loyal Davis, who had trained under Harvey Cushing. “I had hoped that the reports were grossly exaggerated,” he began. Instead, Freeman had openly confessed to the wanton destruction of brain tissue. “The offhand manner in which this surgical procedure is described and discussed is no credit to the essayist as a surgeon, a pathologist, or one who is searching for scientific truth.” Freeman was unabashed. The brain, he insisted, “can stand a good deal of manhandling” and “patients with these psychoses are in a serious condition and do not have much chance of recovery otherwise.”45 Later, he confessed that in the midst of the exchange, “I nearly bit the stem of my pipe off trying to regain control of myself.”46
Nor did the clamor show signs of dying down.47 Beginning in 1935, Cobb had begun to write an influential annual review of developments in neuropsychiatry for the Archives of Internal Medicine. Though he had referred a handful of patients at the Massachusetts General Hospital for lobotomies, his doubts about the procedure led him in 1940 to attack its scientific basis, arguing that far too little was known about the frontal lobes, and the results of similar procedures performed on animals had been quite ominous, producing creatures “who no longer showed any restraint or resourcefulness.… In my opinion,” he said, “[lobotomy] is a justifiable procedure only when the patient is old and the prognosis hopeless.” As for the claims Freeman and others had made for its positive value, one could place no trust in them. Not one, he wrote, was “convincing as scientific evidence.”48
The lead editorial in the May 1940 issue of the Medical Record was harsher still. It denounced “the lobotomy delusion” and attacked “the mutilating surgeons who performed the operation.”49 Four years after Freeman and Watts had performed their first lobotomy, they must have wondered what its fate (and theirs) would be. Perhaps the decision to make a direct assault on the frontal lobes of the brain had been a step too far?