Editing Lobotomy (section)

==Reception==

Moniz rapidly disseminated his results through articles in the medical press and a monograph in 1936.{{sfn|Kotowicz|2005|p=81|ps=}} Initially, however, the medical community appeared hostile to the new procedure.{{sfn|Kotowicz|2008|p=482|ps=}} On 26 July 1936, one of his assistants, Diogo Furtado, gave a presentation at the Parisian meeting of the Société Médico-Psychologique on the results of the second cohort of patients leucotomised by Lima.{{sfn|Kotowicz|2005|p=81|ps=}} Sobral Cid, who had supplied Moniz with the first set of patients for leucotomy from his own hospital in Lisbon, attended the meeting and denounced the technique,{{sfn|Kotowicz|2008|p=482|ps=}} declaring that the patients who had been returned to his care post-operatively were "diminished" and had experienced a "degradation of personality".<ref name="Kotowicz 2008 482">Quoted in {{harvnb|Kotowicz|2008|p=482}}</ref> He also claimed that the changes Moniz observed in patients were more properly attributed to shock and brain trauma, and he derided the theoretical architecture that Moniz had constructed to support the new procedure as "cerebral mythology."<ref name="Kotowicz 2008 482"/> At the same meeting the Parisian psychiatrist, Paul Courbon, stated he could not endorse a surgical technique that was solely supported by theoretical considerations rather than clinical observations.{{sfn|Kotowicz|2008|pp=482–83|ps=}} He also opined that the mutilation of an organ could not improve its function and that such cerebral wounds as were occasioned by leucotomy risked the later development of [[meningitis]], epilepsy and [[brain abscess]]es.{{sfn|Kotowicz|2008|p=483|ps=}} Nonetheless, Moniz's reported successful surgical treatment of 14 out of 20 patients led to the rapid adoption of the procedure on an experimental basis by individual clinicians in countries such as Brazil, Cuba, Italy, Romania and the United States during the 1930s.<ref>{{harvnb|Feldman|Goodrich|2001|p=652}}; {{harvnb|Kotowicz|2005|p=81}}</ref>

=== Italian leucotomy ===
{{quote box|salign=right|align=right|width=35em|quote=In the present state of affairs if some are critical about lack of caution in therapy, it is, on the other hand, deplorable and inexcusable to remain apathetic, with folded hands, content with learned lucubrations upon symptomatologic minutiae or upon psychopathic curiosities, or even worse, not even doing that.|source=—Amarro Fiamberti<ref>Quoted in {{harvnb|El-Hai|2005|p=182}}</ref>}}
Throughout the remainder of the 1930s, the number of leucotomies performed in most countries where the technique was adopted remained quite low. In Britain, which was later a major centre for leucotomy,{{refn|group=n|It was estimated by [[William Sargant]] and [[Eliot Slater]] that 15,000 leucotomies had been performed in the UK by 1962.<ref>{{harvnb|Kotowicz|2008|pp=486 n.1}}; {{harvnb|Sargant|Slater|1963|p=98}}</ref>}} only six operations had been undertaken before 1942.{{sfn|Kotowicz|2008|pp=476–77|ps=}} Generally, medical practitioners who attempted the procedure adopted a cautious approach and few patients were leucotomised before the 1940s. Italian neuropsychiatrists, who were typically early and enthusiastic adopters of leucotomy, were exceptional in eschewing such a gradualist course.{{sfn|Kotowicz|2008|p=477|ps=}}

Leucotomy was first reported in the Italian medical press in 1936 and Moniz published an article in Italian on the technique in the following year.{{sfn|Kotowicz|2008|p=477|ps=}} In 1937, he was invited to Italy to demonstrate the procedure and for two weeks in June of that year, he visited medical centres in [[Trieste]], [[Ferrara]], and one close to [[Turin]]{{snd}}the Racconigi Hospital{{snd}}where he instructed his Italian neuropsychiatric colleagues on leucotomy and also oversaw several operations.{{sfn|Kotowicz|2008|p=477|ps=}} Leucotomy was featured at two Italian psychiatric conferences in 1937 and over the next two years a score of medical articles on Moniz's psychosurgery was published by Italian clinicians based in medical institutions located in [[Racconigi]], [[Trieste]], [[Naples]], [[Genoa]], [[Milan]], [[Pisa]], [[Catania]] and [[Rovigo]].{{sfn|Kotowicz|2008|p=477|ps=}} The major centre for leucotomy in Italy was the Racconigi Hospital, where the experienced neurosurgeon [[Ludvig Puusepp]] provided a guiding hand.{{refn|group=n|The 14 leucotomies reported by Puusepp in his 1937 paper were performed at the Racconigi Hospital.<ref>{{harvnb|Puusepp|1937}}; {{harvnb|Kotowicz|2008|pp=477, 486}}</ref>}}{{sfn|Kotowicz|2008|p=477|ps=}} Under the medical directorship of Emilio Rizzatti, the medical personnel at this hospital had completed at least 200 leucotomies by 1939.{{sfn|Kotowicz|2008|pp=477, 487|ps=}} Reports from clinicians based at other Italian institutions detailed significantly fewer leucotomy operations.{{sfn|Kotowicz|2008|p=477|ps=}}

Experimental modifications of Moniz's operation were introduced with little delay by Italian medical practitioners.{{sfn|Kotowicz|2008|p=478|ps=}} Most notably, in 1937 [[Amarro Fiamberti]], the medical director of a psychiatric institution in [[Varese]],{{sfn|El-Hai|2005|p=182|ps=}} first devised the transorbital procedure whereby the frontal lobes were accessed through the eye sockets.{{sfn|Kotowicz|2008|p=478|ps=}} Fiamberti's method was to puncture the thin layer of [[orbit (anatomy)|orbital]] bone at the top of the socket and then inject alcohol or formalin into the white matter of the frontal lobes through this aperture.<ref name="ElHaiFingerWeiss">{{harvnb|El-Hai|2005|p=182}}; {{harvnb|Finger|2001|p=293}}; {{harvnb|Weiss|Rauch|Price|2007|p=506}}</ref> Using this method, while sometimes substituting a [[leucotome]] for a hypodermic needle, it is estimated that he leucotomised about 100 patients in the period up to the outbreak of World War II.{{sfn|El-Hai|2005|p=182|ps=}} Fiamberti's innovation of Moniz's method would later prove inspirational for [[Walter Freeman (surgeon)|Walter Freeman's]] development of transorbital lobotomy.<ref name="ElHaiFingerWeiss" />

===American leucotomy===
[[File:Lobotomy 1.jpg|thumb|Site of borehole for the standard pre-frontal lobotomy/leucotomy operation as developed by Freeman and Watts]]
The first prefrontal leucotomy in the United States was performed at the George Washington University Hospital, on 14 September 1936, by the [[neurologist]] [[Walter Jackson Freeman II|Walter Freeman]], and his friend and colleague, the neurosurgeon [[James W. Watts]].<ref>{{harvnb|Shorter|1997|p=227}}; {{harvnb|Pressman|2002|p=78}}</ref> Freeman had first encountered Moniz at the London-hosted Second International Congress of Neurology in 1935, where he had presented a poster exhibit of the Portuguese neurologist's work on cerebral angiography.<ref name="Pressman 2002 76 Feldman 2001 649">{{harvnb|Pressman|2002|p=76}}; {{harvnb|Feldman|Goodrich|2001|p=649}}</ref> Fortuitously occupying a booth next to Moniz, Freeman, delighted by their chance meeting, formed a highly favourable impression of Moniz, later remarking upon his "sheer genius".<ref name="Pressman 2002 76 Feldman 2001 649" /> According to Freeman, if they had not met in person, it is highly unlikely that he would have ventured into the domain of frontal lobe psychosurgery.<ref>{{harvnb|Pressman|2002|p=76}}; {{harvnb|Kotowicz|2005|p=94}}</ref> Freeman's interest in psychiatry was the natural outgrowth of his appointment in 1924 as the medical director of the Research Laboratories of the Government Hospital for the Insane in Washington, known colloquially as St Elizabeth's.{{sfn|Pressman|2002|p=73|ps=}} Freeman, who favoured an organic model of mental illness causation, spent the next several years exhaustively, yet ultimately fruitlessly, investigating a [[neuropathology|neuropathological]] basis for insanity.{{sfn|Pressman|2002|pp=73–75|ps=}} Chancing upon a preliminary communication by Moniz on leucotomy in the spring of 1936, Freeman initiated a correspondence in May of that year. Writing that he had been considering psychiatric brain surgery previously, he informed Moniz that, "having your authority I expect to go ahead".<ref>Quoted in {{harvnb|Pressman|2002|p=76}}</ref> Moniz, in return, promised to send him a copy of his forthcoming monograph on leucotomy and urged him to purchase a leucotome from a French supplier.{{sfn|Pressman|2002|p=76|ps=}}

Upon receipt of Moniz's monograph, Freeman reviewed it anonymously for the ''Archives of Neurology and Psychiatry''.{{sfn|Pressman|2002|p=76|ps=}} Praising the text as one whose "importance can scarcely be overestimated",{{sfn|Pressman|2002|p=76|ps=}} he summarised Moniz's rationale for the procedure as based on the fact that while no physical abnormality of cerebral cell bodies was observable in the mentally ill, their cellular interconnections may harbour a "fixation of certain patterns of relationship among various groups of cells" and that this resulted in obsessions, delusions and mental morbidity.{{sfn|Pressman|2002|p=77|ps=}} While recognising that Moniz's thesis was inadequate, for Freeman it had the advantage of circumventing the search for diseased brain tissue in the mentally ill by instead suggesting that the problem was a functional one of the brain's internal wiring where relief might be obtained by severing problematic mental circuits.{{sfn|Pressman|2002|p=77|ps=}}

In 1937 Freeman and Watts adapted Lima and Moniz's surgical procedure, and created the ''Freeman-Watts technique'', also known as the ''Freeman-Watts standard prefrontal lobotomy,'' which they styled the "precision method".{{sfn|Finger|2001|p=293|ps=}}

===Transorbital lobotomy===
The Freeman–Watts prefrontal lobotomy still required drilling holes in the skull, so surgery had to be performed in an operating room by trained neurosurgeons. Walter Freeman believed this surgery would be unavailable to those he saw as needing it most: patients in state mental hospitals that had no operating rooms, surgeons, or [[anesthesia]] and limited budgets. Freeman wanted to simplify the procedure so that it could be carried out by psychiatrists in [[psychiatric hospital]]s.{{sfn|El-Hai|2005|p=184}}

Inspired by the work of Italian psychiatrist [[Amarro Fiamberti]], Freeman at some point conceived of approaching the frontal lobes through the eye sockets instead of through drilled holes in the skull. In 1945 he took an [[icepick]]{{refn|Frank Freeman, Walter Freeman's son, stated in an interview with Howard Dully that: "He had several ice-picks that just cluttered the back of the kitchen drawer. The first ice pick came right out of our drawer. A humble ice-pick to go right into the frontal lobes. It was, from a cosmetic standpoint, diabolical. Just observing this thing was horrible, gruesome." When Dully asked Frank Freeman, then a 79-year-old security guard, whether he was proud of his father, he replied: "Oh yes, yes, yeah. He was terrific. He was really quite a remarkable pioneer lobotomist. I wish he could have gotten further."{{sfn|Dully|2005}}|group=n}} from his own kitchen and began testing the idea on grapefruit{{refn|Rodney Dully, whose son Howard Dully had had a transorbital lobotomy performed on him by Walter Freeman when he was twelve years old, stated in an interview with his son that: "I only met him [Freeman] I think the one time. He described how accurate it [transorbital lobotomy] was and that he had practised the cutting on, literally, a carload of grapefruit, getting the right move and the right turn. That's what he told me."{{sfn|Dully|2005}}|group=n}} and [[cadavers]]. 

The use of lobotomy in the United States was resisted and criticized heavily by American neurosurgeons. However, because Freeman managed to promote the success of the surgery through the media, lobotomy became touted as a miracle procedure, capturing the attention of the public and leading to an overwhelming demand for the operation. In 1945 Freeman streamlined the procedure, replacing it with transorbital lobotomy, in which a picklike instrument was forced through the back of the eye sockets to pierce the thin bone that separates the eye sockets from the frontal lobes. The pick's point was then inserted into the frontal lobe and used to sever connections in the brain (presumably between the prefrontal cortex and thalamus). In 1946 Freeman performed this procedure for the first time on a patient, who was subdued prior to the operation with electroshock treatment.

The transorbital lobotomy procedure, which Freeman performed very quickly, sometimes in less than 10 minutes, was used on many patients with relatively minor mental disorders that Freeman believed did not warrant traditional lobotomy surgery, in which the skull itself was opened. A large proportion of such lobotomized patients exhibited reduced tension or agitation, but many also showed other effects, such as apathy, passivity, lack of initiative, poor ability to concentrate, and a generally decreased depth and intensity of their emotional response to life. Some died as a result of the procedure. However, those effects were not widely reported in the 1940s, and at that time the long-term effects were largely unknown. Because the procedure met with seemingly widespread success, Moniz was awarded the 1949 Nobel Prize for Physiology or Medicine (along with Swiss physiologist [[Walter Rudolf Hess]]).

Lobotomies were performed on a wide scale during the 1940s; Freeman himself performed or supervised more than 3,500 lobotomies by the late 1960s. Freeman performed his first transorbital lobotomy on Ellen Ionesco, a woman who suffered from bouts of manic depression and suicidal ideation. Freeman utilized media coverage and penned editorials for numerous interviews promoting the procedure and achieving accolades for his work in psychiatric care.<ref>{{Cite web |date=2024-07-19 |title=Psychiatry {{!}} Mental Health, Treatment & Diagnosis {{!}} Britannica |url=https://www.britannica.com/science/psychiatry |access-date=2024-08-09 |website=www.britannica.com |language=en}}</ref>

Watts did not favor the transorbital method, and this difference of opinion contributed to the end of their partnership. Watts resisted the technique itself, Freeman's lack of sterile technique when performing it, and the idea of performing the procedure in an outpatient setting. Watts recalled that the hospital reprimanded Freeman, stating that he was "not a surgeon and if he wants to operate he'll have to apply for surgical privileges."<ref>{{Cite journal |last1=Caruso |first1=James P. |last2=Sheehan |first2=Jason P. |date=2017-09-01 |title=Psychosurgery, ethics, and media: a history of Walter Freeman and the lobotomy |url=https://thejns.org/focus/view/journals/neurosurg-focus/43/3/article-pE6.xml |journal=Neurosurgical Focus |language=en-US |volume=43 |issue=3 |pages=E6 |doi=10.3171/2017.6.FOCUS17257 |issn=1092-0684|doi-access=free |pmid=28859561 }}</ref> 

Freeman performed the first transorbital lobotomy on a live patient in 1946. Its simplicity suggested the possibility of carrying it out in mental hospitals lacking the surgical facilities required for the earlier, more complex procedure. (Freeman suggested that, where conventional anesthesia was unavailable, [[electroconvulsive therapy]] be used to render the patient unconscious.){{sfn|El-Hai|2005|ps=}} In 1947, the Freeman and Watts partnership ended, as the latter was disgusted by Freeman's barbarism and neglectful modifications of the lobotomy from a surgical operation into a simple "office" procedure.<ref>{{Cite journal|title=Psychosurgery, ethics, and media: a history of Walter Freeman and the lobotomy.|journal=Neurosurgical Focus|volume=43|issue=3|pages=E6|doi=10.3171/2017.6.FOCUS17257|pmid=28859561|year=2017|last1=Caruso|first1=James P.|last2=Sheehan|first2=Jason P.|doi-access=free}}</ref> Between 1940 and 1944, 684 lobotomies were performed in the United States. However, because of the fervent promotion of the technique by Freeman and Watts, those numbers increased sharply toward the end of the decade. In 1949, the peak year for lobotomies in the US, 5,074 procedures were undertaken, and by 1951 over 18,608 individuals had been lobotomized in the US.{{sfn|Shorter|1997|pp=227–28|ps=}}