In July 1936 – only four months after Moniz started performing his leucotomies – a US neurologist named Walter Jackson Freeman had published a review of Moniz’s work (Freeman, 1936). He discussed such reports with a neurosurgical colleague, James Watts and they ordered a number of Moniz’s leucotomes from Moniz’s instrument-maker in France. After practising the procedure on cadavers in the mortuary they modified Moniz’s technique slightly (adopting a lateral rather than a superior approach), and started treating patients with depression, using a procedure of their own called bilateral frontal leucotomy. It is reported that when Freeman and Watts performed their lobotomies in the USA, Watts operated with the leucotome whilst Freeman gave ‘directions’ from the head end of the bed (Slovick, 2004). Freeman’s knowledge of neuroanatomy was probably unparalleled by most neurosurgeons, but his lack of surgical privileges prevented him from performing the procedure himself. However, in 1937 whilst Watts was unwell he went ahead with a lobotomy, causing a surgeon at George Washington University to complain.
At the Southern Medical Association conference in Baltimore in November 1936 Freeman and Watts presented their results of the first six cases. Freeman chose to refer to their procedure as ‘lobotomy’, both to reflect a more accurate term for the lesion but arguably also to distinguish his technique from Moniz’s procedure. Such a semantic change would also allow him to retain ‘ownership’ of the term when he and Watts went on to further develop the procedure.
In the late 1930s and early 1940s, Freeman and Watts’ results with chronic schizophrenic patients appeared poor, with many patients relapsing. This led Freeman to adopt the view that lobotomy should be made more readily available to other patient groups. One of the perceived problems with the standard frontal lobotomy was that it required a surgical team, and in 1945, inspired by the work of Italian Amarro Fiamberti who had published a report in 1937, he adopted a transorbital approach. Such a route to the brain was not new. A. M. Doglotti had used the route for ventricular puncture and Maurice Ducosté had used a transorbital technique for introducing malaria inoculations into the brain (Ducosté, 1932). Fiamberti had used the approach in approximately 100 patients using alcohol or formalin to create lesions in the frontal lobes before the outbreak of World War II diverted his attentions elsewhere.
Freeman searched for the perfect tool with which to perform such a procedure and is reported to have eventually come across an ice-pick in his kitchen drawer. Indeed, his original tool had the name of the ‘Uline Ice Company’ engraved on it. With a few modifications (including strengthening the tool), the ‘ice-pick lobotomy’ (a.k.a. transorbital lobotomy) was born. The procedure involved inserting an instrument under the eyelids, through the roof of the orbit, and into the fronto-orbital cortex. A quick sweeping motion cut the fronto-thalamic tracts. It was essentially a non-sterile procedure, could be performed with minimal anaesthesia (often two electroconvulsive treatments were used), and required a minimal team.
The first transorbital lobotomy took place in January 1946 and the first 10 cases were performed in Freeman’s office in the subsequent two months. Typically, patients were allowed home with a relative in a taxi after an hour or two, reportedly with little more than two black eyes and some disorientation. Watts disapproved of the procedure from the outset, arguing that ‘brain surgery should not take place as an office procedure’, and he eventually moved out of their shared offices in Washington. Watts intervened to prevent Freeman from performing transorbital lobotomy at George Washington University and Freeman sought permission to perform transorbital lobotomy under ECT anaesthesia (and was successful) at two other hospitals in Washington D. C. Following Watts’ separation from Freeman at this time, Freeman took on a new neurosurgical partner, Jonathan Williams, who was less surgically conservative than Watts. However, Watts and Freeman did not sever their partnership completely and Watts went on to perform 28 transorbital lobotomies with Freeman between 1949 and 1956, albeit in a neurosurgical operating theatre.
Walter Freeman was undoubtedly a gifted neurologist who was devoted to the treatment of mental illness. Like Moniz, he was politically astute and desired recognition. He was very aware of the power of the media to further his cause, and has even been described as a ‘showman’ at times. He exhibited at every American Medical Association conference from 1937-1946, reportedly using a clacker and shouting like a “carnival barker” to draw crowds (El-Hai, 2005, p.123). One frequent criticism of Freeman is that he was cavalier in his approach and there are certainly episodes which do nothing to silence his critics. In the early 1940s, before the use of muscle relaxants during ECT, Freeman treated a private patient with ECT in his offices. His secretary, who usually helped, was unavailable and the patient’s husband was too physically frail to assist. Alone, Freeman proceeded to give ECT but the patient’s seizure broke both of her legs. Freeman gave her morphine before leaving to see patients at the hospital and when he returned he found the patient and her husband angry and litiginous. Freeman eventually settled out of court (El-Hai, 2005, p.133).
Freeman also infamously performed a transorbital lobotomy in a motel room, after the patient had failed to attend for numerous appointments. The patient had been apprehended by police after causing a disturbance and Freeman collected his surgical tools and drove to the motel, where the patient underwent lobotomy after the police restrained him whilst Freeman used ECT to sedate him.
Freeman was cavalier but he was undoubtedly committed, and through his efforts lobotomy entered the public and professional consciousness. Famous people who underwent prefrontal lobotomy include Rosemary Kennedy, the eldest sister of John F Kennedy who was operated on by Freeman and Watts in 1941, at the age of 25. Unfortunately, the operation was unsuccessful, and she lived the remainder of her years in institutional care, inert and with limited speech. Freeman is also widely reported to have operated on the actress Frances Farmer, and whilst it is still claimed in the popular media that she underwent the procedure (Toomey & Young, 2006), there are no clear records to support this assertion and she and her family have persistently denied that she had a lobotomy (Tate, 2003). Despite such incorrect claims about lobotomy’s alleged “victims”, it has nevertheless entered into the public’s perceived history of psychosurgery .