Proliferation of the treatment
Moniz was nominated for the Nobel Prize by the American neurologist Walter Jackson Freeman II (1895–1972). Freeman was one of the founders of the American Board of Psychiatry and Neurology and was the real pioneer who made lobotomy a widely recognised psychiatric treatment. Together with neurosurgeon James W. Watts (1904–94), he developed the Freeman-Watts standard prefrontal lobotomy method and authored the standard work Psychosurgery (2) .
Over a period of only two months in 1936, Freeman and Watts performed twenty lobotomies, and by 1942 they had lobotomised more than 200 patients and published the results. They reported that 63 % of their patients had improved while 24 % saw no change and 14 % became worse (1, 2) . One of the early patients treated by Freeman and Watts was John F. Kennedy's sister, Rosemary Kennedy (1918–2005), who was lobotomised in 1941 at the age of 23. The operation was not successful. She required care for the rest of her life and could no longer walk or talk after the intervention. Several patients suffered such serious complications, but Freeman nevertheless remained convinced that lobotomy was a major medical advancement. However, he was less than pleased with the low number of patients that underwent surgery. Lobotomy required collaboration with a neurosurgeon and other personnel, and it was therefore only available at large university hospitals. Freeman's vision was to make lobotomy a far more prolific treatment (3) .
According to his own account, what we today associate with lobotomy is based on an idea that came to him while cutting ice for his drink with an ice pick. The technique was named transorbital lobotomy. The objective was to sever the connection between the prefrontal cortex and the thalamus by using a thin surgical instrument – an orbitoclast – to cut through the thin layer of bone above the eye socket. A small hammer was used to drive the instrument into the brain (Figure 1). According to Freeman, the operation could be performed without general anaesthetic, and no surgical expertise was required. Strictly speaking, it was not even necessary to use a qualified doctor. He personally performed the first transorbital lobotomy on a patient in 1946 (1) . Watts was highly sceptical of this method and ended their partnership in 1947 (1, 3) .
Figure 1 Dr Walter Freeman II (left), and Dr James W. Watts study an X-ray before an operation (2 ). Photo: Public domain
Despite a mortality rate of 14 %, Freeman performed 3,439 lobotomies in the course of his life
With the introduction of transorbital lobotomy came an upsurge in the uptake of this type of treatment. In 1949 alone, more than 5,000 lobotomies were performed in the United States (1) . Freeman wore neither gloves nor a mask when performing the procedure and was less than diligent when it came to sterilising his equipment. This was one of the reasons why Watts was highly critical of Freeman's procedures. Despite a mortality rate of 14 %, Freeman performed 3,439 lobotomies in the course of his life, the last one in 1967 (1) .
Lobotomy was not considered a cure for a particular disorder, but a means of reducing symptoms. It was initially considered a last resort for patients who had failed to respond to other treatments. Just like the diagnostic criteria could vary, the indications were not clearly defined. The first patients who were operated on, were diagnosed with schizophrenia, but the procedure was at times performed as a last resort for disorders that were considered psychosomatic, like stomach ulcers and ulcerative colitis (4) . Freeman appeared to be reporting particularly positive outcomes in patients who nowadays perhaps would have been diagnosed with obsessive-compulsive disorders (Figure 2), but lobotomy was also considered a potential therapy in palliative care (Figure 3).
Figure 2 Drawing from the book 'Psychosurgery' by Freeman and Watts, 1950, showing how prefrontal lobotomy was carried out (2 ). Facsimile
Figure 3 Typical case notes in the book 'Psychosurgery' by Freeman and Watts, 1950 (2 ). Facsimile
Freeman was personally of the opinion that the treatment could stabilise the patient's personality and alleviate strong emotions. He saw psychosis as the result of excessive self-reflection, thoughts that kept whirring back and forth in the brain. He envisaged that this never-ending circle of painful thoughts could be stopped by literally severing the fibres. Many of the patients he operated on stopped feeling anxious and appeared more child-like. It was later reported that many also became apathetic and passive, that they lost all initiative and their ability to concentrate or produce an emotional response (1) .