History of Psychology 2015, Vol. 18, No. 2, 119 –131

© 2015 American Psychological Association 1093-4510/15/$12.00 http://dx.doi.org/10.1037/a0039061

FREEMAN’S TRANSORBITAL LOBOTOMY AS AN ANOMALY A Material Culture Examination of Surgical Instruments and Operative Spaces Brianne M. Collins and Henderikus J. Stam This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

University of Calgary In 1946, Walter Freeman introduced the transorbital ice pick lobotomy. Touted as a procedure that could be learned and subsequently performed by psychiatrists outside of the operating room, the technique was quickly criticized by neurosurgeons. In this article, we take a material culture approach to consider 2 grounds upon which neurosurgeons based their objections—surgical instruments and operative spaces. On both counts, Freeman was in contravention of established normative neurosurgical practices and, ultimately, his technique was exposed as an anomaly by neurosurgeons. Despite its rejection, the transorbital lobotomy became entrenched in contemporary memory and remains the emblematic procedure of the psychosurgery era. Keywords: lobotomy, psychosurgery, material culture, instruments, operative spaces

Since the mid-20th century, psychosurgery has been cemented into contemporary memory courtesy of sensationalist portrayals in literature, film, and TV. In the last decade, for instance, motion pictures such as the melodrama A Hole in One (Fogel, Infantolino, & Ledes, 2004) have portrayed psychosurgery in particularly provocative ways. Likewise, TV programing has not been immune to the fascination with lobotomies; for example, a recent episode of Criminal Minds made use of the escapades of the infamous Walter Freeman—America’s most recognized lobotomist (Davis, Messer, & Bailey, 2013). Alternatively, and often in the shadow of motion pictures, artistic and literary portrayals have also occasionally surfaced (e.g., Dully & Fleming, 2007; St. Onge, 2011). Although these are by no means all of the popular portrayals of lobotomy that exist, they do share one important commonality; that is, the lobotomies they depict are Freeman’s ice pick transorbital lobotomy.1 Although the ice pick lobotomy continues to capture public attention more than half a cen-

Brianne M. Collins and Henderikus J. Stam, Department of Psychology, University of Calgary. Correspondence concerning this article should be addressed to Brianne M. Collins, Department of Psychology, University of Calgary, 2500 University Drive NW, Calgary, Alberta, Canada, T2N 1N4. E-mail: [email protected]

tury later, Freeman’s procedure should more accurately be viewed as an anomaly that departed from conventional neurosurgical— including psychosurgical— customs of the day. It is through an examination of neurosurgical practices and, in particular, the material culture that helped to produce, maintain, and contest these practices that the transorbital lobotomy is most sharply revealed as a conspicuous aberration. Yet no examination of the material culture of psychosurgery has been conducted, despite ample investigations into the lives of key physicians (e.g., El-Hai, 2005; Valenstein, 1986), the role of physicians and families in its purported success (e.g., Raz, 2013), and as an administrative necessity that emerged during a desperate era (e.g., Pressman, 1998; Shutts, 1982). Despite the richness possible in the study of material remnants and related practices, the history of psychosurgery has remained a textually and, at times, orally based field of inquiry in which correspondence, published medical reports, first-hand accounts, patient files, and newspaper articles have become the field’s core source material

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1 There are, of course, other portrayals of lobotomy more generally not focused on the transorbital ice pick lobotomy such as One Flew Over the Cuckoo’s Nest (Douglas, Zaentz, & Forman, 1975) and Frances (Sanger & Clifford, 1982).

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(e.g., Braslow, 1997; Raz, 2013). Not surprisingly, historians more generally have been criticized for their lack of consideration of material culture. For instance, Hood (2009) questioned why historians had not seriously taken up material culture as a legitimate source when anthropologists and archeologists have successfully relied on such items. Perhaps as a consequence of these critiques, a growing body of literature on the methodology and theory behind the consideration of objects has begun to emerge in recent decades (e.g., Caple, 2006; Taub, 2011). In addition, a variety of material culture investigations have been conducted in the history of psychology (e.g., Sokal, Davis, & Merzbach, 1976; Sturm & Ash, 2005) and psychiatry (e.g., Coleborne, 2001; Wade, Norrsell, & Presly, 2005). Despite this, a dearth of material culture research on modern neurosurgery remains. Because material culture (e.g., apparatus, clothing, furniture, music, architecture) offers a novel way to engage textually based histories, we focus here on two particular forms of material culture—surgical instruments and physical spaces. In regard to the former, scholars have made noteworthy contributions to the study of medicine by exploring its instruments. Rice (2010), for instance, argued that the stethoscope helped both to demarcate the physician as professional and to shape medical identity. Emphasizing the centrality and transformative role of instruments in history, Prown (1993) argued that these objects “reflect, consciously or unconsciously, directly or indirectly, the beliefs of the individuals who commissioned, fabricated, purchased, or even used them, and by extension, the beliefs of the larger society to which these individuals belonged” (p. 1). In this vein, this article examines Freeman’s ice pick as an instrument of exclusion and in opposition to contemporary neurosurgical culture. Although surgical instruments have received some attention, spaces have been considerably neglected in comparison. This could, in part, be a consequence of the tendency to describe aspects of a physical space, such as measurement or construction elements (Pearson & Richards, 1997b), as opposed to considering its symbolism or function (Pearson & Richards, 1997a). Prior (1988) has argued that “schemes of spatial

organization are best understood in relation to the discursive practices of which they form a part rather than as decontextualized and reified social facts which exhibit their own ‘logic’” (p. 86). Accordingly, Adams and Schlich (2006) demonstrated the transformation of surgical space at Montreal’s Royal Victoria Hospital as it came to parallel the modern laboratory for reasons of identity construction that go beyond the traditional explanation of antisepsis and asepsis as catalysts for such a change. Consequently, “spatial structures like operating rooms can be understood as material evidence of ongoing changes in the status and self-image of surgeons” (Adams & Schlich, 2006, p. 303). Taking up such an argument, we consider Freeman’s breech of normative surgical space—specifically, the operating room—in his effort to move psychosurgery beyond the walls of this established domain. In doing so, Freeman transgressed not only the physical boundary of the operating room, but also the way neurosurgeons had fashioned their identities as bound to this space. In order to demonstrate that Walter Freeman’s choice of surgical instrument and his shift in operative space exposed his transorbital lobotomy as antithetical to existing neurosurgical practices, we begin by describing the story of Walter Freeman and his ice pick lobotomy to provide both context and the narrative that, as we noted in our opening paragraph, has captured the public’s imagination. Next, we address the two aspects of material culture— instruments and spaces—as grounds upon which the neurosurgical community cast Freeman’s work aside as an anomaly. Finally, in the conclusion, we consider whether such a revised story has the potential to alter how we remember such a controversial period. Reconsidering the transorbital ice pick lobotomy ultimately serves to situate it more precisely within the broader history of psychosurgery. The Anomaly: The Ice Pick and Freeman’s Transorbital Lobotomy In 1946, Freeman opened his kitchen drawer in the family home to retrieve a common household item. It was an Uline Ice Company ice pick (see Figure 1, Instrument A), which had a wooden handle and a slim, solid, metal shaft

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FREEMAN’S TRANSORBITAL LOBOTOMY AS AN ANOMALY

Figure 1. Walter Freeman’s transorbital lobotomy instruments from 1946 onward (redrawn by the authors from the sources listed; not drawn to scale): (A) original ice pick found in kitchen drawer in 1946 (described in El-Hai, 2005); (B) transorbital leucotome with curved handle in use by 1948 (Freeman, 1949a); (C) transorbital leucotome with T-shaped handle in use by 1949 (Freeman, 1949b); (D) orbitoclast in use by 1952 (Freeman, 1952).

(El-Hai, 2005).2 This crude, nonsurgical tool was ideal because it was strong, slender, and sharp enough for the task Freeman had in mind— breaking through the skull’s orbital plates above the eyes (Freeman, 1949a). It was not surprising that the tool was suited for such a procedure; after all, its original purpose was to break apart large, hard blocks of ice into chunks for a variety of domestic uses. Having found that a number of other instruments—such as a spinal needle—were either too heavy to be maneuvered with precision or too weak and would collapse under the pressure when tested on cadavers (Freeman, 1949a), the ice pick proved ideal. Ten years before holding the infamous ice pick in his hands, Freeman’s career had begun in a very different, and more conventional, manner. Freeman had trained first as a neurologist and then later, in 1931, further specialized in neuropathology. In 1924, he obtained a position at St. Elizabeth’s Hospital in Washington, D.C., overseeing the laboratories where he quickly began to seek neuropathological causes for some of the severe mental disorders he was witnessing around him. Though his efforts yielded nothing substantial, he developed an interest in improving— even through radical

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means—the lot of those entrenched in largely custodial mental hospitals (El-Hai, 2005). As Raz (2013) has argued, Freeman vociferously advocated for the treatment of patients with whatever means necessary, rather than succumbing to “therapeutic nihilism” rampant at the time (p. 23). Given his keen interest in active treatment, Freeman was quickly inspired by the pioneering work of Portuguese neurologist Egas Moniz, who developed and pioneered the prefrontal leucotomy technique in 1935 (Tierney, 2000). As well as requesting an early copy of Moniz’s monograph (Valenstein, 1986), Freeman also ordered the pioneer’s surgical instrument—a leucotome—from a Paris manufacturer (see Figure 2, Instrument A). Unable to perform surgery himself by virtue of his training as a neurologist, Freeman enlisted the help of James Watts—a young neurosurgeon who had recently joined the George Washington University (GWU) faculty where Freeman had been appointed professor of neurology and head of the department in 1926. In September of 1936, Freeman and Watts completed their first prefrontal leucotomy—later modified and renamed prefrontal lobotomy (El-Hai, 2005).3 Over the next decade, Freeman and Watts completed hundreds of surgeries together, until Freeman showed explicit interest in transorbital lobotomies in 1946 (Valenstein, 1986). The original idea of transorbital access to the brain for the purpose of psychosurgery was initially proposed in 1937 by Italy’s Amarro Fiamberti. Inspired by the earlier work of Achile Mario Dogliotti, who had injected radioactive dye into the brain via transorbital entry, Fiamberti used a hypothermic needle to sever fibers in the frontal lobes (Kotowicz, 2008). According to Freeman, Fiamberti’s initial work seemed promising yet generally inconclusive 2 In the literature there seems to be some disagreement as to whether the first ice pick had a wooden handle (El-Hai, 2005) or metal handle (Shutts, 1982). 3 Both today and during the psychosurgery era, there was confusion surrounding the terms leucotomy and lobotomy. Freeman (1958) himself admitted to the presence of technical ambiguity with the terms. Although differences certainly existed between surgical techniques (e.g., entry sites, surgical instruments), the language used to differentiate procedures was not regulated, and other factors—such as national boundaries and mentorship—may also have contributed to the confusion.

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Figure 2. Various international prefrontal leucotomy wired leucotomes (redrawn by the authors from the sources listed; not drawn to scale): (A) first leucotome designed by Egas Moniz (Arana Iniguez & Galeano Munoz, 1950); (B) one of the variations of K. G. McKenzie’s leucotome (Miller, 1954); (C) leucotome with rotating blade (McGregor & Crumbie, 1942).

(Freeman, 1949a). Moreover, the outbreak of the Second World War effectively halted any work in Italy— or at least publication of such investigations—leaving the transorbital technique temporarily on hiatus (Kotowicz, 2008). Freeman’s version of the transorbital lobotomy, first attempted in 1946, was radical among other psychosurgical procedures at the time. Rather than use anesthesia, Freeman used electroconvulsive shock therapy to render patients unconscious. Initially using the ice pick, Freeman would lift the upper eyelid and insert the ice pick below, so it rested on the upper surface of the eyeball. Then, the ice pick was “brought parallel with the bony ridge of the nose, and its base [was] tapped lightly with a hammer to drive it through the orbital plate” (Freeman, 1948a, p. 372). The goal was then to use a sweeping motion to disconnect the anterior, ventral white matter connecting the limbic system to the frontal lobes (Freeman, 1948a). In

only a matter of minutes, patients—ideally— would go from mentally disturbed to vastly improved; the only interim physical indication any operation had even occurred was the black eyes the patients left with (El-Hai, 2005; Freeman, 1948b, ca. 1950). Even though Freeman only employed the ice pick for his initial transorbital lobotomies, the procedure swiftly became known as the “icepick operation” (Moore, 1949, p. 741; Scoville, 1949). Possibly to avoid this crude characterization, or as a consequence of his ambition, Freeman transitioned through a number of instruments that he called transorbital leucotomes (see Figure 1, Instruments B and C) in search of the ideal instrument for the procedure. At last, in 1952, Freeman (1952) introduced what he felt was a solution to some of the problems that had been encountered since he began using the transorbital method, such as bending and breakage. Manufactured in Washington, D.C., and presumably designed by Freeman, the orbitoclast (see Figure 1, instrument D) was found to be suitable after Freeman had “tested [it] by inserting the point through the keyhole of a door and lifting with a force of 25 kg. on the handle” (Freeman, 1952, p. 826). Satisfied that the orbitoclast would not bend or break, Freeman proceeded to use it in an initial 70 operations for which earlier transorbital leucotomes had proven ineffective (Freeman, 1952). Freeman seems to have found an optimal instrument, as this appears to be the instrument used to lobotomize Howard Dully—a young boy operated on at 12 years of age—7 years later in 1960 (see photograph in Dully & Fleming, 2007, p. 95). Accompanying his new orbitoclast, Freeman employed what he thought was a solid rhetoric to rationalize his new technique to patients and medical colleagues. In part, Freeman (ca. 1950) claimed “The results with Transorbital lobotomy have been nearly twice as good as those with prefrontal lobotomy” (p. 1), and there were fewer side effects, such as personality alterations (Freeman, 1948b). Moreover, Freeman (ca. 1950) argued that neurosurgeons—who had been primarily performing prefrontal lobotomy operations—were “fully occupied with their own problems of tumors and disks, pain syndromes, epilepsy and head injuries” (p. 3). Other duties performed by neurosurgeons meant that patients (and their families) often needed to wait in line for psychosurgical oper-

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FREEMAN’S TRANSORBITAL LOBOTOMY AS AN ANOMALY

ations, creating a backlog of those awaiting the treatment. Proposing a solution to a growing demand, he controversially promoted the transorbital operation as “a minor one [that] may be performed by the psychiatrist provided he has thoroughly familiarized himself with the technique and landmarks through previous practice on the cadaver” (Freeman, 1948a, p. 373). Lastly, Freeman also argued that the safety, speed, and simplicity of the procedure made it sufficiently versatile to be offered outside neurosurgical units in general hospitals (e.g., Freeman, 1948a, 1949a, 1949b). This was particularly attractive to many psychiatrists by virtue of the fact that not all mental hospitals had surgical facilities to accommodate major psychosurgical operations (Freeman, 1949a). As will be shown, the move outside the operating room was alarming to neurosurgeons and led to objections leveled against both Freeman’s rhetoric and his move to performing transorbital lobotomies himself. Although Freeman defended his procedure and continued to attend neurological, psychiatric, and neurosurgical conferences and contribute to respective journals (e.g., Freeman, 1949b, 1952), Freeman largely became an outcast among his neurosurgical colleagues as a consequence of his move to the transorbital method. Though most widely recalled today under the umbrella of psychosurgery, Freeman’s procedure was not consistent with normative practices of the day and might be more appropriately considered in an altogether different category. As we consider in the next section, the medical community was predominantly appalled by Freeman’s work and separated itself from the man, his crude instruments, and his overly simplistic technique that had been moved outside the operating room. Cast Aside: Condemnation of the Ice Pick Lobotomy Whereas the transorbital lobotomy would prove to be too much for the professional and ethical sensibilities of many neurosurgeons, Freeman’s original partnership with Watts and their resulting prefrontal lobotomy technique were not. As early as 1938, the esteemed neurosurgeon Harvey Cushing was cautiously optimistic about the potential for this type of neurosurgery (McKenzie, 1938). Undeterred by

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some initial disapproval in the late 1930s, within a decade, prefrontal lobotomy had largely been accepted as an effective somatic treatment for mental disorders (Collins & Stam, 2014). Alongside burgeoning research in the area, growing support from the medical community was evident by the early 1940s: The road to universal recognition has not been easy, since unjustified and harsh criticism at first by competent neurologists and psychiatrists would have discouraged many an investigator. However, the knowledge that [prefrontal] lobotomy has its indisputable merits in neuropsychiatry has carried their work to success and silenced forever uninformed and old fashioned critics. (Reese, 1943, p. 96)

With endorsements such as this, it is not surprising that prefrontal lobotomy was taken up in a variety of countries such as Italy, Canada, and the United Kingdom by this time (Collins & Stam, 2014). Despite psychosurgery finally being considered part of the armamentarium for the treatment of mental disorders by the latter half of the 1940s, Freeman’s transorbital lobotomy came as a shock to the medical community. Notwithstanding Freeman’s claims of extraordinary success, safety, and practicality, neurosurgeons wasted no time voicing their disapproval (Valenstein, 1986). In particular, there were two grounds upon which Freeman and his transorbital method faced scrutiny and were ultimately discredited—instrumentation and operative spaces. On both counts, Freeman deviated from normative practices of the period serving to ostracize himself from the mainstream neurosurgical community. In the remainder of this section, we review both aspects individually— including helpful background on the establishment of each of these aspects as conventional in the first place—in order to demonstrate how Freeman’s work was deemed an anomaly as a consequence of his blatant departure from established customs. Surgical Instruments The surgical instruments used in neurosurgical and psychosurgical procedures in the mid20th century did not appear without prerequisite. Instead, Valenstein (1980) explicitly made the connection between ancient cranial trepanation (see Arnott, Finger, & Smith, 2003) and modern psychosurgery to address mental distur-

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bances. Moreover, there were 19th-century surgical attempts to alter the brain to eliminate troubling mental symptoms. Prior to Moniz’s inaugural operation in 1935, Swiss psychiatrist Gottlieb Burckhardt and the Russian neurosurgeon Ludvig Puusepp experimented with their own brazen procedures (Lichterman, 1993; Stone, 2001). There were also other sporadic surgeries that took place in the United Kingdom and in North America in the late 19th century by individuals such as Thomas Claye Shaw and Harrison Cripps (Berrios, 1997). Yet there is little information on the surgical instruments or techniques employed by these physicians. As an exception, we do know that, in 1888, Burckhardt used a “sharp spoon or Graefe’s knife” to remove small amounts of the cerebral cortex in his brief series of operations (Stone, 2001, p. 84). Nevertheless, none of these physicians successfully developed a definitive approach to operating on patients with mental illness, or a specialized surgical instrument in which to accomplish the task. In fact, in the late 19th century, surgical work of this kind was so contentious that those involved were largely forced to abandon their research trajectories (e.g., Stone, 2001). Courtesy of the emergence of the formal specialty of neurosurgery in the late 19th and early 20th centuries (Bliss, 2005), a foundation had been established for psychosurgery by the time Moniz’s first patient underwent the first prefrontal leucotomy. By this time, neurosurgeons were already accustomed to removing tumors and surgically addressing other neurological conditions (Bliss, 2005). Thus, applying neurosurgery to treat mental disorders (i.e., psychosurgery)—at least as far as the instruments and operative spaces were concerned—was not inconceivable. Much remained consistent; neurosurgeons, in the comfort of the familiar operating room, continued to open the skull, cut and cauterize the same physical brain, and used many of the same instruments in the process (e.g., trephine, scalpel). Essentially, neurosurgeons only needed to adapt familiar tools and techniques to new purposes. Of course, it was that purpose—the cure or improvement of psychiatric illness—that proved conspicuously different and, initially, most startling.4 For instance, two prominent American neurosurgeons, Walter Dandy and Byron Stookey, were initially “rather antagonistic toward the

idea” (McKenzie, 1938, p. 1). Aside from the questionable rationale that eventually abated, from the outset neurosurgeons were indeed qualified and most suited to operate given their familiarity with the brain, surgical protocol, and neurosurgical instruments. Turning to the materiality of surgical tools, an impressive instrument ancestry supports the notion that neurosurgeons simply needed to adapt existing tools for the new psychosurgical agenda. For millennia, as Kirkup (2005) has documented, surgical instruments have been modified and “subjected to repeated reformation, reflecting persistent attempts to improve established functions or to adapt to new functions as surgical techniques evolved” (p. 144). Although neurosurgeons would eventually work to better existing instruments used in psychosurgical procedures, Moniz and other early psychosurgeons initially applied familiar instruments to a new purpose. Moniz designed the first psychosurgical instrument—the leucotome (see Figure 2, Instrument A)—inspired by other surgical instruments already in use. As Rasmussen (1947) explained, the use of trocars with “concealed stilettes” was not a novel invention; rather, this configuration had been used by a number of surgeons as early as the turn of the 20th century (p. 78). Moniz, as Kirkup (2005) suggested, altered the way such an instrument was used to meet Moniz’s desired function of cutting cores in the white matter of the frontal lobes (Moniz, 1937). Less than a decade later, when Canada’s Kenneth George McKenzie devised his own variation of the leucotome (see Figure 2, Instrument B; Miller, 1954), his was reminiscent not only of Moniz’s leucotome but also of a “Vacher’s snare” for removing tonsils (see Kirkup, 2005, p. 302, Figure 382, Instrument E).5 Thus, not only did McKenzie attempt to improve upon Moniz’s leucotome, he may have been inspired by an instrument used for an altogether different surgical purpose. Although blunt instruments 4 Although not discussed here, because of a more welcoming reception in the medical community (see Bailey, 1949), psychosurgery also became a highly regarded therapeutic tool for treating unbearable pain (e.g., Freeman & Watts, 1948; Lyerly, 1951). 5 We thank Dr. Shelley McKellar (University of Western Ontario) for sharing her observation that these two instruments were indeed similar.

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FREEMAN’S TRANSORBITAL LOBOTOMY AS AN ANOMALY

would become the most commonly used tools for psychosurgical operations, some neurosurgeons continued to use and improve wired leucotomes throughout the psychosurgical era (e.g., McGregor & Crumbie, 1942; see Figure 2, Instrument C). Despite efforts to perfect wired leucotomes, it was Freeman and Watts’s standard prefrontal lobotomy technique that became most commonly employed around the globe (McLachlan & Falconer, 1950). Although amending Moniz’s procedure by moving the entry site into the skull and altering the way in which the white matter was disrupted, Freeman and Watts also began to use two markedly different instruments in their procedure (Freeman, Watts, & Hunt, 1942). In their two-stage operation, they first used a “brain canula” in order to mark the boundaries of where the white matter would be disrupted (p. 83). Then, “[a] blunt dissector . . . [specifically a] Killian’s periosteal elevator” (p. 83; see Figure 3, Instrument A) was used to complete the vertical sweeping motions to disconnect the white matter (Freeman et al., 1942, p. 84).

Figure 3. Various international prefrontal lobotomy leucotomes (redrawn by the authors from the sources listed; not drawn to scale): (A) Killian periosteal elevator used by Freeman and Watts (Freeman, Watts, & Hunt, 1942); (B) blunt instrument used in Carrillo’s selective leucotomy (Carrillo, 1947); (C) Kerrason blunt dissector used by Lyerly (Lyerly, 1951); (D) brain cannula used by Sorour in Egypt (Sorour, 1957); (E) scalpel used by Guerra and Sacco in Italy (Guerra & Sacco, 1954).

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Freeman et al.’s (1942) use of a cannula and elevator was, like Moniz’s leucotome, likely inspired by preexisting surgical instruments. Tubular shaped instruments, precursors to cannulas and the like, were in use for millennia and initially fabricated out of a variety of material including plant stems, animal bones, bronze, and lead. At times even trocars—which were similar instruments upon which the wired leucotomes were based—were encapsulated in a cannula and used in the 17th and 18th centuries (Kirkup, 2005). Elevators, on the other hand, were characteristic of existing instruments that were “rounded or blunted at one end to form probes and probelike instruments” (Kirkup, 2005, p. 144). Following Freeman et al.’s (1942) lead, other blunt instruments (see Figure 3, Instruments B to D), and even scalpels (see Figure 3, Instrument E), were developed for psychosurgical operations similar to the prefrontal lobotomy. By now it should be clear that nearly all of the instruments that emerged for the practice of psychosurgery were, in one way or another, modified or inspired by existing surgical tools. Even Fiamberti’s use, in 1937, of a hypothermic needle for his transorbital technique, which later inspired Freeman’s ice pick procedure (Kotowicz, 2008), was adapted for a new function from an existing instrument (i.e., transorbital entry to the brain vs. the injection of fluid into the body). Taken together, there was a clear surgical, and in this case, specifically neurosurgical, practice of using, improving, and adapting existing instruments for the many psychosurgical variations that emerged between 1935 and the 1960s. Although there was no clear consensus on which operative technique or surgical instrument was optimal (Money, 1955), the process of deriving these techniques and instruments was normative in the neurosurgical community. The implication of this existing conventional practice around instrumentation was that Freeman’s choice of instrument for his transorbital lobotomy created an immediate fissure between himself and contemporary neurosurgeons. Rather than drawing inspiration from existing surgical instrumentation as others had done, Freeman stepped outside the bounds of medical practice by procuring and subsequently employing a tool found in his kitchen drawer (see Figure 1, Instrument A). Although ice picks of Freeman’s era were remarkably similar to trocars still in use during the 1940s (see Kirkup, 2005, p. 186,

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Figure 225), Freeman’s decision to deliberately employ a tool from his home is, arguably, indicative of his quest for a particular kind of instrument that he felt did not already exist in the medical domain. It was not surprising, then, that neurosurgeons were quick to object to Freeman’s ice pick procedure; for them, the very name of the procedure clearly exposed the supposed surgical instrument as a crude, household tool unfit for neurosurgical application. Scoville (1949), for instance, noted that Freeman’s technique was “sometimes vulgarly known as the ìce pick operation’” (p. 3), which was an “unappetizing term” that promoted stigmatization (Moore, 1949, p. 741). Perhaps in an attempt to ameliorate the perception of the procedure, Moore (1949) introduced his own instrument for conducting transorbital lobotomies. Interestingly, even his instrument— called a “transorbitome” (p. 741)— was visibly based on surgical precursors, as were, incidentally, Freeman’s later variations (see Figure 1, Instruments B to D). Surely cognizant of the reputation the “ice pick operation” (Scoville, 1949, p. 3) had garnered, Freeman moved away from referencing the ice pick in his publications on transorbital lobotomy even when the history of the procedure was provided (e.g., Freeman, 1948a, 1949b). By initially introducing and endorsing the use of an ice pick as a neurosurgical instrument, Freeman both astounded and repulsed contemporaries. Surgical instruments, as we have shown, have a long history of adaption and improvement; however, Freeman engaged in neither of these when he selected the ice pick for his new procedure. On the other hand, neurosurgeons who were following in the footsteps of Moniz and others remained inside the boundaries of their discipline by modifying familiar instruments for a new, albeit controversial, purpose. Instrumentation, however, was only one of Freeman’s missteps that left him an anomaly in the neurosurgical field. He also offended the sensibilities of neurosurgeons by moving the most complex of surgeries (i.e., on the brain) outside the operating room. Operative Spaces As was the fact that Freeman had used a common kitchen tool for a new and brazen procedure, his lack of training in neurosurgery was similarly palpable by virtue of Freeman’s

contempt for established neurosurgical practices. His disregard for these practices became a pressing concern for neurosurgeons when Freeman began performing his ice pick transorbital lobotomy outside of the operating room. Convinced that his procedure might offer greater accessibility to treatment by psychiatrists trained to perform the technique, Freeman forged ahead and began performing in-office operations. Early on, James Watts was forced to confront Freeman’s radical ways when he walked in on an ice pick transorbital lobotomy in progress in the office the two shared: . . . [Watts was] astounded to see Freeman standing over an unconscious patient who had an ice pick protruding from his face. . . . Without showing any surprise at this intrusion, Freeman gamely asked Watts to hold the ice pick while he snapped a photograph. Watts refused and angrily protested that brain surgery should not be an office procedure. (El-Hai, 2005, p. 190)

As a respected member of the neurosurgical community, Watts’s response foreshadowed the cold, indignant reception Freeman would soon receive, and indefinitely endure, from the larger neurosurgical community. Of gravest concern for neurosurgeons was Freeman’s betrayal of established surgical praxis; in particular, his disregard for the importance of control as intricately bound to the operating room. According to Schlich (2007), once surgery became formally situated within the hospital in the 19th century, a maximally controlled setting for surgery became possible. This move was crucial for existing and emerging technologies of control—such as minimizing infection and pain management—that were necessary for successful surgical outcomes. In particular, the operating room’s “walls and doors limit[ed] access and protect[ed] it against visual and acoustic distraction as well as pollution by dirt and germs” (p. 237). Moreover, segregated operative space was symbolic as “these specially designed spaces [allowed] the patient’s body [to] be rearranged, controlled and visualized in new ways that ma[de] it possible to manipulate its structure” (p. 237). For surgeons, the operating room was the “’only ethical place’ to do surgery” (p. 246). Therefore, the emergence of a distinct operative space provided surgeons with an acceptable, agreed upon, and inviolable setting in which to perform their craft—a space that became intricately tied to their identities.

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FREEMAN’S TRANSORBITAL LOBOTOMY AS AN ANOMALY

For the emerging surgical specialty of neurosurgery forging its professional identity in the early 20th century, the operating room was at the heart of “their technical performance” (Gavrus, 2011, p. 8). This performance was known as “the Cushing ritual,” which consisted of “attention to detail, a slow meticulous surgery, an intolerance of both blood loss and the sacrifice of healthy tissue along with certain prescribed steps taken to open and close the skull” (Gavrus, 2011, p. 84). Named after Harvey Cushing—traditionally heralded as the father of neurosurgery (Bliss, 2005)—the successful completion of this method was only possible in a contained and controlled operative space. For Cushing, the identity of the neurosurgeon was intricately tied to these technologies of control enacted in the operating room (Gavrus, 2011). In particular, Cushing was convinced that The best brain surgeon had to aspire to put on “a tedious and dull show” in the operating room, a slow and careful performance whose aim was to lead to the best result for the patient rather than to a quick and dazzling show that nourished the surgeon’s vanity. (Gavrus, 2011, p. 71)

Thus, any failure to dutifully follow prescribed mechanisms instituted for the safe and successful execution of brain surgery was perceived by the neurosurgical community as a rejection of normative practices. Individuals who did not meet the professional and moral imperatives of neurosurgery were quickly relegated to the outskirts of the specialty by members who policed the boundaries for those who did not meet their expectations. When an individual was found not to coalesce with the identity of the early-20thcentury neurosurgeon, they were excluded from the community (Gavrus, 2011). When James Watts refused to participate in Freeman’s new in-office procedure, this was a distinct sign that Freeman had violated sacrosanct practices. Although the two would maintain a professional relationship at GWU, Freeman’s move to the transorbital method forever fractured their relationship (El-Hai, 2005). By 1950, Watts remained resolute in his opposition to Freeman’s new technique, which was evident in the preface of the second edition of their monograph: “The authors regret to announce that they have been unable to reach an agreement on the subject of transorbital lobotomy”

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(Freeman & Watts, 1950, p. x). Freeman, however, remained undeterred in his effort to promote his method to neurosurgeons and his psychiatric colleagues. Along with Watts, many other neurosurgeons made their objections known inside the neurosurgical and broader medical communities, but also directly to Freeman himself. For instance, Wylie McKissock, a highly respected neurosurgeon from the United Kingdom, “admit[ted] that his neurosurgical principles were gravely upset by [the transorbital method] and even more by the fact that it should be done by a psychiatrist” (Rees, 1949, p. 15). Moreover, many thought it demonstrated a “total disregard for all the principles of modern neurosurgery” (Money, 1955, p. 9). All of the ways in which Cushing and his contemporaries helped to establish a particular identify for neurosurgery— and the centrality of the operating room to this identity—was carelessly dismissed by Freeman. In the words of Percival Bailey (1949), the transorbital lobotomy, in its pernicious violations of neurosurgical practices, “is of a nature to distress the surgeon greatly” (p. 493). Aside from having their sensibilities offended, neurosurgeons were also concerned about the possible dangers that might befall a patient who underwent the procedure outside the operating room. Technologies of control, like asepsis and methods for maintaining hemostasis, “made it possible to reproduce the optimum conditions for surgery . . . [and] allowed the replication of good operation results” (Schlich, 2007, p. 238). Bailey (1949) raised such a concern by indicating that transorbital lobotomies were “being used in psychiatrists’ offices without provision to deal with complications which must occasionally result” (p. 493). For instance, neurosurgeons were surely horrified by Freeman’s tendency to conduct his transorbital lobotomies without surgical gloves (El-Hai, 2005). Although a debated technology in the 1890s (see Schlich, 2013), the controversy had abated by the psychosurgery era and surgeons had incorporated the use of surgical gloves into their regular routines. Thus, not only had Freeman moved outside the operating room, he also failed to comply with even the most basic of practices that ensured safe surgical outcomes for patients.

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If Freeman had not already been exposed as a neurosurgical imposter, his response to the concerns of neurosurgeons would have confirmed any remaining suspicions. In fact, his rebuttal signified a lack of socialization into the neurosurgical community and disrespect for the normative practices of the field. In essence, Freeman’s response only cemented the position of his opponents. However, rather than address the concerns of neurosurgeons, Freeman tried to turn the negative appraisals on their head. For instance, at a 1949 meeting of the Royal Society of Medicine in the United Kingdom, Freeman listened to McKissock’s scathing critique (Rees, 1949) and concerns from other notable neurosurgeons before giving his retort. He replied by stating that the “objection[s] to the transorbital method was hardly a matter for professional wailing” (Rees, 1949, p. 21). In fact, a year later he confidently claimed that “[t]he fears of my surgical colleagues have turned out to be largely unfounded” (Freeman, ca. 1950, p. 4). Yet despite Freeman’s effort to dismiss mounting criticism, the vast majority of neurosurgeons never relented in their staunch opposition, leading to the exclusion of Freeman and his transorbital procedure from the neurosurgical community. As we have shown, Freeman’s insistence that transorbital lobotomies could be performed by psychiatrists outside the operating room translated into the removal of functional safeguards and control procedures that ensured successful outcomes. Established practices conducted within segregated operative spaces “permitted surgeons to do things in those special settings that would be considered insane if they were done elsewhere” (Schlich, 2007, p. 246). Thus, Freeman’s move outside the operating room was deemed as irrational and would not be tolerated by the community of neurosurgeons who classified him as an anomaly in the arena of neurosurgery. Conclusion In the 1930s when psychosurgery was first introduced, there was cause for concern on a variety of fronts. For instance, the pioneers were charged with mutilating physically healthy brain tissue with only a faint hope of cure (Valenstein, 1986). Whereas prefrontal leucotomy and lobotomy became internationally accepted by the latter half of the 1940s (Collins & Stam,

2014), transorbital lobotomy never really gained broad acceptance despite a small number of neurosurgeons who sided with Freeman (e.g., Hirose, 1966). As we have argued in this article, Walter Freeman’s transorbital lobotomy— though curiously most often remembered today as representative of psychosurgery— did not reflect conventional neurosurgical practices of the era. In a time where neurosurgeons were among the elite in the medical profession and had largely established a safe and precise surgical specialty, Freeman’s innovation was unwelcome, repulsive, and, ultimately, an unaccepted anomaly. Moving beyond the use of textual sources alone, as has been common in histories of psychosurgery, we have contrasted Freeman’s transorbital work with accepted neurosurgical practices by drawing on a material culture approach that considered surgical instruments and operative spaces. Rather than attack Freeman’s results, neurosurgeons became preoccupied with these elements that placed him outside the boundaries of the discipline. In regard to the former, we have demonstrated that Freeman’s use of the ice pick was not only crude but also unconventional, given that it was not a surgical tool for which the function was simply adapted for a modified purpose. In our consideration of the operating room as a site where established neurosurgical practices merged with practitioner identity, we showed that Freeman’s transorbital lobotomy, as a procedure that could be done by psychiatrists outside the operating room, violated the ethics and better judgment of neurosurgeons. On both counts, Freeman’s affront to normative neurosurgical culture was noted by the majority and mobilized as grounds upon which neurosurgeons legitimized their exclusion of him and his clumsy technique. Although the transorbital lobotomy was, in actuality, an anomaly among other psychosurgical techniques, it remains the emblematic procedure of the psychosurgery era. There are a number of possible reasons for this preoccupation with the transorbital method. In part, as we have argued previously (see Collins & Stam, 2014), it is the American experience that has been most studied and documented in the last 60 years. Thus, it should not be surprising that Walter Freeman—the man who brought leucotomy to America and performed a significant number of transorbital operations—is most

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FREEMAN’S TRANSORBITAL LOBOTOMY AS AN ANOMALY

readily remembered. Additionally, his transorbital work became sensationalized, in part, as a consequence of the audacious procedure itself (Collins & Stam, 2014). Though surely Freeman never intended his radical procedure to be memorialized as a procedure fit for a horror story, this is primarily how it has been remembered and continues to be portrayed in popular culture. Because of the intrigue associated with the procedure and the perennial interest in the outlandish and disturbing, it is unlikely that our article alone will have much of an effect on how psychosurgery is remembered by mainstream culture. Instead, our study is an attempt to use a material culture approach as a way to revise how transorbital lobotomies are talked and written about, so that its status as an anomaly can be more accurately reflected. The tendency to group the procedure with other, largely accepted psychosurgical procedures of the day is incongruent with the historical record. In effect, this is one way in which historians have the opportunity to contribute to current, popular understanding of the psychosurgical era and, more broadly, the period in which somatic treatments dominated psychiatry in the mid-20th century. After all, the writers who created the scripts for the popular portrayals of psychosurgery that were referred to in the opening of this paper (e.g., Criminal Minds, A Hole in One) presumably sought out historical material on which to base their plot lines.

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Freeman's transorbital lobotomy as an anomaly: A material culture examination of surgical instruments and operative spaces.

In 1946, Walter Freeman introduced the transorbital ice pick lobotomy. Touted as a procedure that could be learned and subsequently performed by psych...
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