As soon as he had read that first, brief article Freeman requested a copy of Moniz’s full monograph on the process from its Paris publisher. He had seen his way forward. Although he was a neurologist, Freeman had no qualifications as a surgeon. He needed a neurosurgeon as a collaborator so he showed the book to his colleague, James Watts. They ordered from France two of Moniz’s leukotomies, knives specially designed for the operation, and after practicing for a week on brains from the morgue, Freeman and Watts operated on their first living patient. Watts did the cutting; Freeman navigated.
She was a 63-year-old woman from Kansas, the type of agitated, depressed and fearful personality that Moniz had experimented on. Faced with a choice of a mental institution or surgery, she and her husband opted for the knife. On the operating table, she had second thoughts when she realized that her head was about to be shaved, and she would lose the curls that she was proud of. Freeman assured her that her curls would be saved; this was not the case, but after the operation, as Freeman himself noted, “She no longer cared”.
The operation was carried out on 14 September 1936. Freeman and Watts Moniz had altered his prescribed technique since the first leukotomy, and six holes were now cut in the patient’s head. When she had been stitched together and had awoken from the anaesthetic, the sense of calm she exuded in contrast with her former terror was striking. When asked by Freeman if she could remember why she had previously been so upset, she could only say: “I don’t know. I seem to have forgotten. It doesn’t seem important now.” Freeman and Watts were thrilled.
A week after surgery, the woman began to behave strangely. She talked incoherently, becoming stuck on certain syllables, repeating them endlessly and hopelessly jumbling up her sentences. She could no longer recite the days of the week, and when she was asked to write, the same repetitions and sad, nonsensical constructions occurred on paper. A few days later, her speech had largely returned and she went placidly home, showing neither eagerness nor apprehension.
The two surgeons proceeded to operate on another five patients over the next six weeks, and in November 1936 published a report in which they wrote: “In all our patients there was a… common denominator of worry, apprehension, anxiety, insomnia and nervous tension, and in all of them these particular symptoms have been relieved to a greater or lesser extent.” They further said that in some patients disorientation, confusion, phobias, hallucinations and delusions had been relieved or had altogether disappeared. They concluded by stating the grounds on which they had undertaken the operations – to relieve symptoms that were causing “great distress to the patients and to their families” – and added: “We wish to emphasize that indiscriminate use of the procedure could result in vast harm. Prefrontal [targeted at the parts of the brain behind the frontal lobes] leukotomy should at present be reserved for a small group of specially selected cases… every patient probably loses something by this operation, some spontaneity, some sparkle, some flavor of the personality.”
Privately, however, Freeman was not only optimistic but triumphant. Talking about their first patient, he said: “This woman went back home in 10 days, and she is cured.” The “indiscriminate use” he and Watts counselled against would come, irrespective of their warnings; Freeman himself would provide both the means and the motivation for it.
Freeman and Watts considered that leukotomy was an incorrect name for the procedure. It suggested that it was only the white matter, the leukos, that was affected. They saw that they also destroyed actual nerve cells. Hence, they renamed it the lobotomy. This also helped to establish their version of the operation as distinct from that performed by Moniz. They were now the pioneers.
They began to perceive the limitations of the current mode of operation: eight of their initial 20 patients had two operations, and two of these had a third; there were two fatalities. Soon they were trying variations on the theme. They tried it with more holes in the top of the head, and penetrated deeper. They substituted for the cutting wire of the leukotome a more rigid blade, but found that the blade frequently broke off in the patient’s brain; and, when it could eventually be dragged out, bits of blood vessel and brain tissue came with it.