Lobotomy Nation: The History of

Psychosurgery and Psychiatry in

Denmark 1st Edition Jesper Vaczy
Kragh
Visit to download the full and correct content document:
https://ebookmass.com/product/lobotomy-nation-the-history-of-psychosurgery-and-ps
ychiatry-in-denmark-1st-edition-jesper-vaczy-kragh/
MENTAL HEALTH IN HISTORICAL PERSPECTIVE

Lobotomy Nation
The History of Psychosurgery
and Psychiatry in Denmark
Jesper Vaczy Kragh
 Mental Health in Historical Perspective

Series Editors
Catharine Coleborne, School of Humanities and Social Science,
University of Newcastle, Callaghan, NSW, Australia
Matthew Smith, Centre for the Social History of Health and Healthcare,
University of Strathclyde, Glasgow, UK
Covering all historical periods and geographical contexts, the series
explores how mental illness has been understood, experienced, diagnosed,
treated and contested. It will publish works that engage actively with
contemporary debates related to mental health and, as such, will be
of interest not only to historians, but also mental health professionals,
patients and policy makers. With its focus on mental health, rather than
just psychiatry, the series will endeavour to provide more patient-centred
histories. Although this has long been an aim of health historians, it has
not been realised, and this series aims to change that.
The scope of the series is kept as broad as possible to attract good
quality proposals about all aspects of the history of mental health from
all periods. The series emphasises interdisciplinary approaches to the field
of study, and encourages short titles, longer works, collections, and titles
which stretch the boundaries of academic publishing in new ways.

More information about this series at

http://www.palgrave.com/gp/series/14806
 Jesper Vaczy Kragh

Lobotomy Nation
The History of Psychosurgery and Psychiatry
in Denmark
Jesper Vaczy Kragh
Centre for Health Research
in the Humanities
University of Copenhagen
Copenhagen, Denmark

ISSN 2634-6036 ISSN 2634-6044 (electronic)

Mental Health in Historical Perspective
ISBN 978-3-030-65305-7 ISBN 978-3-030-65306-4 (eBook)
https://doi.org/10.1007/978-3-030-65306-4

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
This work is subject to copyright. All rights are solely and exclusively licensed by the
Publisher, whether the whole or part of the material is concerned, specifically the rights
of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc.
in this publication does not imply, even in the absence of a specific statement, that such
names are exempt from the relevant protective laws and regulations and therefore free for
general use.
The publisher, the authors and the editors are safe to assume that the advice and informa-
tion in this book are believed to be true and accurate at the date of publication. Neither
the publisher nor the authors or the editors give a warranty, expressed or implied, with
respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.

Cover image: © Lennart Nilsson/TT Nyhetsbyrån

This Palgrave Macmillan imprint is published by the registered company Springer Nature
Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
 Preface

This book tells the story of one of medicine’s most (in)famous treatments:
the neurosurgical operation commonly known as lobotomy. The book itself
is the serendipitous result of a series of more or less random events that
occurred some years ago, at a time when I knew nothing about high-risk
neurosurgical practices on psychiatric patients. Back then, I was studying
a group of Danes who claimed to commune with the dead—the spir-
itualists from the twentieth century—and the history of psychiatry was
unknown territory to me.1 Nevertheless, I made my way, via a some-
what circuitous route, from spiritualism to psychiatry. It turned out that
early-twentieth-century psychiatrists had taken a keen interest in the spiri-
tualists’ conversations with the dead. In order to gain insight into the link
between the two groups, I started searching for information about the
evolution of psychiatry. It was not easy to find. The history of psychiatry
in Denmark has only been sparingly and sporadically recorded. I decided it
was worthy of closer study, and I was fortunate enough to secure funding
for a research project in 2002. To this day, my interest in psychiatry has
remained undiminished.
In the course of my research, I was particularly drawn to the somatic
treatments in psychiatry. In the early twentieth century, Danish psychi-
atrists all seemed to agree on the use of therapies like Cardiazol shock,
insulin coma therapy, electroshock and lobotomy on patients admitted
to the big mental hospitals. Accounts ranged from miraculous healing to
severely adverse side-effects, from sky-high recovery rates to zero effect.

v
vi PREFACE

The popularity of the last of these physical treatments, lobotomy, came

as a particular surprise to me. A picture started to emerge of a Danish
lobotomy tradition. In fact, evidence suggests that more lobotomies were
performed in Denmark than any other country, an unofficial world record
that I was surprised to find had failed to make its way into the history
books. Indeed, even in works on the history of Danish medicine, there
was not one word about the thousands of people who had undergone
this surgical procedure to their prefrontal lobes. Why the silence? Why did
Danish psychiatrists so enthusiastically embrace this method? Lobotomy
became the focal point of the project, and the question of its widespread
use in Denmark became the starting point for my studies.
In search of potential explanations for the widespread use of lobotomy,
I turned to the international literature on the subject but discovered
no unambiguous answers. In fact, I found only a few in-depth studies,
and even the most illustrious works offered explanations that pointed
in different directions. As a consequence, I started to relate the Danish
example to theories in international research and follow other paths not
covered in the literature.
One such path led me to contemporary perspectives on methods
of physical treatment in twentieth-century psychiatry. For many Danish
psychiatrists, somatic treatments—not just lobotomy, but also elec-
troshock and others—represented a turning point in the history of their
discipline. The intriguing idea that these kinds of treatments, which would
be so harshly criticised by posterity, were revolutionary for so many psychi-
atrists opened up for other questions: How did lobotomy and other
somatic therapies fit into the bigger picture of the way both psychiatry
and society were developing in the early twentieth century?
This book is the result of those studies. The story begins in 1922 and
ends in 1983—at least, in so far as it can be said to end at all. The debate
about lobotomy rumbles on, and to this day, psychosurgery is still a topic
of debate in many parts of the world. In the recent past, neurosurgeons
and psychiatrists have stressed that this new form of surgery is a rapidly
evolving discipline, and plans to reintroduce psychosurgery have been on
the agenda in several countries—including Denmark. The most recent
innovation is Deep Brain Stimulation, which has created high expectations
in many circles. This, on the other hand, has encouraged other researchers
to express concern about repeating the mistakes of the past. My book
represents a contribution to that discussion.
 PREFACE vii

A note on terminology. In this book, the terms “leucotomy” and

“lobotomy” are both used for the procedures performed from 1935 to
1955, and “psychosurgery” is used as an umbrella term that encompasses
both the early lobotomy/leucotomy and later forms of surgery (stereo-
tactic, etc.) that took off in the late 1950s and used slightly different
techniques. In the UK, leucotomy is often used as a generic term for
all psychosurgical operations, i.e. prefrontal lobotomy (American term)
would be called prefrontal leucotomy in the UK. In this book, I primarily
use the term “leucotomy” to describe the operation invented by Egas
Moniz (who coined the term) and lobotomy to describe the later surgical
procedures introduced by Walter Freeman and James Watts.
Without external funding, this book would not have been possible. In
particular, I would like to express my gratitude to the Povl M. Assens
Foundation. I also received a great deal of help from other institutions
and individuals, whom I will thank properly in the postscript. But now to
the topic at hand.

Copenhagen, Denmark Jesper Vaczy Kragh

Note
1. On psychiatry and spiritualism, see Jesper Vaczy Kragh, “Mellem religion og
videnskab. Spiritismen i Norden i 1800 og 1900-tallet,” Scandia. Tidskrift
for historisk forskning, 68 (2002), 53–75; Kragh, “History of spiritualism
in Denmark, 1853–2011,” in: Christopher Moreman (ed.), The Spiritu-
alist Movement. Speaking with the Dead in America and Around the World
(California: Praeger, 2013), 73–82.
 Contents

1 White Incisions and Black Butterflies 1

Part I Towards Lobotomy

2 State Mental Health Services—Danish Hospitals
and the Directorate, 1922–1952 31
3 Malaria and the Interwar Years—Malaria Fever
Therapy and Other Innovations in Psychiatry,
1922–1937 47
4 Shock and Coma—Insulin and Cardiazol Shock
Therapy, 1937–1942 69
5 Psychiatric Cooperation—Shock Treatment,
Diagnoses and Psychiatric Textbooks, 1938–1942 93

Part II The Heyday of Lobotomy

6 Something Different—Lobotomy, Electroshock
and Plans for Psychiatry, 1939–1947 121
7 The First of Many—Lobotomy and the State Mental
Hospital in Vordingborg, 1940–1947 149
8 The Apostles of the Knife—Lobotomy, the Directorate
and the General Public, 1946–1956 171

ix
x CONTENTS

9 Last Resort?—Selecting Patients for Lobotomies

in Vordingborg, 1947–1956 219
10 Women and the Problem of Psychopathy—Gender
and Control in Vordingborg, 1947–1956 263

Part III The Demise of Psychosurgery

11 A Question of Consent—Coercion and Consent
to Lobotomy, 1946–1958 291
12 Lobotomia Sequelae—The Side-Effects of Lobotomy,
1955–1983 337
13 The Final Cut—Summary and Conclusion 393

Postscript 425
Appendix I: Diagnoses 427
Appendix II: Lobotomy Patients, Vordingborg State
Mental Hospital 431
Appendix III 441
Author Index 443
Subject Index 449
 List of Figures

Fig. 2.1 The psychiatric map of Denmark in 1952, with a list of all
psychiatric hospitals, wards and units. The term “branch
institutions” covered the county hospitals that operated
under the state mental hospitals and took in elderly
patients. These county institutions were not authorised
to provide actual treatment and were primarily for elderly,
placid or able-bodied patients (Medical Museion) 40
Fig. 3.1 Chief physician Axel Bisgaard to the left and staff
doctor Sigurd Hansen rightmost. Nurse Lise Madsen
in the middle with the first two patients with dementia
paralytica just before departure to Vienna in 1922
(Medical Museion) 53
Fig. 4.1 Insulin coma therapy at the Danish State Mental
Hospital in Augustenborg in 1943 (Psychiatric Museum
Augustenborg) 76
Fig. 5.1 So-called pyknic body type from a Danish psychiatric
textbook (Medical Museion) 100
Fig. 5.2 On the left, the astenich or “leptoform” body type
that was typical for schizophrenia, according to Danish
psychiatrists. On the right side, angular profile (Medical
Museion) 102

xi
xii LIST OF FIGURES

Fig. 6.1 Participants at the third International Neurological

Congress in Copenhagen, 1939. Walter Freeman can
be glimpsed as number two from the left, wearing
a light-coloured jacket and tie. On the opposite side
of the picture by the lamp post, Ugo Cerletti can be seen
wearing a light-coloured jacket, holding paper and his hat
(Medical Museion) 128
Fig. 6.2 Electroshock therapy at the state mental hospital
in Augustenborg in 1943. The photographs were
taken when Billed-Bladet visited in March to make
“a unique report of the most modern treatments
of the mentally ill.” Billed-Bladet presented
the “talked-about electro-convulsive method that has had
so many good results that the psychiatric hospitals
do not need to suffer from a lack of beds as before”
(Augustenborg Psychiatric Museum) 135
Fig. 6.3 One of the large wards in Augustenborg where the beds
were positioned close together. On the picture,
a screen used in connection with electrohock therapy
can be seen. The electro-convulsive devices were
on trolleys that the doctors could push around the wards
(Augustenborg Psychiatric Museum) 139
Fig. 7.1 Architectural plans for the mental hospital in Vordingborg,
1857. The hospital was designed by the architect Gottlieb
Bindesbøll (Heidi and Henning Gøtz) 154
Fig. 7.2 Aerial view of the hospital in Vordingborg in the 1940s.
On the left are the pavilions. Further back, on the right,
the main building towers above the others in the complex
(Medical Museion) 155
Fig. 8.1 Richard Malmros rightmost performing surgery
at the neurosurgery ward in Aarhus in the late 1940s (Ib
Søgaard) 193
Fig. 9.1 The State Mental Hospital in Middelfart on aerial
photograph from the 1940s (Medical Museion) 225
Fig. 9.2 Map of the state mental hospitals’ catchment areas
in the 1950s (Medical Museion) 229
Fig. 9.3 Patient in a straitjacket and cotton-drill mittens, which
could be strapped to the bed, in a ward for unruly
patients in Augustenborg in 1943. Patients wearing these
gloves had to be hand-fed (Augustenborg Psychiatric
Museum) 234
 LIST OF FIGURES xiii

Fig. 9.4 Indication I and II. Total number of indications for male
and female lobotomy patients from Vordingborg (N =
285) 250
Fig. 9.5 Time spent in hospital, lobotomy patients, Vordingborg.
All patients, men and women, before lobotomy (N =
313) 252
Fig. 9.6 Total time spent in hospital before lobotomy
and the general patient population in Vordingborg
01/01/1947. Lobotomy patients in blue, general patient
population 1947 in red 253
Fig. 9.7 All diagnoses for male and female lobotomy patients
from Vordingborg (N = 345) 254
Fig. 11.1 Aerial photo of the Neurosurgery Department
at Tagensvej in Copenhagen (Medical Museion) 313
Fig. 12.1 Stereotactic device for precision surgery. The technique
was invented by the American neurosurgeon Henry
T. Wycis in 1947. The image shows device used
at Rigshospitalet in Copenhagen, a so-called Leksell
frame, invented by the Swedish neurosurgeon Lars Leksell
(Medical Museion) 364
 List of Tables

Table 9.1 Other treatments used before lobotomy, women

and men. Cardiazol, insulin, electroshock, summation
and other (i.e. hormone treatment, sulfosin,
narco-analysis, psychoanalysis) (N = 285) 251
Table 12.1 Type of injury as a percentage of all lobotomy patients
in Vordingborg (N = 285) 358
Table 12.2 Number of psychosurgery operations performed
in Denmark, 1944–1979. The total is based
on information from a combination of contemporary
sources and later studies128 375
Table A.1 Gender distribution 431
Table A.2 Marital status 431
Table A.3 Patients with children, gender distribution 432
Table A.4 Schooling, evaluation of school abilities 432
Table A.5 Schooling, secondary education/higher education 432
Table A.6 Patients’ occupation 433
Table A.7 Diagnosis, females and males 434
Table A.8 Length of stay before lobotomy 435
Table A.9 Lobotomy patients age 435
Table A.10 Other treatments before lobotomy 436
Table A.11 Indication I 436
Table A.12 Indication II 437
Table A.13 Assessment of lobotomy, observation time 0–2 years 437
Table A.14 Assessment of lobotomy, observation time 3–20 years 438
Table A.15 Length of stay after lobotomy (all years) 438
Table A.16 Readmissions after lobotomy 439

xv
 CHAPTER 1

White Incisions and Black Butterflies

Prologue
On 11 November 1935, a 63-year-old woman with a psychiatric diagnosis
of involutional melancholia was admitted to the neurology ward at Santa
Marta Hospital in Lisbon, Portugal.1 She had been suffering from severe
anxiety attacks, insomnia and auditory hallucinations, and was convinced
that her neighbours and the police were hounding her. She had spent
three years as a patient at the Manicome Bombarda asylum, where the
psychiatrists described her as depressed, restless and prone to tears. She
was transferred to Santa Marta to find out whether a special new form
of treatment—as yet unnamed, but later known as frontal leucotomy—
would help. She would be the first patient to undergo the experimental
procedure devised by 61-year-old Professor of Neurology Egas Moniz
and carried out the next day by his assistant, the neurosurgeon Almeida
Lima. The veteran professor, who had previously enjoyed a successful
political career and gained international recognition for his neurological
research, was unable to operate due to chronic arthritis. However, Lima,
thirty years his junior, was accustomed to assisting Moniz in the oper-
ating room. The operation would be the first time in history that deep
incisions were made in the front parts of the brain of a psychiatric patient,
but Lima had no qualms: Moniz was his superior and needed his hands.2
The night before the operation, the patient’s hair was shaved off. The
next morning, her scalp was disinfected with alcohol. She was laid out

© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2021
J. V. Kragh, Lobotomy Nation, Mental Health in Historical Perspective,
https://doi.org/10.1007/978-3-030-65306-4_1
2 J. V. KRAGH

on an operating table and given an injection of Novocaine as an anaes-

thetic, as well as adrenaline to reduce bleeding during the operation.
Using a scalpel, Lima then made two incisions, three centimetres from
the midline of the skull, either side of the crown, exposing a narrow
strip of bone. Two holes were then drilled so that the surgeon could
operate on the front of the two halves of the woman’s brain. Moniz
had asked Lima to operate on an area in the frontal lobes with a high
density of white nerve fibres, which connected the front of the brain
to its centre.3 Moniz had considered various methods of severing the
neural pathways. Ultimately, he decided to use pure alcohol, which, when
injected in small amounts, would destroy selected areas of the brain. On
12 November, Lima inserted a needle through the holes in the patient’s
skull and administered a total of four injections.
About four hours after the operation, the patient had recovered suffi-
ciently well for Moniz to start asking her simple questions. He began by
asking where she lived and how many fingers he had on his hand. She
named the city and, after a brief hesitation, answered “five” to the second
question. However, when asked her age, she had difficulty remembering
it. On the question about the name of the hospital, she fell silent.4
After the surgery, the woman still had a fever and a tendency to
burst into tears, but Moniz nevertheless observed what he considered
to be improvements in her condition. When her temperature returned to
normal, she was sent back to Manicome Bombarda. Two months later,
the psychiatrists there described her as less anxious, restless and paranoid,
but still depressed. Moniz referred to the outcome of the treatment as a
“cure,” even though the woman never left the hospital again.5
While the psychiatrists at Manicome Bombarda were assessing the first
patient’s condition, Moniz forged ahead with his experiments. Within five
weeks, Lima had performed the same procedure on six other patients.
However, for the eighth operation, Moniz introduced a new technique
that would give the treatment its name. He had commissioned a custom-
made surgical device for the purpose from a specialist in Paris—a thin,
tubular, 11-cm-long instrument that would function as a knife. Pressing
a plunger on it released a sharp wire loop that extended from the bottom
of the narrow instrument. As the surgeon rotated the instrument, the
wire excised a round section, approximately one centimetre in diameter,
from the white matter of the brain. Moniz called the treatment “leuco-
tomy,” after the Greek words for white (leukos ) and cut (tomia)—hence
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 3

its colloquial name in Danish (det hvide snit ), which translates as “the
white incision.”6
The instrument, which Moniz dubbed a “leucotome,” was first used
on 27 December 1935 on a 47-year-old female patient who had been
transferred from Manicome Bombarda to Moniz’s hospital. “The patient
was admitted to our ward at Santa Marta in a highly troubled state,”
Moniz wrote. “She screams, never sits still, and begs not to be hurt.”
The patient refused to be photographed and had to be held down by two
nurses so that Moniz could take a pre-op photograph for the treatise he
was writing on the treatment.7
The woman was prepared for surgery and anaesthetised the same day.
Lima inserted the leucotome four centimetres into the woman’s brain
before pressing the plunger and releasing the wire loop. He then rotated
the instrument and made the first incision. Lima then completed the oper-
ation by making another three incisions. No post-op complications were
recorded, but Moniz noted that “the patient complains of headaches” and
tried to remove her bandages, so he administered an appropriate dose of
the sleeping drug Veronal (barbital).8
However, Moniz had to acknowledge that this operation was not
an unqualified success; she was cured of her anxiety but still seemed
depressed. She also became apathetic—a symptom she had not previ-
ously displayed. In his final notes, Moniz considered a second operation
in order to achieve “a more complete result.”9
After the first leucotomy, the number of incisions increased to six over
the next few operations. In the first series of surgery, which lasted until
February 1936, 20 patients with various psychiatric diagnoses underwent
the procedure at Santa Marta Hospital. In his assessment of the results,
Moniz reported that seven had been cured, seven had improved consid-
erably, and six remained unchanged. According to Moniz, the best results
were in patients with affective disorders, such as involutional melan-
cholia and manic-depressive psychosis. Patients with schizophrenia did
not appear to show much improvement.10
Moniz worked quickly, and very few of his patients were kept under any
form of observation for more than two months after their operations. He
wrote a steady stream of publications about the treatment. In 1937, he
completed a major book about leucotomy and had 13 articles published
in scientific journals in six countries. His peers abroad sat up and took
notice, and within a few months of the publication of the book in 1936,
4 J. V. KRAGH

doctors in the United States, Italy, Romania, Cuba, France and Brazil had
begun to experiment with the new treatment method.11
The speed at which leucotomy was adopted outside Portugal bore
witness to the fact that Moniz’s procedure was not an entirely new idea.
Nor was he the first doctor to consider neurosurgery as a cure for various
forms of human disorders. Trepanation—cutting holes in the skull—is
an ancient practice used in an attempt to cure health problems. One
of the oldest archaeological finds is a 10,000-year-old trepanned skull
from Ukraine. In Denmark, examples have been found dating to the
early Neolithic period, i.e., 4000–3200 BCE. However, it is doubtful
whether this practice was used to treat what we would call mental disor-
ders today.12 Actual surgical intervention—not just opening the skull but
removing specific parts of the brain in order to treat mental disorders—
was first recorded in the late nineteenth century. The earliest operation of
this kind took place in Switzerland.13
In 1888, the Swiss doctor Gottlieb Burckhardt performed the first six
neurosurgery operations on patients with mental disorders, believing it
better to try something new than do nothing at all. He also believed
that mental illnesses arose in specific parts of the brain and that removing
selected areas of the patients’ cerebral cortex might ameliorate or cure
their conditions. Burckhardt was the head of a small psychiatric hospital
in Préfargier, Neuchâtel, and had no real surgical experience. One patient
died after an operation, while others suffered serious injuries. Nonethe-
less, Burckhardt claimed that three of the patients showed signs of
improvement, which led him to think that there was a future for this
kind of treatment. He presented his findings at a major medical congress
in Berlin in 1890.14 But his arguments did not go down well. In fact,
most of the doctors who attended the congress were shocked by the
risks involved and predicted that the idea would soon peter out. Critical
voices were also raised when news of Burckhardt’s experiments reached
Denmark. A report in Hospitalstidende (Hospital Times) in 1892 noted
that “provisionally, surgical treatment for mental disorders, as proposed
by Burckhardt at the most recent International Congress, lacks any basis
in science.”15 The prominent Danish psychiatrist Knud Pontoppidan
also wrote about the Swiss doctor’s experiments. Pontoppidan failed to
discern any glorious future for the treatment and asserted that “apart
from the operation’s uncertainty and danger, the theoretical reasoning
that it is supposed to justify it is far from unassailable.” He concluded,
“given the imperfect state of our knowledge of the topography and
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 5

mechanics of mental processes, the requisite scientific basis for surgery

to treat mental illnesses does not seem to have been established.” Most
doctors concurred, and over the next few years, surgical experiments on
psychiatric patients were very rare.16
By the 1930s, Egas Moniz felt that he had established a solid scientific
foundation for his treatment. “We did not perform random surgery on
the mentally ill,” he explained in a 1936 article. “We were led by theory,
which seems to prove that we were right.”17 Like Burckhardt, Moniz
believed that mental disorders had physical causes. His supposition was
that the brain’s frontal lobes were the seat of “mental activities,” and
that thoughts and ideas were stored in neural pathways. Mental illness
was the result of thought processes that had become “fixed,” and these
fixed ideas were maintained by neural pathways in the frontal lobes.18
According to this logic, it made sense to sever the pathways in order to
eliminate abnormal thoughts and behaviour. Moniz also believed that his
theory was supported by experiments on monkeys and observations of
patients with damaged frontal lobes.19 He was particularly interested in
reports of World War I veterans who had suffered gunshot wounds to
the front of the brain. Studies showed that soldiers with damaged frontal
lobes suffered from mood swings and lack of initiative, but that their
memory and intellectual capacity were rarely negatively affected.20
Moniz’s theories of “fixed ideas” and surgical intervention in the
frontal lobes did not escape criticism. Doctors in his homeland voiced
their displeasure from the outset. Nor was the new treatment immediately
rubber-stamped abroad. Some critics were horrified by the insubstan-
tial nature of his theory, which they dubbed “brain mythology.” Others
accused leucotomy of being a “destructive operation.”21 However, even
among critics, the results caused a stir. Moniz’s claims of cures and
improvements in up to 70% of patients indicated a success rate unpar-
alleled in 1930s psychiatry. Other doctors began to express an interest in
trying it out, none more enthusiastically than the American neurologist
Walter Freeman.22
Freeman first read about leucotomy in May 1936 was fascinated by
the idea and contacted his Portuguese colleague right away. “Here was
something tangible, something that an organicist like me could under-
stand and appreciate. A vision of the future unfolded,” wrote Freeman.23
He soon persuaded the surgeon James Watts to test the method on Amer-
ican soil. The two doctors quickly put a plan into action and ordered
leucotomes from Moniz’s supplier in Paris. George Washington Hospital
6 J. V. KRAGH

allowed them to practise with the new instruments on the heads of dead
people. In July that year, Freeman found the first patient for the new
treatment—a depressed 63-year-old housewife who had just been referred
to his practice in Washington. In September 1936, Freeman and Watts
performed a leucotomy on the woman—the first procedure of its kind in
the United States. More soon followed, as the duo sought to improve on
Moniz’s technique. Rather than enter the brain via the top of the skull,
they went in from the side, by boring holes in the temple region on both
sides of the head. A blunt instrument resembling a paperknife was then
inserted horizontally into the frontal lobes, and a fan-shaped incision was
made in the white matter. Operating from the side reduced the risk of
severing blood vessels in the brain, but it also meant that the surgeon
could not see where precisely in the brain they were making the incisions.
Freeman and Watts named the surgery “lobotomy,” after the Greek words
for lobe (lobos ) and cut (tomia).
Like Moniz, the American duo quickly published a series of arti-
cles on the new procedure. In 1942, they published a 300-page book
with numerous illustrations and photographs of patients before and after
surgery. The title page featured an image of a skull with boreholes from
a lobotomy, out of which flew four black butterflies. It was a reference to
the French term for depression: “I have black butterflies” (J’ai des papil-
lons noirs ), for which the frontal lobotomy was thought to be the cure.24
The book was favourably received by the American press and helped to
draw worldwide attention to lobotomy in the 1940s.25
Freeman spent the next few years refining the method. In 1945, he
began to promote a simplified operation that did not require major
surgical equipment or preparations. The process was quick and straight-
forward, but also controversial. The anaesthesia consisted of a series
of electroshocks, administered in quick succession. An instrument that
looked like an ice pick was then inserted along the bridge of the nose and
up through the tear duct.26 It was hammered through the thin part of the
skull at the eye socket, further into the frontal lobes, and wiggled from
side to side in order to cut a part of the brain’s white matter. The proce-
dure took less than ten minutes. Freeman liked the simplicity, but Watts
got cold feet after happening upon Freeman performing the procedure
on an unconscious patient in his office. Watts was shocked that Freeman
found it acceptable to perform brain surgery outside the hospital, and
told him he wanted no part in the trials of this new technique.27
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 7

However, Watts’ objections did not persuade Freeman to proceed with

caution. After introducing the procedure, which Freeman dubbed “tran-
sorbital lobotomy,” he visited numerous psychiatric hospitals around the
United States to demonstrate it, arguing that it was less invasive than an
ordinary lobotomy, and claimed that patients suffered fewer side-effects.
From an early stage, Freeman, Watts and Moniz all acknowledged
that their procedures often led to adverse effects. In his earliest publica-
tions on the subject, Moniz reported complications such as incontinence,
eye problems and vomiting, as well as psychological consequences such
as apathy, loss of initiative, muteness and lethargy. Freeman also noted
personality changes, with patients becoming insensitive, inconsiderate or
unrestrained. Many also became sluggish and unimaginative or showed a
lack of judgement and an inability to plan ahead.28 Freeman and Watts
also noted other complications, in the form of fits and damage to vital
parts of the brain. Lobotomy incisions were often highly irregular—not
only could the surgeons not see where they were making their incisions,
but the procedures failed to take proper account of the different shapes
of the patients’ brains. The post-operation scar tissue that built up in
the frontal lobes could also lead to patients developing epilepsy. In fact,
Freeman and Watts noted that 10% of their patients suffered seizures. The
most serious complication was bleeding during surgery, and some patients
died during or after the operation. The mortality rate for Freeman and
Watts’ early studies was 5%. In other countries more startling figures have
been disclosed with death rates of 17 and 27% reported in Sweden and
Norway in the late 1940s.29
Despite the deaths and side-effects, few doctors considered the method
unethical. Although the procedure attracted critical voices and fierce
opponents, several of the world’s leading neurologists and neurosurgeons
tried it out and spoke positively about Moniz’s invention. It was often
stressed that neurosurgery was a last resort for patients whose illness
seemed chronic and who did not seem to respond to other forms of
treatment.30 By late 1948, the lobotomy wave was reaching its peak.
A large number of doctors had tested and refined the procedure. Their
different techniques were grouped under the heading “psychosurgery,”
which Moniz coined as an umbrella term for early leucotomy, lobotomy,
transorbital lobotomy and new variations on the same theme.31 Most of
these techniques were presented at the “First International Psychosurgery
Congress” in Lisbon, 4–7 August 1948, which was attended by more than
100 scientists from 27 countries. The congress heard that approximately
8 J. V. KRAGH

8,000 psychosurgery operations had been performed on patients around

the world. Surgeons attended lectures on the new open-skull techniques,
where they could see the parts of the brain where the incisions were to
be made, and on methods such as pre-frontal lobectomy, which removed
a large area of the frontal lobes. Other presentations discussed the selec-
tion of patients for operations and how the procedure had changed since
Moniz’s initial experiment. The majority of those selected for neuro-
surgery were patients with a schizophrenia diagnosis, but those with
diagnoses such as compulsive neurosis, epilepsy and psychopathy were
chosen as well. Some countries also selected prison inmates—and, in a
few cases, even young children.32
A small Danish delegation attended the congress, including the psychi-
atrists Einer Geert-Jørgensen and Mogens Ellermann, as well as the
world-famous neurosurgeon Eduard Busch—the only Dane to give a
lecture in Portugal.33 Busch was a keen advocate of lobotomy for psychi-
atric patients and held Moniz in high regard. Shortly after the congress,
he was one of the nine scientists to nominate the Portuguese professor for
the Nobel Prize. In January 1949, he wrote to the Nobel Committee,
emphasising that “the advent of surgery to the frontal brain has been
epoch-making both in therapeutic and scientific terms.” According to
Busch, this invention alone and its “revolutionary significance” must
make Moniz worthy of the prestigious accolade.34
The call was heeded, and in September of that year the Nobel
Committee awarded Moniz the Prize for Medicine and Physiology for
inventing psychosurgery, along with Walter Rudolf Hess, who received
it for his studies of the functional organisation of the diencephalon
(interbrain).35
After Moniz was granted the highest honour that a researcher can
receive, his method became even more popular in many countries, where
the use of psychosurgical interventions intensified. Even though exact
figures for the period are not available, various more recent attempts
have been made to map most of the extent in several countries. In the
United States alone, it is assumed that around 25,000 to 30,000 psychi-
atric patients were operated on after the procedure’s introduction in 1936
and during the following 20 years. In Great Britain, it is estimated that
around 12,000 psychosurgical interventions were conducted during the
same period. The figures are also high for Finland, Norway and Sweden,
where 1,550, 2,500 and 4,400 operations, respectively, took place, and
for Brazil and Switzerland, where over 1,000 patients in each country are
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 9

estimated to have undergone operations.36 In other countries, the level of

activity was considerably lower, and in nations such as Germany, Austria,
Israel, Turkey, Greece, Poland and Russia (USSR, where lobotomy was
prohibited by law in 1950), only a few interventions took place.37 An
estimate of the total number of lobotomies is that between 60,000 and
80,000 people all over the world underwent this operation during the
period up to 1956.38

Introduction
Until now, Denmark has not been included in the international statistics
for the number of psychosurgical interventions, yet comparison with the
figures available shows that the Danish history is, nonetheless, remarkable.
As this book will demonstrate, Denmark commands a special position
in a worldwide context. At least 4,500 psychosurgical interventions took
place on Danish neurosurgical wards from 1939 and up to 1983. More
than 4,000 of these were lobotomies. With a population of only 4 million
in 1945, this is an extremely high number. In fact, no other country in
the world has equivalently high figures, in relation to population size.
Compared to countries such as Switzerland and Finland, equivalent to
Denmark in terms of population size (but with larger psychiatric hospital
systems), the Danish figure is three to four times higher. In relation to
the UK and the United States, which have often been described as the
most active countries in the psychosurgical area, the figure for Denmark
is also significantly higher.39
This book is the first in-depth study of the extensive and very well-
preserved source material concerning the history of psychosurgery in
Denmark. The material shows that besides the large number of interven-
tions, an active approach to psychosurgery was also taken in other ways.
Patients with a wide range of different diagnoses underwent brain surgery,
just as the ages of the persons concerned showed considerable variation.
Patients with mental disorders who were very old, up to 80 years of age,
and also very young patients, down to the age of 14, were operated on. In
addition, numerous children, of whom the youngest was 6 years old, from
institutions for people with intellectual disabilities were lobotomised at
the Department of Neurosurgery in Copenhagen. There was an awareness
of the adverse effects, such as personality changes and epilepsy. Lobotomy
was also related to high mortality in Denmark, and one hospital reported
a death rate for lobotomy patients of 9.5 per cent in the late 1940s. A
10 J. V. KRAGH

mortality rate of 2–6 per cent was common in Danish psychiatric literature
and in reports on lobotomies up to the 1950s, after which the mortality
rate declined.
The medical literature of the period also shows that there was no clear
insight into how the brain functions and the actual effect of a lobotomy.
Physicians knew that lobotomy was not a causal treatment that could cure
patients. Perceptions of lobotomy were based on clinical assessments, as
minor studies of patients who had been operated on, where presumed
positive effects on the patients’ various symptoms were noted.
The unclarified theoretical basis for lobotomy and the extensive adverse
effects have made it difficult for many more recent observers to under-
stand the history of psychosurgery. In many parts of the world, the
treatment has often provoked alarm or consternation. Many people asso-
ciate the results of the treatment with the film One Flew Over the Cuckoo’s
Nest (1975), in which Jack Nicholson, in the role of McMurphy, is
reduced to an inane sleepwalker after receiving a lobotomy. Other films,
TV, radio programmes and novels have subsequently tackled the issues
raised by One Flew Over the Cuckoo’s Nest . In recent years, a special role is
reserved for lobotomy in horror movies such as Asylum (2008), in which
six college freshmen, one by one, are picked off by the lobotomist Dr.
Burke (alias Walter Freeman). Today, lobotomy is often considered to
be a risky, fatal intervention, a form of treatment that provokes disgust,
or—in atypical cases—morbid fascination from death metal bands among
whom the term lobotomy is popular in song lyrics and band names.40
The gap between the past and the present is wide when it comes to the
history of psychosurgery in Denmark. This book will show that today’s
critical viewpoints did not feature at all during the time from the 1940s
and right up to the 1970s. There were no critical films, radio broadcasts
or books about psychosurgery. Nor was there any significant public criti-
cism or debate concerning lobotomy in the psychiatric journals or among
medical institutions such as the Danish National Board of Health, the
Directorate of the State Mental Hospitals or the Medico-Legal Council. It
is important to remember that, at that time, lobotomy was not a dubious
or sinister practice that was only undertaken by the “black sheep” of the
medical profession. Nor was it a treatment which the more distinguished
medical journals did not wish to be associated with; quite the contrary, in
fact. It was described and acclaimed in well-reputed journals, which was
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 11

echoed by the Danish press that praised lobotomy to the skies. Interna-
tionally, the treatment was also seen as a breakthrough. The Nobel Prize
to Moniz in 1949 is clear evidence of this.
How could it be that a procedure which today’s books on medical
ethics cite as a key example of dubious medical practice was assessed
so differently by the general public and among physicians in the 1940s
and 1950s? How could what is today seen as a controversial treatment
be promoted as a major medical achievement just a few decades previ-
ously? This paradox is investigated in this book. The book will analyse
the widespread use and the key factors which contributed to the positive
reception given to psychosurgery: What was the background to using a
treatment which ultimately put patients’ lives at risk? And which factors
contributed to the very extensive use of psychosurgery?
To get answers to these questions, we need to relinquish the contem-
porary view of lobotomy and seek to understand the great prevalence of
the treatment on the basis of the times of which it was part. In the first
instance, it is necessary to set aside our contemporary scruples and focus
on what once led many people to consider brain surgery as a sound option
for psychiatric patients. In this regard, we need to examine the prevailing
conditions in twentieth-century psychiatry and society, and relate these to
the use of psychosurgery as a treatment method. Only then can we form
a comprehensive picture of the history of psychosurgery.
Various attempts at this have been made in the literature on the history
of psychosurgery. However, these studies have a rather narrow geograph-
ical scope. So far, all books in English concern the American aspect of the
history of psychosurgery and, in particular, the role of Walter Freeman.
Except for Portugal, development of lobotomy in European countries
has generally been overlooked. As Brianne M. Collins and Henderikus
J. Stam note in their historiographical survey of lobotomy, “the history
of psychosurgery in the United States and Portugal has been overem-
phasized while eclipsing the rest of the global story.” In fact, only one
European monograph (in German) on lobotomy in Switzerland has been
published in the last decades.41
The early American works on lobotomy are characterised by a critical
version of this history. The first studies were published during the heated
debates of the 1970s, in which lobotomy was denounced as an inde-
fensible form of domination.42 In this area of the literature, it has also
been emphasised that the surgical interventions were targeted at vulner-
able groups such as women and poor, working-class patients.43 The first
12 J. V. KRAGH

well-researched and well-written book with a critical perspective is Elliot

S. Valentein’s Great and Desperate Cures (1986) on psychosurgery in the
United States and Portugal. Even though Valenstein describes somatic
treatments as “bizarre” and “obsolete,” he also points out that lobotomy
was “not an aberrant event but very much in the mainstream of psychi-
atry.”44 Whereas Valenstein’s focus is on the prominent figures in the
history of psychosurgery, i.e. Walter Freeman and Egas Moniz, psychi-
atrist and medical historian Joel Braslow concentrates on records from
two California state mental hospitals in an attempt to explore the close
connection between control and therapeutics. As Braslow writes in his
book Mental Ills and Bodily Cures (1997): “Lobotomy completed the
work begun by hydrotherapy in the 1900s and ECT in the early 1940s by
fashioning therapeutics completely into a disciplinary practice of control-
ling bodies and minds.”45 Braslow’s work provides interesting insights
into therapeutic decision-making in American state hospitals for working-
class people, but his study does not place these findings in a broader
historical context.
The most extensive study of American lobotomy is Jack D. Pressman’s
Last Resort (1998). Even after more than 20 years, the monograph is still
considered “as the authoritative history of American psychosurgery.”46
Pressman explores not only the scientific, but also the professional and
cultural context that made lobotomy a viable treatment at the time.
He also analyses a sample of 80 patient records from Mclean Hospital
(Belmont, Massachusetts), one of the most well-reputed private hospi-
tals for affluent patients. On this backdrop, he challenges the critical
story of psychosurgery. Even though lobotomy could be used to “restore
order to the wards,” psychiatrists’ key motive was not to control deviating
behaviour, but to help patients who were in a lot of pain. As Pressman
explains, psychosurgery was a “last resort”; a form of treatment that was
tried on patients who had spent long time in hospital, after all other treat-
ments had failed.47 In this interpretation, critical history is reversed, and it
is emphasised that lobotomy often had a humanitarian aim, which was to
ease or improve the patients’ condition, so that they might be discharged
from hospital. In Pressman’s view, lobotomy is not an “an anomaly in
medicine,” but rather an example of how general medicine often works.48
Pressman’s study has been supplemented by two recent monographs
on American psychosurgery: Mical Raz, The Lobotomy Letters (2013)
and Jenell Johnson’s American Lobotomy (2014). Like others before
them, Raz and Johnson focus on Walter Freeman, but they nevertheless
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 13

employ new perspectives to the history of psychosurgery. Drawing from

the extensive correspondence between Freeman and lobotomy patients
and their families, Raz explores the role of the patient-doctor relation-
ship in ambulatory settings of care to shed light on new aspects of
how lobotomy was interpreted. Johnson, on the other hand, conducts
a detailed rhetorical analysis of representations of lobotomy in a wide
variety of cultural texts, focusing on how the meanings of psychosurgery
emerged, accrued and transformed as they circulated between medicine
and public culture.49
In her book Spannungsherde. Psychochirurgie nach dem Zweiten
Weltkrieg (2015), Marietta Meier draws on the previous historical
research, but she also constructs a new comprehensive analytic framework
in order to analyse the history of psychosurgery in Switzerland and, to a
lesser extent, other German and French-speaking European countries.50
According to Meier, the narrative of last resort (“letzer Ausweg”) also
played a large role for psychiatrists in Switzerland. Lobotomy was a treat-
ment reserved for “chronic patients,” suffering from “affective tension.”
By using the surgical intervention, the tension or the “sting” of the
psychosis could be reduced.51 However, in her extensive studies of patient
records, Meier also notes that so-called difficult patients (“schwierigen
Patienten”), in particular, disruptive, noisy and aggressive women, were
most often operated on. Mainly because of gender stereotypes, female
patients with this profile were seen as being more ill and in need of
treatment than their male counterparts. Meier also follows the fall of
psychosurgery in Switzerland, stressing that this decline was due to a
new psychoanalytic style of thought, rather than the introduction of
neuroleptics in the 1950s.52
Even though the last resort narrative has a prominent role in recent
studies, as well as in psychiatric literature of the time, it might require
further scrutiny. In this regard, Danish source materials offer new
options of analysing lobotomy decision-making. Patient records from
three different Danish psychiatric hospitals are analysed. There is partic-
ular focus on records from one selected hospital, the Mental Hospital in
Vordingborg, which was the first psychiatric institution to introduce the
treatment in Denmark. In the case selected, the entire archive from a
period of around 80 years was reviewed in order to locate patient records
concerning the treatment. The records were then entered to a database,
comprising 336 patients’ records from the hospital in Vordingborg, and
30 for selected years from the Mental Hospital in Nykøbing Sjælland and
14 J. V. KRAGH

the Mental Hospital in Middelfart. In addition, 250 neurosurgical records

of lobotomy patients from over ten different institutions within the
psychiatric and mental health services on Zealand were reviewed for their
information on psychosurgery. Finally, 50 records concerning lobotomy
patients from an institution for people with intellectual disabilities in
Zealand were analysed.
As a case, the hospital in Vordingborg presents some new analyt-
ical opportunities. Compared to the American research, which either has
focused on advanced private hospitals for rich patients, or public hospitals
for the less fortunate, the Danish study has a more varied patient group.53
The hospital in Vordingborg received patients from rural areas, the islands
and the capital Copenhagen, and also—as one of two state hospitals—had
a first-class section for wealthy patients. Studies of the selection practice
at the hospital in Vordingborg can thereby show whether a particular
social category from a heterogeneous patient group was recommended for
lobotomy. This book will also introduce a number of systematic analyses
of such matters as indication, consent practice and the legacy of lobotomy
that have not been considered in relation to the last resort narrative.
Patient records are the closets we get to the decision-making process by
physicians, but as noted in recent historical studies, case notes do not
give privileged access to “what really happened,” and they only partly
and incompletely describe what was said and done.54 Like all historical
sources, medical records must be evaluated carefully and, furthermore,
compared to other available sources. In order to acquire a broader view
of the psychiatrists’ considerations regarding somatic treatment, I will
thus examine other kinds of information from diaries, letters, government
archives, annual reports and hospital files.
Wider study of the specific context in which psychosurgery took place
is also required in order to gain further insights into the treatment prac-
tice. The decision to use psychosurgery at the individual hospitals was
based on a choice, with various other treatment methods also consti-
tuting therapeutic options. Prior to the introduction of lobotomy, physical
treatment methods with Cardiazol, insulin and electroshock had especially
won ground at the Danish mental hospitals. This aspect must therefore be
included. For example, was psychosurgery only used after all other treat-
ment had been attempted? Or was it initiated quickly for patients with
highly deviant behaviour? The introduction of the other somatic treat-
ments also affected the approach to psychosurgery. Concerning the issue
of adverse effects, lobotomy did not introduce completely new problems,
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 15

and acceptance of treatment that entailed risk had already been estab-
lished with the earlier methods. Various rules and procedures introduced
with these therapies also came to include psychosurgery.
As Andrew Scull points out in his article “Somatic treatments and
the historiography of psychiatry,” therapeutic change and the continued
employment of particular treatments are dependent on much more than
just intellectual processes. The scientific and the social are inextricably
intertwined in the therapeutic field.55 Cultural factors play a role too.
As medical historian John Harley Warner has shown, major differences
between approaches in therapeutics could exist between, e.g. France and
the United States in the nineteenth century.56 A similar observation can
be applied to twentieth-century psychiatry. On a global scale, physicians
addressed the risks and possible benefits of using lobotomy differently.
Mical Raz notes, that an “activist approach” to shock treatments and
psychosurgery was adopted in the United States, while a more cautious
attitude was seen in a number of European countries. For many American
doctors, it was preferable to try a treatment—no matter how risky—in
an attempt to do something.57 I will argue that similar principles were
held by Danish psychiatrists. This active treatment approach was estab-
lished in the early twentieth century and played a crucial role for the later
acceptance and use of psychosurgery in Denmark.
However, the background to psychosurgery’s widespread use in
Denmark should also be viewed in a wider societal context. For physi-
cians at the mental hospitals, the new therapies were not only part of
the day-to-day treatment, but were also elements of a larger project
to achieve greater recognition of psychiatry by the Danish public in
general and also in other fields of medical specialisation. The somatic
treatments were often cited to be an overall factor that had led to posi-
tive changes in psychiatry. This could also apply the other way around,
however, and public authorities with responsibility for state psychiatric
services were also aware of various benefits from the treatment methods.
Moreover, acceptance of psychosurgery was related to conditions which
extended beyond the considerations of psychiatrists and administrators.
The fact that psychosurgery was not seen as a highly radical method in
the twentieth century was also related to external factors. It was thus
significant that, outside psychiatry, invasive procedures were also used for
specific groups in society. In this regard, in many ways lobotomy was an
extension of other surgical measures such as sterilisation and castration,
which had already been introduced by the Danish government in 1929.
16 J. V. KRAGH

Moreover, the acceptance of psychosurgery was associated with attitudes

towards psychiatry among the general public. A particular factor was that
the Danish press did not take a problem-oriented approach to medical
treatment methods during this period.
In order to understand how lobotomy decisions easily could be
executed, we also need to look at the social and legal position of patients
in twentieth-century Danish society. In the lobotomy era, their legal rights
were strictly limited, and there were no groups or associations outside
psychiatry who represented patients’ interests. When it came to the use
of therapeutics, there were few restrictions: regulations regarding compul-
sory treatment were only included in the Danish Psychiatric Act in 1989.
I will argue that the marginalised position of people with psychiatric
disorders also paved the way for an active lobotomy course.
As this book will show, the history of psychosurgery’s rise and fall is
thus related to internal conditions at the mental hospitals, but also to
psychiatry’s relation to other fields of medicine, social and health policy,
and the Danish public. As the Danish study differs somewhat in terms
of methodology from the international literature, no direct comparison
can be made, and there is also a substantial lack of in-depth studies from
several countries in order to achieve even a fairly comprehensive picture
of the treatment’s international history. On the other hand, the book will
give a full account of the international development which influenced the
introduction and use of psychiatric therapies in Denmark.
The book is divided into three parts, of which the first presents an
overview of the psychiatric hospital system in Denmark and the key events
which led to the introduction of lobotomy. The book commences with a
depiction of the events in 1922, which in many ways denoted a water-
shed for Danish psychiatry. In this year, the Directorate for the State
Mental Hospitals was established and a process of change was initiated.
This directorate within the Ministry of the Interior gained control of the
various state mental hospitals which had previously been run by local
authorities. General regulations for all the state hospitals were enacted,
and a process of harmonisation of state psychiatry was consequently
started in the 1920s. As a result, the state mental hospitals developed
closer ties with each other. On the therapeutic side, the hospitals shared
information about new psychiatric therapies and coordinated treatment
options for their patients. Chapter 2 outlines this process of harmonisa-
tion and provides an overview of the Danish mental hospital system in
the first part of the twentieth century.58
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 17

Chapter 3 describes the therapeutic state of the art in the period

from the late nineteenth century to the early 1930s. In 1922, the first
of the new somatic treatments, malaria fever therapy, was introduced in
Denmark. This therapy was used for patients suffering from syphilitic
infection of the nervous system with the psychiatric diagnosis dementia
paralytica (also known as general paralysis of the insane). The chapter
follows the invention of malaria therapy in Austria and the treatment’s
path to Denmark. The Directorate of the State Mental Hospitals played a
leading role in implementing a treatment programme for these patients.
The first set of rules regarding malaria treatment was introduced in the
early 1920s; later on, these rules were used as a model for other somatic
treatments such as shock therapy and psychosurgery. Malaria fever therapy
was regarded as a great step forward by physicians who hoped to achieve
similar breakthroughs in the treatment of other mental disorders.
Malaria fever therapy was followed by Cardiazol shock and insulin
coma therapy in the late 1930s, which also raised the hopes for a new
beginning in psychiatry. Chapter 4 examines the introduction of these
two therapies in Europe. In Denmark, Cardiazol and insulin therapy were
very well received, not only by psychiatrists, but also by the Directorate
and Danish politicians. Consequently, the state mental hospital obtained
large grants from the Ministry of the Interior in order to implement these
treatments. Psychiatrists, however, were also aware of the fact that shock
treatment could be harmful to the patients. The chapter explores how
positive and negative effects of the new somatic treatments were evalu-
ated by psychiatrists. The chapter will show that a programme of active
treatment was initiated by all state mental hospitals, and only very few
doctors recommended that precautions should be taken to prevent harm
to patients during the period 1937 to 1942. This consensus regarding the
use of Cardiazol and insulin therapy was also of great significance for the
later introduction of lobotomy in state psychiatry.
Common ground regarding somatic treatments was also reached in
other ways. In 1908, the Danish Psychiatric Society (DPS) was founded
and became an important meeting point for almost all Danish psychia-
trists. The DPS played a central role for the introduction and evaluation of
the new somatic therapies. In 1938, the psychiatric society took the initia-
tive to examine the effect of Cardiazol shock and insulin coma therapy.
All Danish mental hospitals and psychiatric departments contributed to
this study organised by the DPS. The same year, the DPS also established
a committee with the task of producing a diagnostic nomenclature for
18 J. V. KRAGH

the psychiatric departments and hospitals. The DPS list of diagnosis was
introduced in 1938 and it was used by all psychiatric institutions until
1980, where the ICD system replaced it. Drawing on archival sources
from the DPS, Chapter 5 concentrates on the new diagnosis system,
its links to European and American psychiatry, and the investigation of
somatic treatments by the DPS. The chapter shows how the new ther-
apies and a somatic view of mental disorders were promoted within
Danish psychiatry, which was generally characterised by a high degree of
consensus.
The subsequent five chapters in the book’s second part deal with the
initial consideration of lobotomy in the 1940s and the treatment’s preva-
lence in Denmark. Chapter 6 traces the introduction of electroshock
therapy and lobotomy. These two therapies were presented at the Third
International Neurological Congress in Copenhagen in 1939. After the
introduction of these treatments in Denmark, many psychiatrists argued
for a modernisation of psychiatry, and state committees were subsequently
appointed to work out new plans for the state mental hospitals. The
chapter discusses the important role of somatic treatments in this project
of modernisation of psychiatry in the period up to 1947.
Chapter 7 follows the initial considerations regarding lobotomy at the
state mental hospitals in the 1940s. The first lobotomy on a patient from
a state mental hospital was conducted in Vordingborg. Using information
from patient records, internal reports and the hospital’s correspondence
with the Directorate concerning lobotomy, the chapter investigates the
selection of the first small group of patients from the Vordingborg mental
hospital. The chapter also examines if various factors such as overcrowding
contributed to the decision of Vordingborg psychiatrists to let their
patients undergo neurosurgical treatment.
Chapter 8 focuses on the introduction of lobotomy in Europe and
other continents in the period 1936 to 1945. Subsequently, the chapter
documents the use of lobotomy at Danish psychiatric hospitals and
intellectual disability institutions. By exploring neurosurgery records,
meeting minutes between the senior consultants and the Directorate, and
internal lobotomy reports by all psychiatric hospitals, various considera-
tions regarding the use of psychosurgery are documented. Furthermore,
all articles on lobotomy in Danish medical journals are subsequently anal-
ysed. These reports on lobotomy by psychiatrists are compared with press
coverage of the treatment in the 1940s and early 1950s. The chapter
shows that lobotomy was quickly accepted in Denmark, where no public
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 19

or internal medical debates about the treatment’s negative effects took

place in this period.
Chapter 9 first outlines various responses to psychosurgery in Europe
after World War II. Then lobotomy at the State Mental Hospital in
Vordingborg is further analysed. Using a database containing informa-
tion about all lobotomies at the Vordingborg hospital, the selection of
patients for lobotomy is studied in detail. Theories concerning the use of
lobotomy as a last resort are also examined by focusing on features such as
indications for lobotomy noted in the patient records, the patients’ length
of stay at the hospital and the number of other treatment used before
lobotomy. Finally, issues of social class and the distribution of psychiatric
diagnosis are analysed.
A striking fact is, that a large number of lobotomy patient had the
diagnosis psychopathy. Furthermore, a large majority of these patients
were women. Chapter 10 discusses this psychopathy and gender bias. In
general, female lobotomy patients were recommended for psychosurgery
at an earlier stage of their hospitalisation than the male patients, had
undergone less treatment with other therapies and were overrepresented
among the young lobotomy patients. The chapter shows that a number of
factors possibly contributed to this imbalance. Gender stereotypes of the
period, but also the patients’ social networks and practical circumstances
at and outside the hospital could have played a role.
Chapter 11 in the third part of the book investigates a topic that has
not been addressed in the literature on psychosurgery, i.e. the question of
consent to lobotomy. The performance of lobotomy required the psychi-
atrist to obtain the consent of the patient, or his or her next-of-kin,
to the treatment. The chapter analyses the role played by the consent
requirement when neurosurgery was being considered. The consent issue
gives an insight into the patient-doctor relationship and how psychiatrists
interpreted patients’ rights in the 1940s and 1950s. In addition, consent
practices show that there were tensions between psychiatrists and neuro-
surgeons who had different views about this. The issue of consent was
also significant to the discontinuation of psychosurgery, since the initial
criticism of the treatment was raised due to complaints concerning lacking
consent. The background to the decline of psychosurgery is described in
the following chapter.
Chapter 12 first describes the late phase of European psychosurgery
in the 1950s and onwards. In American studies on the history of
psychosurgery, a decline in the use of lobotomy in this period is often
20 J. V. KRAGH

noted.59 It is assumed that lobotomies rapidly decreased after the intro-

duction of psychopharmacology in the 1950s, where higher standards
of research and medical safety regulations were implemented. However,
critical comments about lobotomy were rarely expressed in the Danish
medical literature from the period 1955 to 1975. Rather, psychiatrists
presented ideas about a revival of psychosurgery in this period. Mental
hospital records also reveal that lobotomy was still being used on small
groups of patients in the 1970s. Chapter 12 also addresses the issue of
side-effects. What kind of side-effects could be observed in patients who
underwent psychosurgical interventions? This question was also raised by
the Danish Ombudsman in the late 1970s, leading to the discontinuation
of psychosurgery in Denmark in 1983. The chapter follows this last phase
of the history of psychosurgery.
Chapter 13 is a summary and conclusion in which the question of
the widespread use of psychosurgery is reviewed. Arguments will be put
forward for a new account of psychosurgery in order to provide a nuanced
history of the treatment and its consequences.

Notes
1. Egas Moniz, Tentatives opératoires dans le traitement de certaines psychoses
(Paris: Masson, 1936), 56. “Mélancolie involutive anxieuse” or involu-
tional melancholia was a name for a depression, usually occurring in the
involutional years (40s and 50s), with symptoms such as anxiety, agitation,
restlessness, somatic concerns.
2. Moniz, Tentatives opératoires, 56–59; Elliot S. Valenstein, Great and
Desperate Cures : The Rise and Decline of Psychosurgery and Other Radical
Treatments for Mental Illness (New York: Basic Books, 1986), 102–103.
On Moniz, see, e.g., Ann Jane Tierney, “Egas Moniz and the origins of
psychosurgery: A review commemorating the 50th Anniversary of Moniz’s
Nobel Prize,” Journal of the History of the Neurosciences, 9 (2000), 22–
36; J. M. Ferro, “Egas Moniz (1874–1955),” Journal of Neurology,
250 (2003), 376–377; Dominik Gross & Gereon Schäfer, “Egas Moniz
(1874–1955) and the ‘invention’ of modern psychosurgery: A historical
and ethical reanalysis under special consideration of portuguese original
sources,” Neurosurgery Focus, 30 (2011), 1–7.
3. Moniz, Tentatives operatoires, 194. “La technique que nous avons d’abord
choisie a été l’alcoolisation de certaines parties du centre ovale du lobe
préfrontale.”
4. Ibid., 60.
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 21

5. Herbert Jasper, “A historical perspective: The rise and fall of prefrontal

lobotomy,” Advances in Neurology, 66 (1995), 102; Valenstein, Great
and Desperate Cures, 104; Robert P. Feldman & James T. Goodrich,
“Psychosurgery: A historical overview,” Neurosurgery, 48 (2001), 651.
6. Moniz, Tentatives opératoires, 195; Rainer Fortner & Dominik Gross,
“Egas Moniz und die Leukotomie-Debatte unter besonderer Berücksich-
tigung des pourtugiesischsprachigen Schrifttums,” Suddhoffs Archiv, 86
(2002), 142–143.
7. Moniz, Tentatives opératoires. “Elle ne veut pas qu’on la photographie”
(p. 115).
8. Ibid., 114–120 and 17.
9. Ibid., 119–120.
10. Egas Moniz, “Attempt at surgical treatment of certain psychoses,” in
R. H. Wilkins et al. (eds.), Neurosurgical Classics (New York: Johnson,
1965), 448.
11. Tierney, “Egas Moniz and the origins of psychosurgery,” 31; Elliot S.
Valenstein, “The prefrontal area and psychosurygery,” Progress in Brain
Research, 85 (1990), 544; Feldman & Goodrich, “Psychosurgery: A
historical overview,” 651; Brianne M. Collins & Henderikus J. Stam,
“A transnational perspective on psychosurgery: Beyond Portugal and the
United States,” Journal of the History of the Neurosciences, 23 (2014),
335–354. On early operations in France, see Marc Zanello et al., “History
of psychosurgery at Sainte-Anne Hospital, Paris, France, through trans-
lational actions between psychiatrists and neurosurgeons,” Neurosurgical
Focus, 43 (2017), 1–9.
12. Maria Mednikova, “Prehistoric trepanations in Russia. Ritual or surgical,”
in Robert Arnott et al. (eds.), Trepanation: History, Discovery, Theory
(Lisse: Swets & Zeitlinge, 2003), 164; Frank P. Saul et al., “Trepanation:
old world and new world,” in S. H. Greenblatt (ed.), A History of Neuro-
surgery, in Its Scientific and Professional Contexts (Illinois: Thieme, 1997),
29–36. On Denmark, see Pia Bennike, “Ancient trepanation and differ-
ential diagnosis: A re-evaluation of skeletons from Denmark,” in Arnott
et al., Trepanation, 95–116.
13. G. E. Berrios, “The origins of psychosurgery: Shaw, Burckhardt and
Moniz,” History of Psychiatry, 8 (1997), 61–63.
14. Zbigniew Kotowicz, “Gottlieb Burckhardt and Egas Moniz—Two begin-
nings of psychosurgery,” Gesnerus, 62 (2005), 77–101; James L. Stone,
“Dr. Gottlieb Burckhardt—The pioneer of psychosurgery,” Journal of the
History of the Neurosciences, 10 (2001), 79–92; Dominik Gross, “Der
Beitrag Gottlieb Burckhardts (1836–1907) zur Psychochirurgie in medi-
zinhistorischer und ethischer Sicht,” Gesnerus, 55 (1998), 221–248; Yves
22 J. V. KRAGH

Joanette et al., “From theory to practice: The unconventional contribu-

tion of Gottlieb Burckhardt to psychosurgery,” Brain and Language, 45
(1993), 572–587.
15. Gross, “Der Beitrag Gottlieb Burckhardts,” 245; Berrios, “The origins
of psychosurgery,” 69–71. “Om moderne Hjernekirurgi,” Hospitalsti-
dende, 31 (1892), 796. This article was originally from the German
Therapeutische Monatsheft, June 1892.
16. Knud Pontoppidan, “Hallucinationerne,” Bibliotek for Læger, 85 (1893),
354. A few operations were performed after Burckhardt by the Esto-
nian neurosurgeon Lodivicus Pusepp. However, he did not mention these
operations before the 1930s. Surgery on patients with dementia paralytica
was also conducted before Moniz took up psychosurgery, see, e.g., Valen-
stein, Great and Desperate Cures, 43–44; Patrick Blomsted, “Cerebral
impaludation—An ignoble procedure between two Nobel Prizes: frontal
lobe lesions before the introduction of leucotomy,” Stereotactic and Func-
tional Neurosurgery (2020) https://doi.org/10.1159/000507033. In
Denmark, epilepsy surgery was performed in the 1890s, but this did not
include psychiatric patients. See Ib Søgaard, “Epilepsikirurgi i Danmark
i forrige århundrede,” Dansk Medicinhistorisk Årbog, 27 (1997), 57–
70; “Tidlig Neurokirurgi i Danmark,” Dansk Medicinhistorisk Årbog, 16
(1986), 153–165.
17. Moniz, “Attempt at surgical treatment of certain psychoses,” 445.
18. Valenstein, Great and Desperate Cures, 84; Tierney, “Egas Moniz and the
origins of psychosurgery,” 27–28; Kotowicz, “Gottlieb Burckhardt and
Egas Moniz,” 81.
19. Valenstein, Great and Desperate Cures is the first book in which the
link between Moniz and the Americans Fulton and Jacobsen is ques-
tioned. Jack D. Pressman has in his book Last Resort. Psychosurgery and
the Limits of Medicine (New York: Cambridge University Press, 1998),
47–101 further shown that this story does not hold up to under closer
scrutiny.
20. On Moniz’ theoretical inspiration, see Valenstein, Great and Desperate
Cures, 80–100. The often cited story of the railroad construction worker
Phineas Gage, who survived an accident in which a large iron rod was
driven completely through his head, was no inspiration to Moniz. See
Malcolm Macmillan, An Odd Kind og Fame: Some Stories of Phineas Gage
(Cambridge, MA: MIT Press, 2000), 229–230; Zbigniew Kotowicz, “The
strange case of Phineas Gage,” History of the Human Sciences, 20 (2007),
115–131.
21. Fortner & Gross, “Egas Moniz und die Leukotomie-Debatte,” 151;
Kotowicz, “Gottlieb Burckhardt and Egas Moniz,” 85. On critique in
Europe, see Marietta Meier, Spannungsherde. Psychochirurgie nach dem
Zweiten Weltkrig (Göttingen: Wallstein, 2015), 127–138.
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 23

22. On Freeman, see Jack El-Hai, The Lobotomist: A Maverick Medical Genius
and His Tragic Quest to rid the World of Mental Illness (Hoboken, NJ:
Wiley, 2005); Jack D. Pressman, Last Resort: Psychosurgery and the Limits
of Medicine (New York: Cambridge University Press, 1998), 71–85 and
128–146; Valenstein, Great and Desperate Cures.
23. Freeman quoted from El-Hai, The Lobotomist, 107.
24. On Freeman’s illustration see Valenstein, Great and Desperate Cures, 165–
166; El-Hai, The Lobotomist, 165.
25. George Fenton, “Psychosurgery,” in H. Freeman (ed.), A Century of
Psychiatry (London: Mosby, 1999), 162; Anastasia Kucharski, “Frontal
lobotomy in the United States, 1935–1955,” Neurosurgery, 14 (1984),
767. Valenstein notes in Great and Desperate Cures that there had prob-
ably “been fewer than one thousand lobotomies worldwide” in 1942
(p. 164). See also Marietta Meier, Spannungsherde. Psychochirurgie nach
dem Zweiten Weltkrieg (Göttingen: Wallstein, 2017), 85–86.
26. For his first transorbital lobotomy Freeman used an ice pick. As he noted,
the “humble” icepick was “ideally suited” to penetrate the thick bone of
the orbital plate. Cf. Jenell Johnson, American Lobotomy: A Rhetorical
Analysis (Ann Arbor: University of Michigan Press, 2014), 6. See also
El-Hai, The Lobotomist, 182–199.
27. Walter Freeman & James Watts, Psychosurgery, 2nd ed. (Illinois: C. C.
Thomas, 1950), 55–57; El-Hai, The Lobotomist, 184–185 and 189–191.
Freeman was inspired by the Italian psychiatrist Amarro Fiamberti who
had experimented with a similar action in 1937. See Zbigniew Kotowicz,
“Psychosurgery in Italy, 1936–39,” History of Psychiatry, 19 (2008), 476–
489.
28. Moniz, Tentatives opératoires dans le traitement de certaines psychoses, 234–
245. Walter Freeman & James W. Watts, Psychosurgery (Illinois: C. C.
Thomas, 1942), 205–209.
29. Freeman, Psychosurgery (1942), 284. The Norwegian hospital Gaustad
reported a 27% lobotomy mortality rate in 1946. On lobotomy in
Norway, see NOU, Utredning om lobotomi (1992: 25), 50. In Sweden,
mortality rates of 10 to 17% were reported in the 1940s. On Sweden,
see Kenneth Ögren, The Surgical Offensives Against Mental Disorders:
Psychosurgery in Sweden 1944–1958 (PhD dissertation, University of
Umeå, 2005), 50. A 4% mortality rate was reported in the British survey
of more than 10,000 lobotomies in 1942–1954. G. C. Tooth & Mary
P. Newton, Leucotomy in England and Wales, 1942–1954 (London: Her
Majesty’s Stationary Office, 1961).
30. Walter Dandy, Wilder Penfield and Hugh Cairns and other world
famous neurosurgeons conducted lobotomies. See, e.g., Zbigniew
Kotowicz, “Gottlieb Burckhardt and Egas Moniz—Two beginnings of
psychosurgery,” 95; Pressman, Last Resort 52; Mical Raz, “Between
24 J. V. KRAGH

the ego and the icepick. Psychosurgery, psychoanalysis, and psychiatric

discourse,” Bulletin of the History of Medicine, 82 (2008), 387–420. Posi-
tive accounts on lobotomy were published by the press. On this, see
Diefenbach et al., “Portrayal of lobotomy in popular press,” Journal of
the History of the Neurosciences, 8 (1999), 60–69; Valenstein, Great and
Desperate Cures, 155–165.
31. Jürgen Hill, Der Frontale Griff in das Gehirn und die Entwicklung der
Psychochirurgie (Hamburg: Lit. Verlag Münster, 1991), 3–4.
32. Psychosurgery. 1st International Conference (August 4th–7th, 1948), Lisbon
1949, s. 1–330; Hill, Der Frontale Griff in das Gehirn, 197; R. Corria,
“Frontal decortication in ‘oligphrenic eretic (children with aggressive
asocial behavior),” Psychosurgery. 1st International Conference (August
4th–7th, 1948), 321. Freeman was one of the first doctors to lobotomise
children. On this, see El-Hai, The Lobotomist, 174–175. On children, see
also Hill, Der Frontale Griff in das Gehirn, 107 and 188 (France and
Brazil); Meier, Spannungsherde, 151 (Switzerland).
33. Eduard Busch, “Unilateral and bilateral lobotomy in pain,” Psychosurgery.
1st International Conference (August 4th–7 th , 1948), s. 323.
34. Medicinska Nobelstiftelsens Arkiv [The Archive of the Nobel Foun-
dation]. Stockholm. Nominations for the Nobel Prize. Eduard Busch.
“Pédiatrie” no. 83. January 25, 1949.
35. Carl-Magnus Stolt, “Moniz, lobotomin och 1949 års Nobelpris,” Svensk
Medicinhistorisk Tidskrift, 3 (1999), 258.
36. On lobotomy in the United States see Elliot S. Valenstein, “History of
psychosurgery,” in S. H. Greenblatt (ed.), A History of Neurosurgery (Illi-
nois: The American Association of Neurological Surgeons, 1997), 513;
Pressman, Last Resort, 147. The UK: see David Crossley, “The introduc-
tion of leucotomy: A British case history,” History of Psychiatry, 4 (1993),
553; Victor W. Swayze II, “Frontal leucotomy and related psychosurgical
procedures in the era before antipsychotics (1935–1954),” The American
Journal of Psychiatry, 152 (1995), 512. Canada: Brianne M.
Collins, Ontario’s Leucotomy Program: The Roles of Patient, Physi-
cian, and Profession (Master’s thesis, University of Calgary, 2012). Brazil:
see André Luis Masiero, “A lobotomia e a leucotomia nos manicômios
brasileiros (lobotomy and leucotomy in Brazilian mental hospitals),”
História, Ciências, Saúde-Manguinhos, 10 (2005), 549. Switzerland:
see Marietta Meier, Spannungsherde. Psychochirurgie nach dem Zweiten
Weltkrieg (Göttingen: Wallstein 2015). Sweden: Kenneth Ögren, “Psy-
chosurgery in Sweden 1944–1964,” Journal of the History of the Neuro-
sciences, 14 (2005), 353. Norway: NOU: Utredning om lobotomi (Oslo,
1992), 29. Finland: Risto Vataja, Lobotomia. Taustatietoa ja selvitys
leikatuista potilaista Suomessa 1946–1969 (Helsinki: Stakes, 1997); Ville
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 25

Salminen, “Lobotomy as a psychiatric treatment in Finland,” Psychia-

tria Fennica, 42 (2011), 110–127; Salminen, “The history of stereotactic
psychosurgery in Finland,” Psychiatria Fennica, 45 (2014), 85–106.
37. On lobotomy in Germany and French speaking countries (especially
Switzerland), see Meier, Spannungsherde. Germany: Meinhard Adler
& Rolf Saupe, Psychochirurgie. Zur Frage Einer biologischen Therapie
psychischer Störungen (Stuttgart: Enke Verlag, 1977); Lara Rzesnitzek,
“‘Shockterapien’ und Psychochirurgie in der frühen DDR,” Nervenartz,
86 (2015), 1412–1419. Rakefet Zalashik & Nadav Davidovitch, “Last
resort? Lobotomy operations in Israel, 1946–60,” History of Psychi-
atry, 17 (2006), 91–106. Oguzhan Zahmacioglu et al., “The history of
psychosurgery in Turkey,” Turkish Neurosurgery, 19 (2009), 308–314.
Dimitri Ploumpidis et al., “History of lobotomy in Greece,” History of
Psychiatry, 26 (2015), 80–87. Kinga Jeczmínska, “History of lobotomy
in Poland,” History of Psychiatry, 29 (2018), 3–21. Less than 200
lobotomies were performed in Polen. B. L. Lichterman, “On the history
of psychosurgery in Russia,” Acta Neurochirurgica, 125 (1993), 1–4;
Benjamin Zajicek, “Banning the Soviet lobotomy: psychiatry, ethics, and
professional politics during late Stalinism,” Bulletin History of the History
of Medicine, 91 (2017), 33–61. See also Jürgen Hill, Der frontale Griff in
das Gehirn und die Entwicklung der Psychochirurgie (Hamburg: Lit. Verlag
Münster, 1992). On lobotomy in Italy, see Zbigniew Kotowicz, “Psy-
chosurgery in Italy, 1936–39,” History of Psychiatry, 19 (2008), 476–489.
For a historiography on lobotomy, see Brianne M. Collins & Henderikus
J. Stam, “A transnational perspective on psychosurgery: beyond Portugal
and the United States,” Journal of the History of the Neurosciences, 23
(2014), 335–354; Meier, Spannungsherde, 23–27.
38. On the total number of operations, see Elliot S. Valenstein, “History
of psychosurgery,” in S. H. Greenblatt (ed.), A History of Neurosurgery
(Illinois, 1997), 505. Others put the numbers lower, e. g. Meier, Span-
nungsherde, 11 (70,000, 1935–1970). For higher figures, see Collins
& Stam, “A transnational perspective on psychosurgery,” 349 (100,000
surgeries 1935–1971).
39. Per Haave, Ambisjon og handling. Sanderud sykehus og norsk psykiatri
i historisk perspektiv (Oslo: Unipub, 2008), 311. According to Haave,
the number of operations per 1,000 people was approximately 0.98 in
Denmark, while in England and the United States it was about 0.33 and
0.28, respectively.
40. See Barron H. Lerner, “Last-ditch medical therapy—Revisiting
lobotomy,” The New England Journal of Medicine, 353 (2005), 119–
121. Films, e.g. Frances (1982), A Hole in One (2004) Sucker Punch
26 J. V. KRAGH

(2011). On lobotomy and popular culture, see Jenell Johnson, Amer-

ican Lobotomy: A Rhetorical Analysis (Ann Arbor: University of Michigan
Press, 2014).
41. Collins & Stam, “A transnational perspective on psychosurgery,” 336. On
Switzerland, see Marietta Meier, Spannungsherde.
42. Cf. Jack D. Pressman, Last Resort, 3. David Shutts, Lobotomy: Resort to the
Knife (New York: Van Nostrand, 1982); Marc O’Callaghan, Psychosurgery:
A Scientific Analysis (Lancaster: MTP Press, 1982). See also Valenstein
(ed.), The Psychosurgery Debate: Scientific, Legal and Ethical Perspectives
(San Francisco: W. H. Freeman, 1980).
43. Joar Tranøy, Lobotomi i skandinavisk psykiatri (Oslo: KS series, 1992).
See also Harvey G. Simmons, “Psychosurgery and the abuse of psychi-
atric authority in Ontario,” Journal of Health Politics, Policy and Law,
12 (1987), 537–550; Allan Horwitz, The Social Control of Mental Illness
(New York: Academic Press, 1983), 132; Peter Conrad, “Types of medical
social control,” Sociology of Health and Illness, 1 (1979), 3.
44. Valenstein, Great and Desperate Cures; Valenstein, Brain Control: A Crit-
ical Examination of Brain Stimulation and Psychosurgery (New York:
Wiley, 1973).
45. Joel Braslow, Mental Ills and Bodily Cures: Psychiatric Treatments in the
First Half of the Twentieth Century (Berkeley, CA: California University
Press, 1997), 172.
46. Mical Raz, The Lobotomy Letters: The Making of American Psychosurgery
(Rochester, NY: University of Rochester Press, 2013), 3. On the reception
of Pressman’s book, see also Nancy Tomes, “Beyond ‘the two psychia-
tries’: Jack D. Pressman’s Last Resort and the history of twentieth-century
American psychiatry: introduction,” Bulletin of the History of Medicine,
74 (2000), 773–777. On studies inspired by Pressman’s book, see e.g.,
R. Zalashik & N. Davidovitch, “Last resort?,” History of Psychiatry, 17
(2006), 102; D. Ploumpidis et al., “History of lobotomy in Greece,”
History of Psychiatry, 26 (2015), 85; Chris Heller et al., “Surgery of the
mind and mood: A mosaic of issues in time and evolution,” Neurosurgery,
59 (2006), 720–739.
47. Jack D. Pressman, Last Resort: Psychosurgery and the Limits of Medicine
(New York: Cambridge University Press, 1998), 427.
48. Pressman, Last Resort, 441.
49. Raz, The Lobotomy Letters; Jenell Johnson, American Lobotomy: A Rhetor-
ical History (Ann Arbor: University of Michigan Press, 2014).
50. Marietta Meier, Spannungsherde. Psychochirurgie nach dem Zweiten
Weltkrieg (Göttingen: Wallstein, 2015). For fuller descriptions of Meier’s
book in English, see Greg Eghigian review in German History, 34 (2016),
722–723.
51. Meier, Spannungsherde, 300–301.
 1 WHITE INCISIONS AND BLACK BUTTERFLIES 27

52. Ibid. 305 and 261–274.

53. Braslow reviewed the records for 147 patients from two state hospitals
for poor patients in California, while Pressman analysed 80 records from
Mclean Hospital (Belmont, Massachusetts), which was one of the most
well-reputed private hospitals for affluent patients.
54. Joel Braslow, Mental Ills and Bodily Cures, 8. The use of patient record
as a source for historians is usually dated back to the article by Erwin
Ackerknecht, “A plea for a ‘behaviourist’ approach in writing the history
of medicine,” Journal of the History of Medicine and Allied Sciences,
22 (1967), 211–214. Since then, a substantial literature on medical
history and patient records has been produced: Guenter B. Risse &
John Harley Warner, “Reconstructing clinical activities: Patient records in
medical history,” Social History of Medicine, 5 (1992), 183–205; Steven
Noll, “Patient records as historical stories: The case of Caswell Training
School,” Bulletin of the History of Medicine, 68 (1994), 411–428;
Jonathan Edwards, “Case notes, case histories, and the patient’s expe-
rience of insanity at Gartnavel Royal Asylum, Glasgow, in the nineteenth
century,” Social History of Medicine, 11 (1998), 255–281; Jonathan Gillis,
“The history of the patient history since 1850,” Bulletin of the History of
Medicine, 80 (2006), 490–512. See also Robert Ellis, Sarah Kendal, &
Steven J. Taylor (eds.), Voices in the History of Madness: Personal and
Professional Perspectives on Mental Health and Illness (London: Palgrave,
2021).
55. Andrew Scull, “Somatic treatment and the historiography of psychiatry,”
History of Psychiatry, 5 (1994), 12. See also Petteri Pietikainen, Madness.
A History (London: Routledge, 2015), 242–264.
56. John Harley Warner, Against the Spirit of the System: The French Impulse
in Nineteenth-Century American Medicine (Baltimore: John Hopkins
University Press, 1998). On history of therapeutics, see also Warner,
The Therapeutic Perspective: Medical Practice, Knowledge and Identity in
America, 1820–1885 (Cambridge, MA: Harvard University Press, 1986);
Charles E. Rosenberg & Morris J. Vogel (eds.), The Therapeutic Revo-
lution: Essays in the Social History of American Medicine (Philadelphia:
University of Pennsylvania Press, 1979); William Bynum & Vivian Nutton
(eds.), Essays in the History of Therapeutics (Atlanta: Rodopi, 1991). On
psychiatric treatments, see Jonathan Sadowsky, “Somatic treatments,” in
Greg Eghigan (ed.), The Routledge History of Madness and Mental Health
(London: Routledge, 2017), 350–362.
57. Raz, The Lobotomy Letters, 17–25. See also Pressman, Last Resort, 147–
193. On differences between the US and European attitudes to lobotomy,
see Meier, Spannungsherde, 124–126.
58. In the late 1940s and early 1950s, there were seven state mental hospitals
with beds for about 7,500 patients. The municipal mental hospitals had
28 J. V. KRAGH

approximately 3,000. The private mental sector was small, comprising of

only one mental hospital in Dianalund (Zealand) with a little less than
300 beds.
59. Jenell Johnson is one of the few, who has questioned this issue in her
book American Lobotomy (2014).
 PART I

Towards Lobotomy

It is often asserted that the big revolution was in the early 1950s, when
psychiatry started to use tranquiliser drugs, but actually the first revo-
lution was the introduction of active treatments such as insulin coma
therapy, Cardiazol shock treatment and later electroshock. That was when
changes started to be made to the psychiatric institutions. (Jørgen Ravn,
Mit psykiatriske liv, Odense: Syddansk Universitetsforlag, 1977: 73)
 CHAPTER 2

State Mental Health Services—Danish

Hospitals and the Directorate, 1922–1952

For many Danish psychiatrists, 1922 was a watershed. Malaria fever

therapy reached the country, the first effective treatment for a group of
patients who would otherwise have faced a tragic fate, and the Direc-
torate of the State Mental Hospitals was established, paving the way for
the regulation of state psychiatry. Psychiatrists were particularly preoccu-
pied with the plans for the new Directorate and held numerous meetings
to discuss it. Leading psychiatrists wrestled with the issue in the Danish
Medical Journal (Ugeskrift for Læger). Hjalmar Helweg, the head of the
state mental hospital in Vordingborg, expressed the hope that the change
would be “beneficial to both the hospitals as humane institutions and
to psychiatry as a science.”1 Despite such high expectations, the chief
physicians at the state mental hospitals also had concerns. Most believed
that a national system would have advantages, but they also worried that
the Directorate would be a millstone around the neck of their hospitals.
Hjalmar Helweg also feared that his hopes might not be realised and that
the Directorate might simply be “one more cook to spoil the broth, one
more office to pass through.”2
The hospitals taken under the wing of the Directorate in January 1922
had all emerged from a long process that started in the early nineteenth
century. Before then, there were no mental hospitals or doctors who
specialised in a separate discipline called psychiatry. Nor was it the state’s
job to take care of people who, at the time, were described as “mad”

© The Author(s), under exclusive license to Springer Nature 31

Switzerland AG 2021
J. V. Kragh, Lobotomy Nation, Mental Health in Historical Perspective,
https://doi.org/10.1007/978-3-030-65306-4_2
32 J. V. KRAGH

or “insane.” That was the inescapable duty of the family. The very term
“psychiatry” was not even coined until 1808, when the German doctor
Johann Reil first used it.3 In other words, before the mental hospitals
were built, the science of psychiatry was established and the state became
involved, treatment and care options were extremely thin on the ground.
In fact, outside of the four walls of the family home, there were very few
places that could accommodate the so-called insane.
The earliest method of isolating the insane made use of a type of
wooden cage, first mentioned in Danish sources in the 1450s. These
had thick walls of heavy timber, and an iron door with a hatch through
which food was passed. Often no bigger than 2.5 square metres, they
were usually kept in town halls and hospitals, but similar devices were
also found in remote chambers or stables, where private landlords were
paid to look after people whose families could not or would not take care
of them. Most of these cages were in the hospitals that would later evolve
into psychiatric units. The largest collection was at St. Hans Hospital,
situated outside of the Copenhagen ramparts in the early seventeenth
century.4
Originally, St. Hans Hospital was not intended solely for patients with
mental disorders. In the seventeenth and eighteenth centuries, it also
housed physically and mentally disabled, and others with all kinds of
serious chronic illnesses. Most of the residents were paupers and were
only admitted if completely destitute. Like other hospitals of the period,
St. Hans was primarily full of incurable patients—those who could not be
looked after elsewhere. This included many “struck by the hard cross of
madness.” In 1770, 87 out of the 212 patients were described as “mad”
or “insane.”5
The living conditions for the inmates, left a great deal to be desired,
and the hospital was not immune from public criticism. In 1788–1800,
the historian and prominent social critic Niels Ditlev Riegel published
several accounts of the dilapidated and decaying St. Hans Hospital, in
which inmates were condemned to live out their lives in miserable condi-
tions. He wrote that it was “not only nudity and hunger with which the
lunatics, who were packed on top of each other and were all sick and
ailing, had to contend. They are also, as it were, homeless. In few of the
12 rooms are they able to lie down and find shelter from the rain and
wind.”6 In the wake of repeated criticism, plans were made to renovate
St. Hans in the early nineteenth century.
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Aircraft in war
 This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this ebook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

Title: Aircraft in war

Author: Eric Stuart Bruce

Release date: September 27, 2023 [eBook #71736]

Language: English

Original publication: London: Hodder & Stoughton, 1914

Credits: Brian Coe and the Online Distributed Proofreading

Team at https://www.pgdp.net (This file was produced
from images generously made available by The
Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK AIRCRAFT IN

WAR ***
 Transcriber’s Note
Larger versions of most illustrations may be seen by right-
clicking them and selecting an option to view them separately,
or by double-tapping and/or stretching them.
New original cover art included with this eBook is granted
to the public domain. It includes an illustration taken from the
original book.
Additional notes will be found near the end of this ebook.
The Daily Telegraph
WAR BOOKS
AIRCRAFT IN WAR
 [Topical Press.
A FARMAN ARMED SCOUTING BIPLANE,
showing gun mounted in position, Gnome motor, ailerons on upper plane, rudders
at rear (see Chapter VII.).
 AIRCRAFT in WAR
By

ERIC STUART BRUCE, M.A. Oxon.

Fellow of the Royal Meteorological Society; late Honorary Secretary
and Member of Council Aëronautical Society of Great Britain;
Vice-President of the Aërial League of the British Empire;
Membre d’Honneur of the Aëro Club of France

I l l u s t r at e d

HODDER AND STOUGHTON

LONDON NEW YORK TORONTO
MCMXIV
 TO MY WIFE,
who during the eight years of my Honorary
Secretaryship of the Aëronautical Society of Great
Britain incessantly and most materially aided me in my
efforts to secure the united interest of the British nation
in the mastery of the air, I dedicate this little volume.
 CONTENTS
CHAPTER PAGE

Introduction ix
I. The Earlier Aërial Scouts 1
II. The Development of the Airship 11
III. Types of Modern Airships: British, French, German,
Italian, Russian, Austrian, and Belgian 18
IV. The German Airship Fleet 37
V. Advantages and Disadvantages of Airships 50
VI. The Advent of the Aëroplane 78
VII. Types of Aëroplanes: British, French, Italian,
Russian, Austrian, Belgian, and Bulgarian 91
VIII. Germany’s Aëroplane Equipment 123
IX. The First Use of the Aëroplane in War—Tripoli—
the Balkans 137
X. The New Arm in Armageddon 144
XI. Present Deficiencies and Future Possibilities of the
Military Aëroplane 166
 INTRODUCTION
When years ago we read in Tennyson’s “Locksley Hall” the following
lines:—

Heard the heavens fill with shouting, and there rained a

ghastly dew
From the nations’ airy navies grappling in the central blue—

we little dreamt that not very far from the beginning of the twentieth
century the fancy of the poet would become the fact of reality; that in
the great European war in which the nation is so strenuously
engaged, “the wonder that would be” would come to pass.
Though happily, at present, in these isles the din of war is
unheard, yet a semi-darkened London and bright searchlights
playing on the skies tell the tale of prudent foresight against the
advent of the enemy’s airfleet. From the battlefields there daily come
the reports of actual battles in the air, sometimes betwixt aëroplane
and aëroplane, sometimes between the lighter and heavier than air
craft. Often such encounters are death-grip duels. Such conflicts of
the air are the direct consequence of the great and important use of
both airship and aëroplane as aërial scouts. These are the eyes of
encountering armies. To destroy as far as possible this penetrating
vision of the enemy and restore to him the fog of war is the untiring
aim of either side.
During those first anxious days of the present war the public
anxiously awaited news of the doings of the Royal Flying Corps, as
well as those of the aviators of our Allies. Expectation was satisfied
in the reading of Sir John French’s report to Lord Kitchener, dated
September 7th, 1914. Speaking of the use of the aëroplane in the
war he says:—

I wish particularly to bring to your Lordship’s notice the

admirable work done by the Royal Flying Corps under Sir
David Henderson. Their skill, energy, and perseverance have
been beyond all praise. They have furnished me with the
most complete and accurate information, which has been of
inestimable value in the conduct of the operations. Fired at
constantly both by friend and foe, and not hesitating to fly in
every kind of weather, they have remained undaunted
throughout.
Further, by actually fighting in the air, they have
succeeded in destroying five of the enemy’s machines.

For those brave heroes of the air our hearts beat with fervid
admiration. In accomplishing their all-important tasks they have not
only to fear disaster from shot and shell of the enemy, but from the
mistaken fire of their comrades and the very forces of nature. These
latter, owing to the imperfections of the flying machines, do not
entirely spare them; the Royal Flying Corps, in order to become
competent to perform the work it is now doing for King and country,
has had in manœuvres at home to pay a high price in the sacrifice of
human life.
It may, indeed, be reasonably thought that the knowledge of the
vast utility of aircraft in the present conflict will dispel the last
remnant of prejudice in this country against the development of
aërial navigation, and the grudging of a liberal national expenditure
on the service of the air. It was, perhaps, this ignoring of practical
utility, so vigorously combated by the pioneers in this country, that
caused Great Britain to be the last of the Great Powers to seriously
take up aircraft for military and naval use. Our delay had been a
wonder to many, since theoretically in the past this nation had been
to the fore. Nearly half a century ago it led the way of the air by being
the first country in the world to found a society for the
encouragement of aërial navigation—the Aëronautical Society of
Great Britain. It is no exaggeration to say that many of the great
principles of human flight were formulated and discussed at the
earlier meetings of that society. The late Mr. Wilbur Wright, when he
came to this country to receive the gold medal of the society, in his
speech testified to the substantial help he had received from the
study of the transactions of the oldest aëronautical society in the
world. As the pioneer in laying the foundations of aërial science, this
country is not without honour amongst the nations.
 CHAPTER I
THE EARLIER AËRIAL SCOUTS

Patriotism has been the most powerful factor in developing aërial

navigation. Montgolfier experimented with his paper balloons filled
with heated air in the desire that his invention might be of use to
France in her wars, and throughout the history of both balloons and
flying machines we find that it has been the desire to employ them
as instruments of war that has most fostered their progress.
Very soon after Charles invented the gas balloon the latter was
pressed into military service for the very same purpose of
reconnaissance for which airships and aëroplanes are now being
used. At the time of the French revolutionary war an aëronautical
school was founded at Meudon under the control of Guyton de
Morveau, Coutelle, and Conté, and a company was formed called
Aërostiers.
Captive balloons were used by the armies of the Sambre and
Meuse, of the Rhine and Moselle. Just before the battle of Fleurus,
1794, two ascents were made, and the victory of the French was
attributed to observations made by Coutelle. At that time several
ascents were made from Liége with a spherical balloon and one of
cylindrical shape. This latter appears to have anticipated the well-
known German kite-balloon.
There is a tradition that in those early days of the balloon the
French were possessed of a varnish which satisfactorily held the
hydrogen gas, but that the secret was lost—a grave loss indeed, if
the tradition has truth in it. The secret was never refound. A really
gas-proof varnish is unknown.
 In the course of the American Civil War of 1861 captive balloons
were again employed with important results.
During the Franco-Prussian War of 1870 three captive balloons
were installed in Paris, the “Nadar” on the Place St. Pierre; the
“Neptune,” manned by Wilfred de Fonvielle, at the gasworks at
Vaugirard; and the “Celeste” on the Boulevard des Italiens.
Thus long before the advent of airships and flying machines the
use of altitude for military reconnaissance was realised. A great
disadvantage of the captive balloon was its stationary nature. It was
not prudent to ascend in it very close to the enemy, as there was not
the same chance of escape as when the aërial observer is in mobile
aircraft.
Though rifle fire has over and over again failed to bring down a
captive balloon owing to the upward pressure of the hydrogen gas,
still, artillery fire has been known to have very destructive effect.
Undoubtedly, the best use that has been made of the captive
balloon was in the Boer War. The British observation balloon
equipment, which under the unceasing labours of Colonel Templer
had reached a state of considerable perfection, then proved to be
highly efficient. But in the light of modern aëronautical progress its
doings were merely the foreshadowings of the achievements the
aviators in the present war are daily carrying out.
Perhaps the most important feature of the balloons in the South
African War was the material of which they were made—gold-
beaters’ skin. We are all more or less familiar with this substance, for
we use it as a plaster when we cut our fingers. We should scarcely
think that so apparently fragile a substance was strong enough to
form the envelope of a balloon. It is, however, an admirable
substance for the purpose on account of its lightness and capacity of
holding the gas, and the desideratum of strength can be obtained by
combining layer and layer of the substance to any desired thickness.
By the use of gold-beaters’ skin it became possible to have much
smaller balloons for a given lifting power than when varnished
cambric or silk was employed. If made of the latter materials a
captive observation balloon had to be at least 18,000 cubic feet to be
of any service. Gold-beaters’ skin reduced the volume to 10,000
cubic feet, or even less.
The only disadvantage of gold-beaters’ skin for the envelope of
balloons and airships appears to be its very great expense. This, in
the case of a large airship, is formidable. It should be mentioned,
however, that it has sometimes been used for the separate gas
compartments which, as will be seen, are a feature of the Zeppelin
airship.
As regards the actual achievements of the balloon in South
Africa, one section did excellent work at Ladysmith. In the words of
Colonel Templer, “it not only located all the Boer guns and their
positions, but it also withdrew all the Boer fire on to the balloon.
Several balloons were absolutely destroyed by shell fire.”
One of the balloons was burst at a height of 1,600 feet, and
came down with a very quick run, but the staff officer in the car was
unhurt. At Ladysmith, by means of the balloon, the British artillery fire
was made decisive and accurate.
With General Buller at Colenso, and up the Tugela River,
Captain Philips’ balloon section was very useful. Splendid work was
done at Spion Kop. There the whole position was located and made
out to be impregnable. It has been said that the British Army was
then saved from falling into a death trap by the aërial
reconnaissance. Captain Jones’ section went up with Lord Methuen
on Modder River. His observations continued every day. It was
considered there was not a single day that they were not of the
utmost importance.
Again, Lord Kitchener and Lord Roberts used balloons. From the
information they obtained from them they were enabled to march on
to Paardeburg. At the latter place itself they were able to locate the
whole position. Another section went to Kimberley and on to
Mafeking. A very important observation was made at Fourteen
Streams. There a balloon was used continuously for thirteen days
without the gas being replenished. By its means the Boers were
prevented from relieving Fourteen Streams.
 It has been pointed out by Colonel Templer that one of the great
difficulties connected with the use of the comparatively small
balloons in the South African War was the heights the armies went
over.

On the march to Pretoria there were hills 6,000 feet above

the sea, and to make an observation from these hills it was
necessary to go up 1,500 or 2,000 feet, so that the
barometrical height was hard work on the buoyancy of the
balloon, because the barometrical height then became 8,000
feet—the 6,000 feet altitude above the sea-level, and the
2,000 feet it was necessary to go over the hills—that was
about all our balloons would do.

That was a disadvantage of the captive balloons which would not

have been felt if the observers had been on aëroplanes!
Certainly, the excellent gas retaining power of gold-beaters’ skin
was well put to the test in the South African War. The thirteen days’
work with one charge of gas mentioned above was a fair trial for a
balloon of such comparatively small size; but Captain H. B. Jones
gave a still more striking experience of the value of gold-beaters’
skin as a gas-holder. Speaking of the Bristol war balloon of 11,500
cubic feet capacity, he says:—

It was used at the engagements at Vet River and Land

River, and arrived at Kroonstad on May 12th. The balloon was
kept in a sheltered place near the river till we marched again,
on May 22nd, and was not emptied till after we had crossed
into the Transvaal at Vereeniging on May 27th. To keep a
balloon going for thirteen days at one station is a good test;
but in our case the Bristol was filled for twenty-two days, and
did a march of 165 miles with the division.

The system of filling the balloons from steel cylinders in which

the hydrogen gas had been compressed, so well exemplified in the
Boer War, was a great improvement on the older methods of
manufacturing the gas on the spot. Speed in filling balloons is a
desideratum for their use in war. By the cylinder method, owing to
the great pressure under which the gas escapes from the cylinder,
the inflation of the observation balloons became a question of
minutes instead of hours. The necessity of speed applies to the
inflation of airships also.
Although the present volume is designed rather to speak of the
aëronautical appliances of the present than those of the past, the
above-mentioned facts concerning aërial reconnaissance in the Boer
War have been included, as the value of the air scouts at the time
was hardly known and appreciated by the general public, whose
mind in those days was not constantly being directed to aërial
matters as it is at the present time. The knowledge of what just a few
well-contrived and well-utilised balloons could then do in the way of
aërial scouting must lead to the thought how the Boer War might
have been shortened had we then possessed the squadrons of fast-
flying aëroplanes that are taking part in the present war. To know,
indeed, what a very few aërial observers could do may enhance our
estimation of the possibilities of the squadrons of the flying machines
of the British and allied armies in the present war as they dart in
search of information over the lines of the enemy.
In the course of some articles on the subject of the new arm of
war, which contain many apt statements, Mr. F. W. Lanchester gives
the opinion that the number of aërial machines engaged in the war is
a negligible quantity. We might, indeed, well say the more the better,
provided they are on the Allies’ side; but no aëronaut or aviator will
allow the number is negligible. The writer compares the supposed
number of aëroplanes the Germans possess with the cost equivalent
of scouting cavalry. The comparison is not a happy one, on account
of the tremendous advantage of altitude and, consequently, long
range of vision possessed by the aërial scout. We have seen that in
the Boer War one observer at Spion Kop from his height and super-
sight saved the situation, and rescued our army from possible
crushing disaster.
 What might not even one shrewd British observer in a swift-
moving modern aërial craft accomplish at a critical moment in the
present conflict?