Who Was Chosen for Lobotomy? Sex, Race and the Hospital Ward

Prefrontal lobotomy reached the United States in 1936 and spread fastest in the decade after the Second World War.¹ Asking who received it means asking who was in a position to be chosen. The answer that emerges from hospital surveys, government reports and later historical work is consistent on some points and uncertain on others. Women were operated on out of proportion to their share of psychiatric patients, in the United States and abroad. Much of the operation’s use in its peak years took place in large public institutions, where crowding and cost made a quick route to discharge attractive.² On race, the evidence for the peak years is fragmentary, and the clearest data come from a later period.

This article looks at selection: which people ended up on the operating list, and why. The career of Walter Freeman, the operation’s best-known promoter, is the subject of a separate article on this site.

Counting the patients

Nobody kept a single national register of American lobotomies, and totals differ widely. A 1951 survey of psychosurgery in the nation’s state hospitals, published by Morton Kramer in 1954, put the total at roughly 20,000; Jenell Johnson, who cites it, thinks the real figure was probably higher.² A federal commission in 1977 gave an estimate of 40,000, most of them performed in the decade after 1945.¹ A figure of 50,000 also circulates; the historian Brianne Collins traces it to the psychiatrist and critic Peter Breggin and notes that other scholars have called it inflated.³

Because totals are so uncertain, historians have studied selection mainly through single institutions, where admission books and case files survive, and through the few national surveys that recorded patients’ sex. None of the surveys from the peak years found for this article recorded race.

Women on the operating list

The most consistent finding concerns sex. Men made up the majority of patients in American psychiatric institutions in the mid-twentieth century, yet Kramer’s 1951 survey found that close to 60 percent of the people lobotomized were women.²

Hospital-level studies show the gap more sharply. Joel Braslow, who studied the use of lobotomy at Stockton State Hospital in California, found that men outnumbered women among Stockton’s patients while women received 85 percent of its 241 lobotomies; of the fourteen patients operated on more than once, all but one were women.² At Fairfield State Hospital in Connecticut, a 1949 report on 107 cases recorded that 78 percent of those operated on were women. Its authors explained the imbalance by describing women patients as more violent and as presenting “greater problems from the standpoint of general management in a state hospital,” in the words Johnson quotes from the article.²

That phrase points to how success was judged. Johnson shows that published case reports, including those of Freeman and his surgical partner James Watts, often treated a woman’s renewed care for her clothes, hair and appearance as evidence that the operation had worked.² Braslow, as Johnson quotes him, put the Stockton pattern bluntly: “If she could cook, clean, care for the children, and provide sex, her recovery was considered complete.”² Johnson argues that “social adjustment” after surgery was measured largely by whether a patient resumed the conduct expected of her sex.

The popular press carried the same assumptions. In 1953 the magazine Jet ran a story under the headline “Can Surgery Cure Evil Women?”, built around case histories of African American women whose supposed disorders, as presented, concerned marriage, housework and sexual behavior. Johnson notes that it was unusual among press stories about psychosurgery in naming patients’ race at all.²

The same imbalance abroad

The pattern was not only American, and the British evidence is unusually complete. In 1947 the Board of Control, which oversaw mental hospitals in England and Wales, reported on 1,000 prefrontal leucotomies (leucotomy was the British term) performed up to the end of 1944, almost all of them in England and Wales. Of those 1,000 patients, 652 were women and 348 were men.⁴ The Board noticed that men appeared to do better and asked whether the difference lay in what happened after discharge: “Was it perhaps easier to place men out in employment than it was to place women at the time when the records were compiled, so that proportionately more men than women were classed as recovered?”⁴ The question is a reminder that “recovery” depended on what the world outside offered each sex.

A much larger survey by the Ministry of Health followed in 1961. G. C. Tooth and Mary Newton counted 10,365 patients who had a single leucotomy in England and Wales between 1942 and 1954: 6,338 women and 4,027 men. Women outnumbered men in each diagnostic group, most of all among patients with affective illness such as severe depression. About 64 percent of all patients had a diagnosis of schizophrenia and 25 percent an affective disorder.⁵ Comparing the operated patients with the general hospital population, the authors were cautious, concluding only that “a slightly greater proportion of females than of males were selected for operation.”⁵ By their own measures, women also fared somewhat better: 44 percent of women and 36 percent of men were reported as at least greatly improved.⁵

Canadian hospitals show similar ratios where records allow a count. At the Brandon Hospital for Mental Diseases in Manitoba, about 200 operations were performed on women and 110 on men, and more than half of the patients operated on at the Ontario Hospital in Hamilton were women. Collins cautions that most western provinces did not report annual totals by sex, so a fuller picture would require patient files.³

Men, veterans and sexuality

Men were not spared, and their selection reveals other pressures. A major American program served veterans, nearly all of them men: that of the Veterans Administration (VA). The 1977 federal commission linked the postwar spread of lobotomy to the urgent demand for treatment of psychiatrically disabled Second World War veterans.¹ Reporting by the Wall Street Journal in 2013, drawing on National Archives documents and summarized by the Advisory Board, found that VA doctors lobotomized 1,930 veterans at 50 hospitals between April 1947 and September 1950. The newspaper described the patients as men the VA had “diagnosed as depressives, psychotics, and schizophrenics, and occasionally […] people identified as homosexuals.” The VA told the paper it held no records of the program.⁶ A former trainee psychologist who recommended one such operation told the reporter that the procedure allowed staff to control aggressive patients on the ward.⁶

The reference to homosexuality is not isolated. Collins notes research by Perreault on Saint-Jean-de-Dieu Hospital in Montreal, where a series of male patients were operated on between 1949 and 1951 in an attempt to treat masturbation and homosexuality.³ In these cases selection reflected judgments about male sexuality rather than about women’s domestic roles, but the logic was similar: behavior that offended social norms was treated as a symptom that surgery could remove.

Race: segregated hospitals and missing numbers

On race, the honest answer is that the statistics needed to measure selection have not been found: none of the sources consulted for this article gives them. Johnson, who drew on the Freeman and Watts papers, states that Freeman provided no figures on the race of his patients and no breakdown by institution.²

What the record does show is that Black patients were held in the same overcrowded public system in which mass lobotomy took place, and, in West Virginia at least, in worse conditions. West Virginia’s Lakin State Hospital was the state’s institution for Black patients under segregation. Discussing a 1949 newspaper exposé of the state’s hospitals, Johnson describes how Lakin’s Black attendants were paid less than those at the white Weston State Hospital and how the state allotted 78 cents a day for each Lakin patient against 97 cents in white institutions.² In 1950 Lakin’s superintendent invited Freeman to demonstrate transorbital lobotomy there, and in the summer of 1952 Freeman operated on 228 patients in twelve days at Lakin and three other state hospitals, a program Johnson calls “the nation’s first and only attempt at surgical deinstitutionalization.”² Johnson thinks Lakin patients were probably a substantial share of that total but says Freeman’s published figures do not allow a count, and adds that the only photograph of an African American lobotomy patient she found illustrated Freeman’s published report on the West Virginia project.²

This evidence establishes exposure, not rates. Black patients in segregated state hospitals were subject to the same institutional pressures that drove lobotomy elsewhere. Whether they were operated on more or less often than white patients in comparable hospitals cannot be determined from the sources found for this article.

The question returns in the 1970s

Race moved to the center of the debate later, when a new generation of more limited brain operations drew public scrutiny. In 1967 three Boston physicians, Vernon Mark, Frank Ervin and William Sweet, wrote to the Journal of the American Medical Association using the urban uprisings in Newark and Detroit to argue for clinical study of individual rioters, so as to identify and treat people with “low violence thresholds.” Johnson describes the letter’s framing as racially coded and notes that it gave little weight to the social and economic causes of the unrest.² Mark and Ervin’s later proposals for surgery on “brain diseased” violent people alarmed many observers.²

When Congress responded with the National Research Act of 1974, the new National Commission for the Protection of Human Subjects took up psychosurgery.² Its 1977 report summarized critics’ fear that the operation “has been, or will be, used selectively against blacks, women, other minorities, and persons who are institutionalized.”¹ The commission also gathered data. The psychologist Elliot Valenstein found that most patients in the 1970s were referred by psychiatrists in private practice with mainly middle-class clienteles; women were 56 percent of those operated on, a share he judged in line with the diagnoses involved; and among 600 patients of several active surgeons, one was Black.¹ A neurosurgeon, M. Hunter Brown, testified that a 1974 review of 600 cases had likewise found one Black patient, and he attributed the low number “not to discrimination on the part of surgeons but to the economic realities and public policy.”¹

At a 1976 conference on minorities and human experimentation organized for the commission, two Black neurosurgeons, Jesse Barber of Howard University and Ernest Bates of the University of California, San Francisco, found no evidence that Black patients predominated among those receiving psychosurgery. Barber argued that minorities should share in decisions so that Black patients were neither subjected to the operation inappropriately nor denied it where it might help; Bates added that care must be taken that such operations did not become tools of social or political institutions. Testifying separately at the commission’s public hearings, he went further: in the commission’s summary of his remarks, neurosurgeons “must always guard against becoming the tools of social and political oppression.”¹

Not every case from these years fits the picture of a private, middle-class practice. Johnson notes, drawing on Harriet Washington’s Medical Apartheid, that many of the subjects of the Mississippi neurosurgeon Orlando Andy, who in the 1960s reported operating on patients for “abnormal” behavior rather than psychosis, were African American children, one as young as six.²

The 1970s figures describe a small, mostly private practice. They cannot be read back onto the state hospitals of 1950, where the patients, the doctors and the economics were very different.

What the evidence supports

Taken together, the sources support several conclusions with different degrees of confidence. Women were lobotomized out of proportion to their numbers in hospitals, a pattern documented nationally in the United States, in individual American and Canadian hospitals, and in two official British surveys.²⁵⁴³ Much of the practice in the peak years took place in public institutions, including state and veterans’ hospitals, though no source found gives an exact share.²¹⁶ Selection often turned on manageability and on whether a patient’s behavior after surgery matched what was expected of a woman or a man. For race in the 1940s and 1950s, the record shows Black patients confined in underfunded segregated hospitals where lobotomy was practiced, but no count of how many were operated on. That gap is itself part of the history: the people with the least power over their treatment were also the least likely to be counted.

Footnotes

1. National Commission 1977, pp. 1-2, 9, 30, 39-40, and public-hearing testimony of M. Hunter Brown and Ernest Bates, pp. 53-54. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

2. Johnson 2014, pp. 29, 50, 54, 57-58, 111-112, 123-125, 159-160, and notes on pp. 179, 189. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹ ↩¹² ↩¹³ ↩¹⁴ ↩¹⁵ ↩¹⁶ ↩¹⁷ ↩¹⁸

3. Collins 2020, pp. 3-4, 9, 237. ↩ ↩² ↩³ ↩⁴

4. Board of Control 1947, “Statistical results” and “Results according to sex and age.” ↩ ↩² ↩³

5. Tooth and Newton 1961, Table I and section “The patients and their operations”; results by sex. ↩ ↩² ↩³ ↩⁴

6. Advisory Board 2013, summarizing the Wall Street Journal’s “The Lobotomy Files.” ↩ ↩² ↩³