By Silmara Mansur.
By Karine Rodrigues
Ana, white, 26 years old and single, had “exaggerated vanity, combined with a striking tendency to chatter and exhibitionism: she wore too much make-up, wore short, low-cut dresses and dated a lot,” according to a medical report. Diagnosed with schizophrenia, she underwent electroshock and insulin therapy. However, given the persistence of symptoms, she underwent prefrontal leucotomy, brain surgery popularly known as a lobotomy.
The best candidates for surgery were girls with 'bad behavior [...], whose resistance to other therapies was seen as proof of their pathology, as well as certain characteristics considered by doctors as amoral
Hospitalized in 1945 at the Juquery Psychiatric Hospital, in Franco da Rocha (São Paulo), Ana was not an isolated case in the history of psychosurgery at that institution. For nearly two decades, approximately 700 surgical interventions were carried out, according to the monograph Surgical Treatment of Mental Illnesses (leucotomy), published in 1951, in which psychiatrist Mário Yahn, neurosurgeon A. Mattos Pimenta and neurosurgery assistant Afonso Sette Junior, the team that worked at Juquery, describe case reports that all corresponded to female patients.
"Why were all case reports exclusively for female patients?" The question, posed by historian Eliza Teixeira de Toledo when reading the study, gave rise to research that resulted in her doctoral dissertation The Circulation and Application of Psychosurgery in the Juquery Psychiatric Hospital, São Paulo: a Gender Issue (1936–1956), defended in 2019 in the Graduate Program in the History of Science and Health at the Casa de Oswaldo Cruz (COC/Fiocruz).
The thesis discusses the historical use of psychosurgery between the 1930s and 1950s in one of the largest hospitals in Latin America, where, at the time, around a third of psychiatric hospitalizations in Brazil took place. There, invasive experimental therapy — one of the most controversial types of therapy of the 20th century due to the risk of sequelae and changes in the patient's personality — was performed for the first time by neurologist Aloysio Mattos Pimenta.
Medical records reveal disputes and violence
Psychosurgery arrived at Juquery in 1936, the same year that Egas Moniz developed prefrontal leucotomy, the origin of other psychosurgical techniques: prefrontal lobotomy, employed by psychiatrist Walter Freeman (1895-1972) and surgeon James Watts, in the United States, also in 1936; transorbital lobotomy, created by Freeman in 1946 based on studies carried out by the Italian neurologist Amarro Fiamberti (1894-1970); and the leucotomy in three stages, by the São Paulo psychiatrist Mário Yahn (1904-1994), among others. Moniz, who was a professor at the School of Medicine of the University of Lisbon, won the Nobel Prize in Physiology/Medicine in 1949 for development of the leucotomy.
Some passages in the medical record recall the pressures that the imposition of marriage on women could represent in that context
A postdoctoral fellow at the Casa de Oswaldo Cruz, Toledo discovered that historiographical studies on psychosurgery in Brazil bypassed clinical dossiers. She then went in search of them. During the four-year investigation, in which thousands of clinical files from those hospitalized at the Juquery Psychiatric Hospital were analyzed, she came across several cases of abuse by partners, both physical and psychological violence. “These documents are filled with suffering. It was hard to read them. They describe very sad lives."
During the investigation, Toledo discovered more details about the patient Ana (the name is fictitious). The document revealed a long history of protests, which began with her first hospitalization.
"Some passages in the medical record recall the pressures that the imposition of marriage on women could represent in that context," writes Toledo. According to the document, Ana said that she had had several boyfriends and still had not found a man "worthy to be a husband." She also reported “fear of the responsibilities of being married” and said that children were “a lot of work.” In another part of the clinical dossier, reproduced by Toledo, the patient mentioned domestic violence: "Considered vain and coquettish, she had been beaten a lot by her father."
Sorting through thousands of medical records with the help of Juquery employees who were cleaning and preserving the documents, Toledo read them systematically and found references to psychosurgery in 431 clinical files held by the institution's Medical Archives and Statistics Service (SAME).
The analysis revealed that more than 95% of the operations found in the medical records were performed on female patients, focusing on the period between 1941, when psychosurgery started to be applied more frequently, and 1956, the date of the last operation found in the documentation. At the time, the proportion of women admitted to the Juquery Hospital Complex, then consisting of the Central Hospital, Camps and Judiciary Hospital, was 39%. Therefore, there was a predominance of male patients.
Female sexuality outside of marriage was 'aberrant'
Toledo found that the use of psychosurgery in Juquery was marked by the issue of gender. For adult women, for example, “it was mainly non-monogamous sexuality outside of marriage that was considered aberrant, especially when they discussed it without seeming to be self-critical or feeling shame,” she writes in her dissertation.
In addition to situations like Ana's, an analysis of all of the medical records found in the collection revealed the existence of patients who underwent successive surgical procedures due to relapse or persistence of symptoms linked to aggression, agitation and disobedience. However, not a single case was found in which this was done to male patients. The data is even more striking when considering that, although the procedures were considered ineffective in more than half of the male patients operated on, they were not forced to undergo further interventions..
The intention was to reaffirm the efficiency of scientific knowledge in the area and as an element of affirmation of psychiatry as a medical science
Psychosurgery, reveals the author of the study, was considered “auspicious” as a response to turbulence, insubordination, aggressiveness, perversity and excitability. “Young women whose sexuality was considered deviant or abnormal also ended up being lobotomized,” writes Toledo in her dissertation. "The best candidates for surgery were girls with 'bad behavior,' who caused disturbances at the hospital, were difficult to treat, whose resistance to other therapies was seen as proof of their pathology, as well as certain characteristics considered by doctors as amoral," the researcher adds.
Another example is Maria do Carmo, a black Brazilian, single, 15 years old, hospitalized in 1945. According to a report by Juquery doctors, included in the study Surgical Treatment of Mental Illnesses (leucotomy), published in 1951, she was a representative case of “the amoral or perverse syndrome,” far from the ideal model of a domestic girl: "It seems to us that, not only because of this case, but in the face of others and what is in the literature itself, that this (amoral) syndrome could be resolved auspiciously using this new therapeutic process called the leucotomy."
Although similar symptoms were seen in male patients, the analysis carried out by Toledo pointed to the existence of different levels of tolerance for misconduct for men and women, due to the naturalization of behaviors for genders. While there was greater acceptance of aggressive behavior by male patients, “calmness, sweetness, passivity and obedience” were expected from female patients.
Regarding gender bias, Toledo discusses one of the cases that caught her attention the most during the investigation, that of a Japanese woman who was only operated on because of her husband's interference. “The physicians did not recommend the therapy, but they operated because her husband insisted. This patient was hospitalized until her death and underwent two psychosurgical operations that were not medically recommended," Toledo affirms.
The historian draws attention to the fact that the main therapeutic objective of psychosurgery was the suppression of symptoms, rather than a specific pathology. Proof of this is that, at the International Psychosurgery Congress in 1948, the physicians admitted to the precariousness of their results, but justified them by blaming the “human material” operated on in public hospitals. The patients, in the physicians' assessment, "left a lot to be desired,” especially due to the lack of family monitoring during the rehabilitation process of patients. The ill were often seen as people of "little culture" and suffering from an advanced disease process, according to the hierarchical notion expressing the class views in that context. Analysis of clinical dossiers and published reports showed that, in more than half of the cases, the effectiveness of psychosurgery was temporary and unstable.
Legitimized by doctors, the technique was considered cutting edge
In order to understand the relationship between psychosurgery and gender, the researcher devoted an important part of her analysis to understanding experimental therapy. While the technique is now associated with cruelty and barbarism, Toledo notes that, when it appeared, it became “a cutting-edge surgical procedure in many countries” and was widely adopted around the world. It inspired great hope for the treatment of psychiatric patients, despite the criticism and controversy it aroused. At the time, experimental techniques such as psychosurgery and electroshock therapy were recurrent in medical-scientific practice.
We cannot deny that some doctors truly wanted to help people with this treatment, even though their therapeutic rationality, which coordinated the indications for psychosurgery and the assessment of its results, was imbricated in issues of gender and control
“This path is essential, especially in view of contemporary works that relegate psychosurgery to the list of 'bizarre' practices that are part of 'bad medicine' and do not understand how it became a possible, disseminated and awarded medical therapy. The intention was to reaffirm the efficiency of scientific knowledge in the area and as an element of affirmation of psychiatry as a medical science," points out the historian, drawing attention to the importance of analyzing the context. "We cannot deny that some doctors truly wanted to help people with this treatment, even though their therapeutic rationality, which coordinated the indications for psychosurgery and the assessment of its results, was imbricated in issues of gender and control."
By placing the technique within the scientific context of the time, she highlights that hospitals, in the 1920s and 1930s, became large laboratories. “They were not just a place for treatment, they were a place to gain knowledge about the body. Psychopharmaceuticals — launched in the early 1950s, with a calming effect for agitated patients — did not yet exist. Psychosurgery emerged as a possibility for obtaining therapeutic results and knowledge of the brain within an organicist perspective of diseases, which was popular at that time. The lobotomy was not contrary to a medical perspective, but rather inserted within an existing epistemology,” observes Toledo, noting that there had been criticism due to the instability of the results since the emergence of psychosurgery.
Historiography on the topic and the publications of the time have indicated that psychosurgery was an experimental therapy used in several countries as a last resort treatment for patients with a "disruptive" character. It arose from a biological view of mental illnesses, since it considered mental illness as a result of some alteration in the brain.
Juquery at the therapeutic vanguard
In this context, Juquery was at the forefront of therapy at an international level. According to Toledo, this occurred for a number of reasons, which included the institutional configuration and the epistemological model in vogue at the hospital (where "a strong organicist current" prevailed), the group of psychiatrists and neurosurgeons who performed psychosurgery and the specifics of its use. There was also a sociability network that developed between the director of the unit (Pacheco e Silva), Moniz and the institution's physicians.
Despite the legitimacy of the technique and doctors' insistence on its therapeutic value, Toledo draws attention to its possible consequences. "If these techniques, which had irreversible effects, were being performed on patients whose families had not been asked for authorization and who did not opt for the surgery themselves, this can be seen as a kind of institutional violence."
Quantification of cases found in medical files between 1952 and 1955 demonstrates an abrupt drop in the use of surgery during that period, even before the emergence of psychotropic drugs. According to Toledo, the reduction was associated with internal tensions related to the use of surgery from 1949 onwards, visible in clinical files, and was also a reflection of the 1947 Nuremberg Code, which regulated medical experiments on humans to avoid atrocities such as those practiced against the Jews during World War II.
Toledo notes that the documentation reveals a lot of gender violence and points out that denying women autonomy over their own bodies is historical and current in Brazil, citing the increase in aggression suffered by women and girls during the pandemic. “The pandemic is just throwing the obvious in our faces. It's something that happens every day,” she adds. “We read cases of women undergoing surgery and are reminded of recent cases of violence that we see all the time in the media. So, it's not a past that has been overcome.”
“I also cannot fail to reflect on the records that indicate the abuse that the patients underwent and that probably exerted a strong influence on their mental states. Even symptoms described as hallucinations would, in some cases, be related to factors such as violence from partners," writes Toledo in her doctoral dissertation, which was supervised by psychoanalyst Cristiana Facchinetti and co-supervised by biologist and historian Ilana Löwy, research director at the National Center for Scientific Research (CNRS), in France.
Translated by Naomi Sutcliffe de Moraes