Italy was the Racconigi Hospital, where the experienced neurosurgeon Ludvig Puusepp provided a guiding hand. Under the medical directorship of Emilio Rizzatti, the medical personnel at this hospital had completed at least 200 leucotomies by 1939. Reports from clinicians based at other Italian institutions detailed significantly smaller numbers of leucotomy operations. Experimental modifications of Moniz's operation were introduced with little delay by Italian medical practitioners. Most notably, in 1937 Amarro Fiamberti, the medical director of a psychiatric institution in Varese, first devised the transorbital procedure whereby the frontal lobes were accessed through the eye sockets. Fiamberti's method was to puncture the thin layer of orbital bone at the top of the socket and then inject alcohol or formalin into the white matter of the frontal lobes through this aperture. Using this method, while sometimes substituting a leucotome for a hypodermic needle, it is estimated that he leucotomised about 100 patients in the period up to the outbreak of World War II. Fiamberti's innovation of Moniz's method would later prove inspirational for Walter Freeman's development of transorbital lobotomy. American leucotomy The first prefrontal leucotomy in the United States was performed at the George Washington University Hospital on 14 September 1936 by the neurologist Walter Freeman and his friend and colleague, the neurosurgeon, James W. Watts. Freeman had first encountered Moniz at the London-hosted Second International Congress of Neurology in 1935 where he had presented a poster exhibit of the Portuguese neurologist's work on cerebral angiography. Fortuitously occupying a booth next to Moniz, Freeman, delighted by their chance meeting, formed a highly favourable impression of Moniz, later remarking upon his "sheer genius". According to Freeman, if they had not met in person it is highly unlikely that he would have ventured into the domain of frontal lobe psychosurgery. Freeman's interest in psychiatry was the natural outgrowth of his appointment in 1924 as the medical director of the Research Laboratories of the Government Hospital for the Insane in Washington, known colloquially as St Elizabeth's. Ambitious and a prodigious researcher, Freeman, who favoured an organic model of mental illness causation, spent the next several years exhaustively, yet ultimately fruitlessly, investigating a neuropathological basis for insanity. Chancing upon a preliminary communication by Moniz on leucotomy in the spring of 1936, Freeman initiated a correspondence in May of that year. Writing that he had been considering psychiatric brain surgery previously, he informed Moniz that, "having your