Privately, however, Freeman was not only optimistic but triumphant. Talking about their first patient, he said: "This woman went back home in 10 days, and she is cured." The "indiscriminate use" he and Watts counseled against would come, irrespective of their warnings; Freeman himself would provide both the means and the motivation for it. Freeman and Watts considered that leukotomy was an incorrect name for the procedure. It suggested that it was only the white matter, the leukos, that was affected. They saw that they also destroyed actual nerve cells. Hence, they renamed it the lobotomy. This also helped to establish their version of the operation as distinct from that performed by Moniz. They were now the pioneers.

They began to perceive the limitations of the current mode of operation: eight of their initial 20 patients had two operations, and two of these had a third; there were two fatalities. Soon they were trying variations on the theme. They tried it with more holes in the top of the head, and penetrated deeper. They substituted for the cutting wire of the leukotome a more rigid blade, but found that the blade frequently broke off in the patient's brain; and, when it could eventually be dragged out, bits of blood vessel and brain tissue came with it.

By 1938, Freeman decided to change the strategy for attacking the brain. He opted to make the holes in the side of the head, to allow a more direct assault on the white matter. He also changed the instrument to a narrow steel blade, blunt and flat like a butter knife, called a Killian periosteal elevator. In principle, the blunt, thin end of this could be gently pushed through the intervening brain tissue with less risk of tearing the blood vessels.

From this development emerged the "Freeman-Watts standard lobotomy"; or, as they called it, the "precision method". After hand-drilling holes on either side of the head which were widened by manually breaking away further bits of the skull, the way would be paved for the knife by the preliminary insertion of a 6 inch cannula, the tubing from a heavy-gauge hypodermic needle. Put in one hole, this would be aimed at the other, on the opposite side of the head. Then the blunt knife would be inserted in the path initially carved by the cannula. Once inside the brain, the blade would be swung in two cutting arcs, destroying the targeted nerve matter. "It goes through just like soft butter," said Watts. The operation was repeated on the other side of the head.

Because the technique was "blind" -- they could not see what they were doing -- it required both men. Watts manipulated the cannula and blade while Freeman crouched in front of the patient, like a baseball catcher, using his knowledge of the internal map of the brain to give Watts instructions such as "up a bit", "down a fraction", or "straight ahead". Watts enjoyed "flying on instruments only", as he put it, and became so expert that, as a special trick, he could insert a cannula through a 2 millimeter hole in one side of a patient's head and thread it through the brain and out of the opposing hole like a shoelace. "That's pretty damn dramatic, you know," he once said. "And of course it always impressed spectators."

The best was yet to come. Having observed that the optimum results were achieved when the lobotomy induced drowsiness and disorientation, Freeman and Watts decided to see if they could use this information to judge how an operation was proceeding; they began to perform lobotomies under local anesthetic. Now they could speak to the patient while cutting the lobe connections and gauge whether they were being successful. They asked patients to sing a song, or to perform arithmetic, and if they could see no signs of disorientation, they chopped away some more until they could.

Initial professional reaction to the 1936 operations was not promising. Although, privately, the technique aroused great interest, it drew outraged responses from psychoanalysts and many psychiatrists, though, in keeping with the medical tradition of discretion, these reservations were not voiced to the public at the time. Ten years later, everybody would declare that they had always opposed the lobotomy.

Critics referred to the "offhand manner" in which the operation was described. Dr. Lewis Polack, angered by Freeman's manipulation of public opinion via the press, said to his face that it was "immoral to offer to the public any sort of a procedure which would awaken expectation and hope without possible fulfillment. It is not an operation, but a mutilation."

For the time being, Freeman and Watts could not obtain the access they coveted to the many thousands of inmates of asylums. "It'll be a hell of a long time before you operate on any of my patients," said one asylum director to Freeman. They remained in Washington, doing what work they could.

However, the introduction and wide acceptance around this time of other shock therapies such as metrazol (the fear drug), sodium amytal (the truth drug) and insulin-coma shock therapy soon began to create a climate in which the lobotomy might seem more acceptable. Freeman was a neurologist, and neurologists had traditionally taken the view that there were physical causes for mental illness that required physical treatment. Psychiatrists, on the other hand, had argued that mental disorder was a problem of the mind exclusively. The two groups had bickered over whose property madness was, and the psychiatrists were initially Freeman's greatest opponents. But in the face of soaring mental hospital populations and the lack of rapid cures, both sides in this bizarre dispute began to adopt increasingly extreme therapies. It was not long before overcrowding and limited mental health budgets began to persuade the superintendents of mental institutions to adopt lobotomy.

The economic arguments were very strong: a lobotomy could be performed for $250, while it could cost $35,000 or more a year to maintain a patient in hospital.

To overcome the initial professional prejudice against the operation, Freeman traveled tirelessly and gave presentations across the nation. He was also a skillful manipulator of the media; his ability to communicate directly with the public was a crucial asset.

In 1936, before Freeman had even disclosed details of his first operations to his professional colleagues, he had lunch with a reporter from the Washington Evening Star, whom he had asked if he "wanted to see some history made. We've done a few brain operations on crazy people with interesting results." The reporter was also given chance to see the two men in action, and so Freeman and Watts were on the front page of the New York Times, their technique -- barely tried and already with some dubious results -- was made as a "shining example of therapeutic courage".

Freeman featured on the front page of the New York Times and other national dailies an periodicals regularly over the following years undoubtedly persuading many surgeons to adopt the technique, and many thousands of patients and relatives of patients to opt for it. The popular coverage was universally optimistic, with headlines such as: "Psychosurgery Cured Me", "Wizardry Of Surgery Restores Sanity To Fifty Raving Maniacs", and, memorably and tragically incorrectly, "No Worse Than Removing a Tooth".

A sanitized version of the operation and it consequences was invariably given, and never more so than in an influential article, entitled "Turning The Mind Inside Out", published in the Saturday Evening Post in 1941. The writer the science editor of the New York Times, began in dramatic fashion by stating that there must be at least 200 men and women in the United States who had had worries, persecution complexes, suicidal intentions, obsessions and nervous tensions literally cut out of their minds with a knife. Freeman had explained the operation to the writer, Waldemar Kaempffert, as one which separated the pre-frontal lobes -- "the rational brain" -- from the thalamic brain -- or "emotional brain". The writer warmed to his theme, saying: "Man must balance emotion and reason. According to the Freeman-Watts theory, the preservation of that balance is a matter of nicely adjusting the 'thalamic' feeling with prefrontal logic." It made it sound disarmingly simple, the brain no more complex than the innards of a watch or a radio. The word "irreversible" was avoided.

Psychosurgery began to gain in popularity in the United States, though in Europe its acceptance was more limited. Basing their work on the Freeman-Watts system, American neurosurgeons rapidly developed a myriad of variations. It was five years since Moniz's first operation, and there had still been no long-term study of those who had undergone surgery.

Up until 1945, Freeman had never actually performed a lobotomy himself. He had always worked in tandem with Watts, and his surgical experience was limited to performing "spinal taps". What was still lacking, for Freeman, was a version of the operation that could be performed not just by neurosurgeons, but by anyone, anywhere, in a few minutes: an over-the-counter, rapid technique, so that one could pop down to the local psychiatrist and get lobotomized in the lunch-break.

He had heard of the work of an Italian called Amarro Fiamberti, who had developed a trans-orbital attack on the frontal lobes; one that went in through the front of the skull, directly over the eyeball. He had perforated the orbital plate of the skull behind the eyes, and injected caustic solutions to destroy the brain tissue, but these had sunk down and caused rather severe damage elsewhere. Fiamberti had also punctured the orbital plate directly through the eye sockets and tried to use the original leukotome knife in this method with few good results, and a lot of mess. The potential advantage of such an approach was that it did not require holes to be made in the skull; everything could, in theory, be performed by one individual administering a simple stab through the back of each eye socket into the white matter of the brain. There would be nothing to set up. The patient would be left with nothing worse than black eyes and a splitting headache - plus the usual effects. It would be very easy, very fast, and very cheap.

During the winter of 1945, Freeman tried to develop a trans-orbital approach to lobotomy, practicing on corpses. Watts cooperated, believing that ultimately he would do the surgery, and Freeman would, as usual, navigate. The two men came up against a familiar problem; the instruments they were using were not strong enough to penetrate the orbital bone and kept breaking off inside the head of their experimental corpses. They needed an implement that was slender, sharp, and strong.

One day, mulling over the problem at home, Freeman remembered that the apple corer had been a source of inspiration for Moniz, and began to rummage through the contents of his kitchen drawers. Soon he found precisely what he was looking for: a cheap, mass-produced ice pick for stabbing pieces of ice off large commercial blocks. Normally used for making cold drinks on hot summer days, it now made its debut as an instrument for brain surgery. Freeman put a special hammer-shaped head on the ice pick, which allowed it to be pushed and pulled more easily. It was this instrument that was used in the first trans-orbital lobotomies in America in a procedure that became known as the "ice pick lobotomy".

Armed with his new weapon, Freeman was convinced that a trans-orbital would be a simple piece of surgery which would not require a neurosurgeon. He decided that he would operate on the first living patient without telling Watts, whom he hoped would be sufficiently impressed to offer his encouragement thereafter. Secretly, he tried his hand on a series of patients, to whom he explained that the technique had been used successfully in Italy for a number of years, which was being quite economical with the truth. He did not dwell on his own lack of surgical experience. He anaesthetized them with three rapid bursts of electric shock. He then drew the upper eyelid away from the eyeball, exposing the tear duct. The sharp point of the ice pick was placed in this, and then, as Freeman put it, "a light tap with a hammer is usually all that is needed to drive the point through the orbital plate".

The ice pick was plunged into the brain. When it was about 2 inch inside, Freeman would pull the ice pick about 30 degrees backward, as far as he could without cracking the skull, and then move it up and down in another 20-degree arc, in order to cut the nerves at the base of the frontal lobes. The procedure took only a few minutes.

Freeman's post-operative advice to relatives was restricted to the order: "Buy them some sunglasses."

By patient number 10, he felt confident enough to invite Watts along. Watts was not happy to find out what Freeman had been doing, and was deeply distressed to see the perfunctory, brutal nature of the operation. He angrily threatened to break with Freeman if he continued. It was the beginning of the end of their relationship, and within months Watts had left the joint practice they ran.

Freeman, now with an incessant itch for surgery, started to sneak off out of Washington, to mental hospitals in other states where he could practice his technique. But he was continually angered by finding himself given the most deteriorated patients to operate on. He wanted trans-orbital lobotomy to be performed on people just developing signs of mental disorder.

The year 1947 brought personal tragedy for Freeman. While walking in Yosemite National Park with his five sons, he saw one of them, 11-year-old Keen, go to the edge of the Vernal Falls on the Merced River to fill a canteen. He fell in, and both he, and the young sailor who tried to save him were swept away by the swollen river and drowned before Freeman's eyes. The bodies were found several days later. Coping with the death was especially difficult for Freeman, who found it impossible to talk about such emotive matters. In his inability to address these he was - though he would have resented the assertion - following a family trait. He had never been communicative with his mother and when, as a child, he had been caught playing truant and dragged before his father, instead of receiving the punishment he expected, Freeman had been horrified to see his father take a small cat-o'-nine-tails from his desk, and beat himself on the back until he bled. All emotion, all anger, and the blind, black rage that many suspected was within Freeman were turned inward, and when they emerged, it was in strange and grotesque fashion. Once he advised a frail woman who consulted him with psychosomatic pains to adopt a heavy routine of exercise and weight lifting. Her original persona was not restored, but utterly changed. She became something new, something she was naturally not: a muscle-bound freak. Freeman was proud of the shocking change he had induced and exhibited her photograph.

Twelve years earlier, Freeman had experienced a nervous breakdown, brought on by overwork. He had been particularly scared by this experience, and ever since had taken at least three capsules of Nembutal every night to guarantee sleep. Nembutal also gave him a dreamless sleep. Freeman did not like his dreams.

His depression had deepened his prejudice against personal introspection; he believed that there was nothing to be gained from self-examination except pessimism. He himself was a great believer in activity and exercise. He went off vigorously walking whenever possible, and often prescribed the same remedy for depressed patients. Trying to talk to them was nonsense. Something that had always been a perverse source of amusement to him was the number of psychoanalysts who committed suicide. He could not help pointing out with a certain amount of glee that no fewer than eight of Freud's associates killed themselves. And while he was sitting in bed, looking at the proofs of his new book, an idea for another came into his head: one day he would write a book about these masters of introspection, whose tortured self-concern led only to self-destruction.

The following year, 1948, was a much better one for Freeman. He was elected president of the American Board of Psychiatry and Neurology; he drove an expensive Lincoln convertible. Royalties and fees from the operation were making him wealthy.

The Freeman-Watts standard lobotomy had been performed on as many as 20,000 disturbed, and not quite so disturbed, individuals worldwide.

The end of the Second World War had brought thousands of traumatized veterans back to join those still suffering from the effects of the First World War. In gratitude for their services in the war, they were given shock treatment and psychosurgery.

Freeman was a celebrity whose work was rarely out of the papers. He took advantage of his status to push his trans-orbital technique into the public eye, so to speak, even exhibiting it on television to general amazement. The ice pick lobotomy grew in popularity, particularly among psychiatrists without any previous experience of surgery.

That year Walter Freeman performed his most famous trans-orbital lobotomy when he hammered his ice pick into the head of the movie star and radical political activist Frances Farmer. She had rebelled all her life against every form of authority, and despite her success in Hollywood and Broadway, found herself incarcerated in the Western State Hospital in Fort Stellacoombe, Washington, aged only 34. The hospital, notorious for its dreadful conditions, had in desperation performed an increasing number of lobotomies on its inmates. Frances Farmer was a particularly sore point, because no treatment yet devised seemed to work on her; she would not be tamed. But her communist sympathies and her aggression towards officialdom had offended too many people for them to give up without "curing" her.

Hither rode Walter Freeman, knight to the rescue, ice pick in one hand, hammer in the other. On an October morning, in front of an eager audience of staff, curious visiting psychiatrists, and photographers, female patients in wheelchairs were ranged before the great showman of psychosurgery. After giving a brief lecture to the assembled crowd on the wonders of the ice-pick lobotomy -- no more complex then a shot of penicillin, no scar, and amazing potential for controlling society's misfits, schizophrenics, homosexuals, communists -- he went to work. Freeman was always quick to seize on new selling points for his art. Patient number one was wheeled before him. He put the electrodes on her temples and shocked her into a faint, lifted her left eyelid, and plunged the ice pick into her head. He pulled it out. Another woman was brought before him. Again he shocked, and stabbed. And another, and then again another, and so on, and on, remorselessly, in a production line of controlled, casual violence until even the director of the hospital, near to passing out with nausea, left the room.

Afterwards, in a dark and silent ward, the patients lay supine on beds, or cried quietly; their faces were disfigured with a questioning blankness. The personality that was Frances Farmer had been effectively terminated earlier in the day, in a remote room to avoid publicity. She was reduced to a state of turgid, generalized mediocrity by the surgery. Society had won its battle with her; she would never again be a threat. She was released and, grown fat and slow, she drifted off into oblivion. She ended her life as a clerk in a hotel, dying of cancer in 1970. Freeman had a photograph of himself performing the lobotomy on her, and, before lobotomy fell into disgrace, he used to show it proudly to friends. In the end, he didn't mention the operation in his memoirs.

People often fainted when watching Walter Freeman at his peak in the late Forties and early Fifties.
Even the eminent Dr. Edwin Zabriskie, a 74-year-old who had been involved in hand-to-hand fighting in the First World War and was a clinical professor of neurology, was observed to crumple on to the carpet at the sight of Freeman in action.

None the less, Freeman toured widely throughout America. He not only taught through live demonstrations, but also made several films, which helped swell the number of operations performed, particularly in the overcrowded hospitals in poorer areas of the country. Within eight months in 1949, 515 trans-orbital lobotomies were performed in Texas alone. At Rusk State Hospital in Texas, where Freeman had made an inspiring personal appearance early in spring, they were already planning another 450 ice-pick lobotomies before the year was out, even though the staff featured no surgeon of any description, only three psychologists, and a couple of doctors.

In addition to the easy-to-use ice pick and Freeman's charismatic energy, a further cause of the great dam-burst of lobotomy was the award of the 1949 Nobel Prize for Medicine to Egas Moniz in Lisbon for his pioneering work in psychosurgery. Freeman was acutely disappointed to go unrewarded himself, but was at least pleased that he was invited to nominate Moniz for the prize.

Moniz's award sealed the future of tens of thousands of psychiatric patients, for it squashed many of the existing reservations about the operation, and more people were lobotomized in the three years after he received the prize then in the previous 14 years. Nearly twice as many women as men were lobotomized. Freeman was very busy, and began to get quite fussy; he wanted to operate on patients within two years of their being institutionalized and, in the case of schizophrenics, within the first year of illness. Quite simply, getting them earlier made the operation's results look better. Over 70 per cent of those admitted to institutions recovered anyway, and if they had been lobotomized early on, it was impossible to tell whether it was because of, or in spite of, the operation. Freeman would proudly say it was the former. He hated operating on chronic, hopeless cases; they were all right to practice on, but they made his recovery statistics look bad. First sold as an operation to be used as a last resort, the lobotomy had now become the first step to creating a manageable personality. Even problem children were being lobotomized. If everybody had their frontal lobes snipped at birth, there would be an end to sorrow in the world.

By 1950, in his frenzy of activity, Freeman had crossed and recrossed America 11 times on what he called his "head-hunting" expeditions, promoting the ice pick, looking for new patients, checking up on his old ones. He found a partner, Dr. Jonathan Williams, to replace the departed Watts. Williams was often shocked at Freeman's cavalier use of the ice pick, wielded anywhere at any time, but for Freeman, the passionate prophet of psychosurgery, these were his golden years.

By the early Fifties, reservations about the effects of the lobotomy could be heard. Its use as a first rather than last resort, by amateur surgeons who did not even bother to give the patient a preliminary psychiatric report, was rife. Post-operative infections, and simple fatalities were common; autopsies showed that large areas of brains, not selected nerves, were utterly destroyed. Astonishingly, there had still been no reliable sustained studies of the effects on patients, only Freeman's eternally optimistic data. Though some patients did continue to pursue their professional and private lives after the operation, it was impossible to state that this was because of the surgery. Furthermore, it was impossible to judge "recovery" in many; they were often so different. The inert, emotionless, inhuman quality of many lobotomized, who were everywhere to be seen, began to revolt the public, though thousands still submitted relatives for the operation.

As early as 1951, even the Soviet Union, where psychiatric abuse was rife, had stopped performing the lobotomy on ideological grounds: it produced unresponsive people who were fixed and unchangeable.

Lobotomy was finally seen for what it was: not a cure, but a way of managing patients. It was just another form of restraint, a mental straitjacket nailed permanently over the brain. It did not create new people; it subtracted from the old ones. It was an act of defeat, of frustration. The Director of the New York State Psychiatric Institute, Nolan Lewis, asked: "Is quieting a patient a cure? Perhaps all it accomplishes is to make things more convenient for those who have to nurse them. The patients become rather child-like; they are as dull as blazes. It disturbs me to see the number of zombies that these operations turn out. It should be stopped."

In 1952, chlorpromazine, the first of the new generation of revolutionary tranquilizers for schizophrenia and depression, was tested in France. It signaled the end for Walter Freeman. From now on, he would be the "ice pick lobotomist", with a rapidly diminishing clientele and shrinking reputation.

By 1954, everybody was on drugs; psychopharmacology had hit America, and the manufacturers of the biggest-selling tranquilizer, Thorazine, could literally not make enough to satisfy popular thirst for the chemical. Most neurosurgeons and psychiatrists who had practiced lobotomy tossed away their instruments with relief.

Not so Freeman; he took to the road, "head-hunting" again, visiting the 55 hospitals in the 23 states where he had once gloriously wielded his ice pick on hundreds of people. He was obsessed with producing a follow-up study that would justify his work. He firmly believed that the pendulum would swing his way again, but by the end of the fifties, he was performing only a trickle of operations. His name had become tarnished; he found it hard to get on the staff of hospitals and colleagues referred few patients to him.

At the 1960 World Psychiatry Congress, Freeman presented the results of his follow-up studies, claiming they showed that 85 per cent of his private trans-orbital patients were now at home, and two-thirds of them were "usefully occupied". His data were so anecdotal, so subjective, that they were not taken seriously. At the same time, a 10-year study on British patients was released which did not make such encouraging reading.
Then, in 1962, One Flew Over the Cuckoo's Nest by Ken Kesey was published. The Pulitzer Prize-winning novel became a classic bestseller; it was a damning portrayal of a psychiatric hospital, and of the effects of lobotomy. It was all over for the psychosurgeons.

Freeman was then 67 years old; most would have had enough. Yet throughout his final years, he remained active, busying himself with projects including his memoirs, and the book on the tendency of introverted psychoanalysts to kill themselves. With typical aggression, he tried to add to the list the psychiatrist Harry Sullivan who had died in 1949. Freeman tried to prove he had killed himself. Sullivan had been a bitter opponent of lobotomy in general, and Freeman in particular.

He also continued to tour the country in a specially equipped camper van, which he called his "lobotomobile", visiting former patients and gathering evidence of their recovery, determined to prove that his love of the blade and the ice pick had not been misguided.

In February 1967, he used his ice pick for the last time. The patient was actually one of the original 10 on whom he had first tried the trans-orbital in secret, in his office in 1946. This was the third time he had administered an ice pick lobotomy to this woman; he had also done it in 1956. He made the customary deep frontal entry with his ice pick, but this time the old magic failed; he tore a blood vessel in the brain. She died within hours. Freeman had his surgical privileges removed.

He refused to see himself as defeated. He had by now lost two of his sons, and his wife would precede him to the grave. He treated his emotions with his habitual long walks and, when told that he had diabetes, eliminated sugar from his diet and cured himself.
In May 1972, after a brief battle with cancer, he died aged 77, still believing in the integrity of his methods and motives.