ADVENTURES W; ITH AN ICE PICK

No one has ever practised lobotomy so enthusiastically as Dr Walter Freeman, who, accordin; g to a new book, developed the now discredited art with a recklessness bordering on lunacy Freeman crouched in front of patients and, using his knowledge of the brain, gave the surgeon instructions like 'Up a bit', or 'Down a fraction'
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AMERICA, 1847: a highly competent and, by all accounts, pleasant manual labourer of Irish extraction named Phineas Gage is involved in rock-blasting operations in mountainous terrain. In the course of one sadly uncontrolled explosion, an iron bar is picked up by the force of the blast and driven clean through the front part of his head. Phineas is sent flying, but, to everybody's surprise, he survives the removal of the protruding bar. As he recovers, however, it is observed that his personality has dramatically changed, though his memory and intelligence remain apparently unaffected. In 1868, a physician named Harlow from Boston writes about him: "His equilibrium, or balance, so to speak, between his intellectual faculties and animal propensities seems to have been destroyed. He is fitful, irreverent, indulging in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires." The now extremely rude Phineas Gage is an object of immense medical interest, for it seems clear, from his somewhat crude experience of psychosurgery, that one can alter the social behaviour of the human animal by physically interfering with the frontal lobes of the brain.

In 1890, Dr Gottlieb Burckhardt, the superintendent of a psychiatric hospital in Switzerland, drills holes in the heads of six severely agitated patients and extracts sections of the frontal lobes, altering their behaviour with varying degrees of success. Two of the patients die. His surgery is considered morally reprehensible at the time, but his work is not forgotten. Phineas and his iron bar have started a train of thought that will come to a strange and tragic fruition in the next century.

IT TOOK a few years, and the work of a dedicated band of pioneers, to establish the various forms of lobotomy as everyday treatment for psychiatric patients. But by 1955 over 40,000 men, women and children in the United States alone had undergone psychosurgery which left large parts of their brains irreparably vandalised by doctors who didn't even need a formal qualification to practise the operation.

The greatest advocate of psychosurgery was Walter Freeman. Born in Philadelphia in 1895, the son of a doctor with strong Calvinist beliefs, Freeman had been appointed Professor of Neurology at George Washington University in the aftermath of the First World War. America was suffering from a huge increase in psychiatric disorders. An influx of shell-shocked soldiers and bereaved, disturbed relatives was swelling the asylum population. In addition, there was still no cure for tertiary syphilis, which had been discovered to cause up to half the known cases of dementia praecox, or schizophrenia. The need for practical measures to counter madness had never been more urgent.

In July 1935, Freeman, then aged 40, attended a neurological conference in London. It was quite a gathering. Also in attendance were the celebrated Russian, Ivan Pavlov, whose trained salivating dogs were to make him legendary; and Egas Moniz, the celebrated Portuguese neurosurgeon, who had pioneered cerebral angiography, the process of mapping the parts of the brain by injecting "contrast" solutions which can be seen by X-rays.

Pavlov might not have brought his dogs to the conference, but John Fulton from Yale University had brought two chimpanzees. These were the subject of a day-long symposium which both Freeman and Moniz attended. Fulton had completely removed the entire frontal lobes from these two animals - a lobectomy - which had radically altered their behaviour. He could no longer generate experimental forms of neurosis in the animals. They were seemingly unperturbable. The symposium was fascinated, and the discussion about the significance of the frontal lobes went on and on, as the assembled company hedged gently around the delicate issue that Fulton's chimpanzees raised. Eventually, to much surprise, it was Egas Moniz who stood up and asked the question that Freeman, for one, had been desperate to put.

"If the frontal lobe removal prevents the development of experimental neurosis in animals and eliminates frustrational behaviour," he asked, "why would it not be possible to relieve anxiety states in man by surgical means?"

Many attending were shocked to hear it put so frankly; they believed that Moniz was talking about performing the full lobectomy on humans. Freeman, however, was struck by Moniz's courage.

A year later, he came across Moniz again, this time in the pages of a French medical periodical. In September 1935, in a Lisbon surgery, Moniz had participated in the first controlled attempt to put into practice the ideas raised at the London conference. With the neurosurgeon Almeida Lima, he had attempted to perform the first leucotomy, on a female asylum patient. The object had been, not to destroy the actual frontal lobes, but rather to destroy (by injecting alcohol into them) the fibres, the white matter or leukos, which connect the frontal lobes - the area they believed to be most immediately concerned with social behaviour - to the main body of the human brain.

The results were inconclusive. After surgery, the woman was certainly less agitated and overtly paranoid than she had been before. But she and the other three patients from the asylum who subsequently underwent the same procedure were also, Moniz admitted, somewhat more apathetic and frankly duller than he had hoped. In addition they suffered from nausea, sphincter disorders, sluggishness and disorientation. Still, the results were spectacular enough for Moniz to be encouraged.

Unfortunately, he found that the director of the asylum was suffering twinges of professional jealousy and was unwilling to supply any more surgical subjects. Quite apart from this, he was, as Lima put it, experiencing "doctrinal and ethical" doubts about the nature of the operation. In order to maintain his flow of patients, therefore, Moniz not only had to exercise his considerable powers of charm, but began to withhold the results of his work that suggested it was less than perfect, so that it appeared that the operation was already a success, and was so simple that it could be quickly applied on a wide, public basis.

When he did publish his results, it was in six countries simultaneously. And, as one contemporary said, "Seldom in the history of medicine has an experimental procedure been so promptly adapted to the treatment of sick patients everywhere."

AS SOON as he had read that first, brief article, Freeman requested a copy of Moniz's full monograph on the process from its Paris publisher. He had seen his way forward.

Although he was a neurologist, Freeman had no qualifications as a surgeon. He needed a neurosurgeon as a collaborator so he showed the book to his colleague, James Watts. They ordered from France two of Moniz's leucotomes, knives specially designed for the operation, and after practising for a week on brains from the morgue, Freeman and Watts operated on their first living patient. Watts did the cutting; Freeman navigated.

She was a 63-year-old woman from Kansas, the type of agitated, depressed and fearful personality that Moniz had experimented on. Faced with a choice of a mental institution or surgery, she and her husband opted for the knife. On the operating table, she had second thoughts when she realised that her head was about to be shaved, and she would lose the curls that she was proud of. Freeman assured her that her curls would be saved; this was not the case, but after the operation, as Freeman himself noted, "She no longer cared".

The operation was carried out on 14 September 1936. Freeman and Watts Moniz had altered his prescribed technique since the first leucotomy, and six holes were now cut in the patient's head. When she had been stitched together and had awoken from the anaesthetic, the sense of calm she exuded in contrast with her former terror was striking. When asked by Freeman if she could remember why she had previously been so upset, she could only say: "I don't know. I seem to have forgotten. It doesn't seem important now." Freeman and Watts were thrilled.

A week after surgery, the woman began to behave strangely. She talked incoherently, becoming stuck on certain syllables, repeating them endlessly and hopelessly jumbling up her sentences. She could no longer recite the days of the week, and when she was asked to write, the same repetitions and sad, nonsensical constructions occurred on paper. A few days later, her speech had largely returned and she went placidly home, showing neither eagerness nor apprehension.

The two surgeons proceeded to operate on another five patients over the next six weeks, and in November 1936 published a report in which they wrote: "In all our patients there was a... common denominator of worry, apprehension, anxiety, insomnia and nervous tension, and in all of them these particular symptoms have been relieved to a greater or lesser extent." They further said that in some patients disorientation, confusion, phobias, hallucinations and delusions had been relieved or had altogether disappeared. They concluded by stating the grounds on which they had undertaken the operations - to relieve symptoms that were causing "great distress to the patients and to their families" - and added: "We wish to emphasise that indiscriminate use of the procedure could result in vast harm. Prefrontal [targeted at the parts of the brain behind the frontal lobes] leucotomy should at present be reserved for a small group of specially selected cases... every patient probably loses something by this operation, some spontaneity, some sparkle, some flavour of the personality."

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 counselled against would come, irrespective of their warnings; Freeman himself would provide both the means and the motivation for it.

Freeman and Watts considered that leucotomy 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 leucotome 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 6in 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 2mm 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 anaesthetic. 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 fulfilment... 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, and that it 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 travelled tirelessly and gave presentations across the nation. He was also a skilful 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 a chance to see the two men in action, and soon Freeman and Watts were on the front page of the New York Times, their technique - barely tried, and already with some dubious results - was hailed as a "shining example of therapeutic courage".

Freeman featured on the front page of the New York Times and other national dailies and 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 Tooth".

A sanitised version of the operation and its 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 off-the-peg, rapid technique, so that one could pop down to the local psychiatrist and get lobotomised 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 leucotome 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, practising on corpses. Watts co-operated, 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 brainsurgery. (Thank heavens the Kenwood Chef and Magimix had not yet been invented.) 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 economical with the truth. He did not dwell on his own lack of surgical experience. He anaesthetised 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 2in 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 practise 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 inwards, 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 weightlifting. 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 traumatised veterans back to join those still suffering from the effects of the First World War. In gratitude for their services, 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, amazing potential for controlling society's misfits, viz, schizophrenics, homosexuals, communists, etc (Freeman was always quick to seize on new selling points for his art) - he went to work.

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, generalised 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 lobotomised in the three years after he received the prize then in the previous 14 years. Nearly twice as many women as men were lobotomised. Freeman was very busy, and began to get quite fussy; he wanted to operate on patients within two years of their being institutionalised, 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 lobotomised 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 practise 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 lobotomised. 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 a 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. It was, furthermore, impossible to judge "recovery" in many; they were often so different. The inert, emotionless, inhuman quality of many lobotomised, 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 tranquillisers for schizophrenia and depression, was tested in France. It signalled 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 tranquilliser, Thorazine, could literally not make enough to slake popular thirst for the chemical. Most neurosurgeons and psychiatrists who had practised 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. On May 1972, after a brief battle with cancer, he died, aged 77.

No one now remembers the drill, the leucotome, and the ice pick with any sentiment other than sadness and remorse. There is no doubt that Freeman believed in the integrity of his methods and motives, but he is now seen as a principal architect of tragedy, not hope.

! Adapted from 'Medical Blunders', by Robert Youngson and Ian Schott, published on 15 April (Robinson, pounds 6.99).

! There is an exclusive pre-publication offer for 'Independent on Sunday' readers, who can buy the book for pounds 5.99, postage and packing free, from the following address: Medical Blunders Offer, Freepost LON 3335, London W8 4BR (no stamp required). Cheques should be made payable to Robinson Publishing. Allow 28 days for delivery (tel: 0171 938 3830 in the event of difficulties).

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