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 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.