Part I: the surgeon

By the late 1950s an estimated 20,000 leucotomies had been carried out in Britain. A few were performed by general surgeons, a few by psychiatrists, but the vast majority were performed by neurosurgeons. And of these neurosurgeons Sir Wylie McKissock (1906-1994) was probably the most prolific, responsible for at least 3,000 leucotomies.
McKissock, who in spite of his Scottish name hailed from Staines in Surrey, is remembered for his achievements in neurosurgery including the treatment of head injuries (he received an OBE for his wartime work) and the treatment of subarachnoid haemorrhages and intracranial aneurysms; and for setting up the world-famous Atkinson Morley’s neurological service. He became President of the Society of British Neurosurgeons and received a knighthood on his retirement in 1971. But his contributions to British psychosurgery seem to have been quietly forgotten.
When McKissock died in 1994, obituaries in the The Times and The Independent newspapers made no mention of psychosurgery. Other tributes were likewise reticent on the subject. For example, psychosurgery was entirely absent from an 800 word article in the Journal of Surgical Neurology in 1988 even though the author Alan Richardson was himself a practitioner of psychosurgery, and a ten page reminiscence in the British Journal of Neurosurgery two years after McKissock’s death containes only the following brief reference to psychosurgery:

“His links to psychiatry were related to his large practice in the 1940s and 1950s as a leucotomist of extraordinary surgical speed, associated with a peripatetic service visiting major institutions in the UK in his motor car with the instrument set in the boot”.

These expeditions in his motor car took McKissock all over the South of England and Wales; among his destinations were St Andrews in Northampton, Graylingwell in Chichester, St Lawrence’s in Caterham, Pen-y-Val in Abergavenny. The institutions (many of them Victorian Asylums) were often situated in pleasant rural locations and in those days the roads were comparatively empty. A visit from a well-known neurosurgeon would have been quite an event and doubtless the red carpet was laid out for McKissock. The operations themselves were quickly done - 15 to 30 minutes each - and so all-in-all these excursions must have been a reasonably agreeable way for McKissock to supplement his income.
Why did McKissock travel round the country rather than having the patients brought to his neurosurgical unit? In the early days of psychosurgery he claimed it was “owing to the extremely unpleasant and dangerous habits of the unfortunates who have been submitted to me for operation, and to the lack of proper facilities for dealing with the habits of such patients in my own neurosurgical unit.” By the 1950s he had become more circumspect, claiming instead it was out of consideration for patients who could be treated in familiar surroundings and receive visits from relatives.
McKissock doesn’t seem to have troubled himself much over the ethics of psychosurgery, although his excursions sometimes resulted in death or disability (some patients were left in what McKissock himself described as a “harmless vegetable state”). What little he wrote on the subject of psychosurgery is largely confined to notes on technique. He admitted that the operation was “academically and scientifically unsound” but felt it was justified if the “experienced psychiatrists” who selected patients felt there was no chance of a cure with other methods of treatment or a spontaneous recovery.
In the early years of his career as a psychosurgeon McKissock used the standard Freeman-Watts technique of leucotomy, drilling two burr holes in the side of his patients’ skulls and severing the connections to the frontal lobes. He was scornful of specially designed leucotomes, referring to John Crumbie’s as a “mechanical egg-whisk” and preferring to operate with an ordinary brain needle. In the late 1940s, as psychosurgeons were experimenting with different techniques in an attempt to avoid some of the complications and devastating effects on personality associated with the standard leucotomy, McKissock devised the “rostral leucotomy” in which holes were drilled in the top of the skull and the cut made in a downwards direction, undercutting Brodmann’s areas 9 and 10 of the frontal cortex. Neuropathologists commented that the resulting lesion was similar to that of Freeman’s transorbital leucotomy although McKissock approached from the opposite direction to Freeman. McKissock had little time for Freeman’s transorbital operation, considering it an offence against “established aseptic surgical principles”. The rostral leucotomy did not however entirely replace the standard procedure; even at the end of the 1950s McKissock was still using the standard technique on a minority of patients.
The last sighting of McKissock in the literature is an appearance at the November 1958 meeting of the Neurological Section of the Royal Society of Medicine where he talked about having performed 125 rostral and 19 standard leucotomies the previous year.

Last week, as Kitty Dukakis (twenty-six year amphetamine habit from the age of twenty; then some problems with alcohol and depression; in recent years a few short courses of unilateral ECT) was promoting the book (Shock: the healing power of electroconvulsive therapy) she has written with journalist Larry Tye, an altogether darker story of ECT emerged from the Appellate Division of the Supreme Court of New York.
Simone D, a Spanish-speaking woman, has been a resident of Creedmore Psychiatric Hospital for twelve years. Over this period she has received several courses of ECT (a total of 148 treatments) under court order. One course in 1996 was stopped because of the damage it was doing, but the courts continued to authorize further treatments even though there appears to be little hope that Simone will ever recover sufficiently to leave hospital or be allowed to make her own decisions about treatment. On this occasion the court voted, by a three to two majority, not to allow an appeal against the latest permission to administer ECT. One of the two dissenting judges had this to say:

“Simone D. was first admitted to Creedmoor Psychiatric Center in 1994 and suffers from a severe depressive disorder. Since 1995, she has undergone, over her objection but pursuant to previous court orders, at least 148 ECT treatments. Prior efforts to help her with medication failed to improve her condition. After two unsuccessful applications in July and September 2005 for permission to administer ECT to Simone D., the petitioner applied again in November 2005. The petition and supporting papers showed that without ECT Simone D. becomes depressed, stops eating and drinking, and requires nasogastric tube feeding. Allegedly, the ECT will diminish her assaultive behavior, enable her to eat, enhance self-care, and promote her ability to socialize. At a hearing on the petition, the court rejected the request of Simone D.’s counsel that it appoint an independent psychiatrist. The petitioner called one of its psychiatrists, Dr. Ella Brodsky, who opined that Simone D. lacked the capacity to make a reasoned treatment decision and that ECT is the least restrictive alternative because there is no other choice…” Read more

Last Thursday, ABC’s Primetime broadcast a report about DBS (Deep Brain Stimulation) at the Cleveland Clinic, Ohio. It featured neurosurgeon Ali Rezai and his patient Cindy Warren, who will already be familiar to viewers of the Pittsburgh Channel and readers of The Plain Dealer. Also appearing were Florida neurosurgeon Kelly Foote and his patient “Kelly”.

Emotions Via Remote Control
However, generating emotions in the operating room is not the true test of this medical trial. That comes later, when Cindy and Kelly head to their psychiatrists’ offices to have the electrodes turned on in such a way that will, they hope, alleviate some of their symptoms. It means they will need permanent pacemakers to power the signals, too.
Using a handheld device that looks similar to a TV remote, Malone [psychiatrist Donald Malone] adjusts the voltage on Cindy’s pacemaker.
“I can actually get to the point where I feel like laughing. I feel kind of giddy, tingly,” she said.
Malone said he’s aware of the power he holds in his hands. “It’s humbling,” he said. “And scary.”
And, amazingly, it’s also a mystery as to why deep-brain stimulation works. But scientists theorize that the electrical currents emanating from the implanted wires scramble the old neural pathways that carried Cindy’s depressive thoughts and patterns. Read more…

Well, something at least has not changed much in seventy years of psychosurgery. Egas Moniz theorized in a very similar sort of way.

The Cleveland Clinic used to perform ablative psychosurgery until a patient successfully sued them four years ago:

Failure to obtain informed consent for experimental surgery
Verdict for a woman who suffered brain damage and a brain infection after undergoing brain surgery. She and her husband sued the hospital, alleging battery, fraud, and medical negligence. Among other things, plaintiffs claimed that the treating surgeon had performed a combined cingulotomy and capsulotomy-the latter a procedure that was unconsented to and experimental in nature. Plaintiffs were represented by *Robert F. Linton Jr., *Mark W. Ruf, and Stephen T. Keefe Jr., all of Cleveland, Ohio.
Zimmerman v. Cleveland Clinic Found., Ohio, Cuyahoga County C.C.P., No. 399411, June 12,2002.

Lobotomy came to Britain via the United States and in the early days most of the operations were of the Freeman-Watts standard type, where burr holes are made in the side of the temples, and an instrument inserted and pivoted up and down to slice through the white matter in the frontal lobes, thus severing the fronto-thalamic connections. British surgeons however didn’t adopt Freeman’s term “lobotomy”, preferring to use Moniz’ original term “leucotomy”.
British surgeons soon began experimenting with modified procedures in an attempt to find an operation that would do less damage than the standard Freeman-Watts standard prefrontal operations. In the 1940s Hugh Cairns in Oxford, for example, experimented with cingulotomy (an operation that is still used in Scotland) while the peripatetic Wylie McKissock devised the rostral leucotomy. But Freeman’s own particular modification, the transorbital lobotomy in which an instrument is inserted through the eye socket, never became popular in Britain perhaps because it dispensed with the need for a neurosurgeon and neurosurgeons in Britain had already gained control of psychosurgery. Wylie McKissock certainly wasn’t going to relinquish his profitable week-end excursions into the English and Welsh countryside: “Freeman’s latest development of transorbital leucotomy”, McKissock wrote, “is mentioned only to be condemned: the whole technique offends established aseptic surgical principles”. What is more, he questioned its effectiveness: “From the number of patients so leucotomised who have come to me for more extensive operations, the results do not appear very satisfactory.” Wylie McKissock’s own rostral leucotomy was designed to cut much the same area of white matter as the transorbital operation, but McKissock approached from above through burr holes in the top of the head, while Freeman approached from below via the eye socket, where the skull is thin enough for the instrument to be hammered through without the need for a drill or a neurosurgeon.
There were, however, a few psychiatrists in Britain who experimented with transorbital lobotomy. John Walsh at Tone Vale Hospital in Taunton, Somerset, operated on eight women in 1949, even on three occasions following Freeman’s example and using electroconvulsive shock as anaesthetic. On one of these occasions the operation was given as a demonstration at a meeting of the south-western division of the Royal Medico-Psychological Association. Walsh was disappointed with the results, finding “no definite clinical improvements” in any of the patients.
Meanwhile, in Napsbury Hospital near St Albans, Hertfordshire, more extensive experiments with transorbital lobotomy were being carried out by psychiatrist Alan Edwards. Napsbury was one of the three “Middlesex in Hertfordshire” county asylums, opened in 1905 to house the pauper lunatics of Middlesex, where suitable sites with sufficient grounds to provide inmates with work, exercise, and recreation were in short supply due to the urban nature of the county (Middlesex now forms part of London). During the first World War, Napsbury became a war hospital; poet and musician Ivor Gurney stayed there briefly. During the 1930s cat artist Louis Wain spent the last years of his life in Napsbury. The hospital closed in 1999.
Alan Edwards operated on seventy-one patients between February 1949 and February 1950, following the Freeman’s technique (although Edwards baulked at using electronvulsive shock as an anaesthetic, preferring intravenous pentothal). Edwards found that the operation was only one third as effective as a standard leucotomy, two-thirds when he adopted Freeman’s “full frontal sweep”.