Bruised UK © 2006

He was bad, so they put an ice pick in his brain...

Elizabeth Day

Sunday January 13, 2008

making waves just one drop - Lobotomy

When Howard Dully met the man who was to change his life for ever, he was not sure what to make of him. He was 11 at the time and paid little attention to the mysterious adult world that surrounded him, to the decisions taken without his knowledge or to the profound impact that Dr Walter Freeman would have on his pre-adolescent existence. Instead, with a child's eye, he noticed the small physical quirks - the round-rimmed glasses, the dapper suit, the well-trimmed goatee. 'It made him look a little like a beatnik,' Dully says. 'He was warm, personable and easy to get along with. Was I fearful? No. I had no idea what he was going to do with me.'

Dully was a withdrawn boy who liked riding his bicycle and playing chess. He occasionally fought with his brother, disobeyed his parents and stole sweets from the kitchen cupboards. He had a weekly paper round and was saving up to buy a record player. According to Dr Freeman's meticulous records, Dully was 62 inches tall and weighed 6½ stone. He was an average child, perhaps a little unruly but nothing that would strike one as exceptional for a boy of his age.

But Howard Dully would soon become exceptional for all the wrong reasons. Barely two months after this first meeting, his father and stepmother had him admitted to a private hospital in his home town of San Jose, California. At 1.30pm on 16 December 1960, he was wheeled into an operating theatre and given a series of electric shocks to sedate him. That much he remembers. The rest is murky.

When Dully woke the next day, his eyes were swollen and bruised and he was running a high fever. He recalls a severe pain in his head and the discomfort of his hospital gown, which gaped open at the back. He had no idea what had happened. 'I was in a mental fog,' Dully says. 'I was like a zombie; I had no awareness of what Freeman had done.'

If Dully appeared superficially vacant or mildly aggressive, there were some obvious explanations. His mother died of cancer when he was five and his father, Rodney, later remarried to a 'cold and demanding' woman called Lou, who found her new stepson's natural ebullience and physical strength almost impossible to control. Relations between the two deteriorated so that Dully grew up in an atmosphere of emotional abuse and casual neglect. He was given regular beatings and forced to eat meals on his own. Increasingly convinced that there was something emotionally wrong with her stepson, Lou started consulting psychiatrists and mental health experts before eventually being referred to Dr Freeman, a renegade physician disowned by the mainstream establishment, who ran a private practice in Los Altos, just outside San Francisco. Freeman diagnosed Dully as a schizophrenic.

'He is clever at stealing, but always leaves something behind to show what he's done,' Freeman recorded in his notes from October 1960. 'If it's a banana, he throws the peel at the window; if it's a candy bar, he leaves the wrapper around some place... he does a good deal of daydreaming and when asked about it he says, "I don't know." He is defiant at times - "You tell me to do this and I'll do that." He has a vicious expression on his face some of the time.'

Discarded sweet wrappers, daydreaming spells and the odd glimpse of youthful defiance - it would appear to be a relatively innocuous list, but it was enough for Freeman. Eight weeks after the doctor first saw him, Dully came round from his operation in a state of numbed confusion. The hospital report stated that he had been given a 'transorbital lobotomy. A sharp instrument was thrust through the orbital roof on both sides and moved so as to sever the brain pathways in the frontal lobes'. Dr Freeman's bill came to $200. Dully was his youngest-ever patient; extraordinarily, he survived.

'People freak out when they realise the person they are talking to had a lobotomy,' he says now, 47 years later, sitting under the corrugated iron awning outside his trailer home on the outskirts of San Jose. 'They expect me to be drooling.'

Over the years, the lobotomy has become almost a caricature of itself, a cultural shorthand that immediately conjures up images of zombies or dribbling madmen. Even the word itself sounds freakish and unwieldy, like an ill-judged verbal joke. For most people, it remains indelibly associated with dramatic invention: with the dazed, incoherent character of Catherine in Tennessee Williams's Suddenly Last Summer or with Jack Nicholson's Oscar-winning performance as a deranged asylum inmate in One Flew Over the Cuckoo's Nest

But for a time in the 1930s and Forties, the procedure was at the forefront of neurosurgery, viewed by the medical establishment as a cutting-edge treatment for mental illness. Before the introduction of antipsychotic drugs or the popularisation of psychotherapy, the lobotomy was touted as a miracle cure for anything from schizophrenia to postnatal depression - and not just in the United States. Neurologists in the UK are estimated to have carried out 50,000 variants of the operation, until the late 1970s.

Derek Hutchinson, a 62-year-old grandfather, underwent a lobotomy in 1974 - without his consent, he says - at the hands of surgeon Arthur E Wall while a patient at the High Royds Asylum near Leeds. Unlike Dully, Hutchinson was awake throughout his operation, which a psychiatrist had insisted would curb his aggressive tendencies.

'What did it feel like?' he says from his home in Leeds. There is a long exhalation of breath on the end of the phone, halfway between a gasp and a sigh. 'It's a situation you should only go through once in your life and that's when you're dying. It felt like a broom handle was being pushed in my brain and my head was splitting apart.'

Originally developed by Portuguese physician Antonio Egas Moniz in 1936, the lobotomy involved drilling two small holes in either side of the forehead and severing the connecting tissue around the frontal lobes. The hope was to dull the symptoms of psychiatric illness by reducing the strength of emotional signals produced by the brain. Although Moniz won the Nobel Prize for his pioneering work in 1949, he insisted that it should only be used as a last resort, in cases where every other form of treatment had been unsuccessfully tried.

Dr Walter Freeman, a neurologist and Yale graduate, brought the procedure to America in the late 1930s. Freeman's first job after medical school was as head of laboratories at St Elizabeth's Hospital in Washington DC, a sprawling mental institution that housed 5,000 inmates in near-Victorian conditions. At the time, the state legislature paid a pitiful $2 a day per patient to cover their upkeep, a sum that included staff salaries, catering, accommodation and treatment.

Spurred on by his first-hand experience of the horrors of state-run mental institutions and determined to make his name as a medical pioneer, Freeman developed a version of Moniz's procedure that reached the frontal lobe tissue through the tear ducts. His transorbital lobotomy involved taking a kitchen ice pick, later refined into a more proficient instrument called a leucotome, and hammering it through the thin layer of skull in the corner of each eye socket. The pick would then be scrambled from side to side in order to damage the frontal lobe. The process took about 10 minutes and could be performed anywhere, without the assistance of a surgeon.

Over the years, Freeman developed a reckless enthusiasm for the operation, driving several thousand miles across the country to carry out demonstrations at asylums and hospitals. An instinctive showman, he sometimes ice-picked both eye sockets simultaneously, one with each hand. He had a buccaneering disregard for the usual medical formalities - he chewed gum while he operated and displayed impatience with what he called 'all that germ crap', routinely failing to sterilise his hands or wear rubber gloves. Despite a 14 per cent fatality rate, Freeman performed 3,439 lobotomies in his lifetime.

For the survivors, the outcomes varied wildly: some were crippled for life, others lived in a persistent vegetative state. Rose, John F Kennedy's sister, was operated on by Dr Freeman in 1941 at the request of her father. Born with mild learning difficulties, she was left incapacitated by the procedure and spent the rest of her life in various institutions, dying in 2005 at the age of 86. Yet occasionally, the operation appeared to have a calming, desensitising effect on the mentally ill. The lobotomy's mixed success rate was a symptom of its imprecision: it was a hit-and-miss procedure developed at a time when little was known about the very specific nature of the brain's structure.

Dully's almost total recovery is thus an anomaly. To look at him, you would never guess that he underwent such brutal surgery. There is no slowness of speech, no telltale squinting of the eyes, none of the lack of social inhibition that characterises most lobotomy survivors. Now 58, he has a full-time job training school bus drivers and has been married to Barbara for 12 years. He has a son, Rodney, 27, and a stepson, Justin, 30, and a tabby cat called Princess who prowls on a parched flowerbed while we talk. His autobiography, My Lobotomy, co-written with journalist Charles Fleming, was published in the US last autumn and will be published in the UK in March.

'I don't feel physically different from anyone else,' he says. 'I get eye infections because I think they destroyed my tear ducts. About the most unusual thing you would notice about me is my size.'

Dully is a broad, bulky man and 6ft 7in tall. When he turns on his laptop to show me photographs of his operation, his hand completely covers the computer mouse. The pictures are disturbing in their very matter-of-factness. Freeman was a fastidious archivist and insisted on recording each stage of the operation on camera. In one black-and-white image, Dully lies unconscious, his mouth lolling open. The tip of a 12cm long leucotome has been pushed deep into his eye socket. How does he feel when he sees these photographs?

'I would describe it as a feeling of loss, like you've lost a whole part of your life.' As he speaks, he gulps intermittently on a mug of milky instant coffee. 'I like hazelnut-flavoured cream in my coffee - it makes life worth living,' he says, grinning through an enormous walrus moustache. On the surface, at least, his life is settled, but it has taken Dully the best part of four decades to be able to speak with such ease about his past.

'It was something I didn't talk about for years. I felt that I was the secret, the skeleton in the closet, the dirty laundry.' That changed in 2003 when he was tracked down by an American radio production company and asked to make a documentary about his life. It was the first time he had seen his medical files and the first time he had found the courage to confront his past and speak to his father.

'Lou [his stepmother] had died in 2001, so a lot of what happened died with her. I asked my dad about it and I don't think he meant any harm. He said he got manipulated by Lou. She threatened him with divorce if he didn't go ahead with it. My dad said he only met Freeman once.'

Dully breaks off and leans back in his chair, arms folded across his black polo shirt. 'You meet a guy once and you're going to let him drive spikes in your son's head?' he asks, incredulously.

His father, now 83, has never apologised, but Dully remains astonishingly sanguine about the operation and the chequered legacy it left him. For years after the lobotomy, he was in and out of mental institutions, jails and halfway houses. He was homeless, drug-addicted and alcoholic, a petty criminal with little concept of how to live a normal life.

'I think I was angry at society for a long time, but I went through that and now I don't think there's any point in dwelling on it. I blame everyone for what happened including myself. I was a mean little ruffian. Lou was looking for a way to get me out of the house, for a solution to the problem, and Freeman was looking for a subject. Both of them came together... and whoopa-dee-doo.

'I don't think Freeman was evil. I think he was misguided. He tried to do what he thought was right, then he just couldn't give it up. That was the problem.'

In many ways, Walter Freeman was shaped as much by human frailty as his patients. Born in Philadelphia in 1895, he was driven from a young age to be exemplary, growing up in the long shadow cast by his grandfather, William Keen, an exceptional surgeon who was the first American successfully to remove a brain tumour. 'He was motivated partly by interest in the well-being of his patients and then also by this very urgent need to feel like he was someone who was accomplishing great things,' explains Jack El-Hai, author of The Lobotomist, a biography of Freeman. 'As he grew more personally attached to the lobotomy, he became more irrational.'

The more the mainstream medical establishment derided Freeman's methods - with the advent of Freudian psychoanalysis and antipsychotic drugs such as Thorazine in the mid-1950s the lobotomy fell out of favour - the more defensive Freeman became. He took pride in what he called 'shrink-baiting' and wrote disobliging limericks about his professional enemies, once saying he would 'rather be wrong than be boring'. By the time Freeman operated on Dully in 1960, he was working exclusively from a private practice - no state hospital would touch him.

Freeman's home life unravelled alongside his professional reputation. His wife, Marjorie, was an alcoholic and Freeman had numerous affairs. In 1946, Freeman had witnessed the horrific death of his 11-year-old son Keen on a camping holiday in Yosemite national park. Keen was bending down at the top of waterfall to fill up his flask when he lost his footing and was swept over the brink. It was an experience that must have affected Freeman greatly, although he made sparse mention of it in later life. But perhaps it was telling that, 14 years after the event, when he first met 11-year-old Howard Dully, Freeman suggested that the two of them should go hiking.

'My sense with Howard is that Freeman thought he was treating a family problem rather than just a boy's psychiatric problems,' says El-Hai. 'But by the standards he used in earlier years, what he did was completely unjustifiable.'

Although Freeman ended up causing unforgivable harm, he was not, essentially, a bad man. After he died of complications arising from an operation for cancer in 1972, his four surviving children - Walter, Frank, Paul and Lorne - became staunch defenders of their father's legacy. Two of them have carried on the familial medical heritage: Paul is a psychiatrist in San Francisco and the eldest, Walter Jnr, is now professor emeritus of neurobiology at the University of California.

Walter Jnr's twin, Frank, 80, is a retired security guard, living in a modest, second-floor apartment in San Carlos, just half an hour's drive from Howard Dully's home. He is a friendly giant of a man, dressed smartly in a double-breasted, dark blue suit and burgundy tie, kept in place by a thin gold clip. 'He was a marvellous father,' Frank says, sitting in a room filled with crossword dictionaries and Dick Francis novels. 'He loved his children and always made time for us out of his busy schedule, taking us camping every summer all across the country.'

Frank recalls being invited to observe a lobotomy when he was 21 and vividly remembers hearing 'a little crack as the orbital plate fractured. It only took about six or seven minutes and Dad kept up a running commentary.' Indeed, the original ice pick used for the first transorbital lobotomy came from the Freeman family kitchen drawer. 'We had several of them,' says Frank, cheerfully. 'We used to use them to punch holes in our belts when we got bigger. I'm enormously proud of my father. I do think he's been unfairly treated. He was an interventionist surgeon, a pioneer and that took guts.'

But however well-intentioned his interventions, Freeman's life-long quest for self-glorification meant that he failed to acknowledge when his methods were doing more harm than good. I ask Frank whether he thinks Freeman was justified in operating on the young Howard Dully, a boy on the brink of adolescence, whose brain had barely begun its transformation to maturity?

'Well...' he pauses, the palms of his hands resting on his knees. 'I've had a couple of chats with Howard [when Dully interviewed him for the 2003 radio broadcast] and he said that growing up, he hated his stepmother and she was afraid of him. He was belligerent and unco-operative, frightening if you like, and I'm convinced that if he'd gone on like that he would have ended up in jail or a mental institution. Frequently, people like Howard have a lobotomy and sooner or later they straighten out. Howard's been self-supporting for a number of years and he's married, in a very pleasant relationship.'

It is impossible to say how Dully's life would have panned out if he had not walked into Walter Freeman's office one long-ago autumn day. Perhaps it would, like Frank says, have been incalculably worse or perhaps it would have carried on much the same. But it could have been better, too, and the true sadness is that Howard Dully will never be able to find out one way or the other.

Mind-boggling: a history of lobotomy

1890: German scientist Friederich Golz experiments with removing the temporal lobe from dogs and reports a calming effect.

1892: Gottlieb Burkhardt, a Swiss physician, performs a similar operation on six schizophrenic patients. Four exhibited altered behaviour. Two died.

1936: Portuguese neuropsychiatrist Antonio Egas Moniz develops the leukotomy, but advises using the operation only as a last resort.

1945: American surgeon Walter Freeman develops the 'ice pick' lobotomy. Performed under local anaesthetic, it takes only a few minutes and involves driving the pick through the thin bone of the eye socket, then manipulating it to damage the prefrontal lobes.

1946: First lobotomy performed in Britain at Maryfield Hospital, Dundee. The procedure is used for 30 years.

1954: Antipsychotic drug Thorazine licensed for the treatment of schizophrenia, causing the lobotomy gradually to fall out of favour.

1960-70: Lobotomies come under scrutiny by sociologists who consider it a tool for 'psycho-civilising' society. They were banned in Germany, Japan and the Soviet Union. Limited psychosurgery for extreme medical cases is still practised in the UK, Finland, India, Sweden, Belgium and Spain.

Howard Dully's autobiography, My Lobotomy, co-written with journalist Charles Fleming, was published in the UK on the 6 March 2008.

The Sunday Times Magazine

The Sunday Times19 February 2006

Note: On the orignal website there was an image at this point, with the next line of text a description of the image.

Dr Walter Freeman performs a lobotomy in America in 1949 by driving an ice pick into the patient's eye socket

Investigation

Mental cruelty

The lobotomy is deemed one of the worst crimes in medical history. But a modern form of it is still practised in Britain - and may soon be performed without the patient's consent. By Christine Toomey and Steven Young

The flashbacks come late at night. First comes the recollection of intense physical pain, as if the bones in his arms are being snapped like twigs. Then he hears the voice of the neurosurgeon applying an electric current to metal pins implanted in the tissue of his brain. "How do you feel, Derek?" the surgeon Arthur E Wall asks, while peering into Derek Hutchinson's eyes to see if his pupils have yet dilated with fear.

When Hutchinson swears at the surgeon, Wall administers another electric shock to nerve centres located in the hypothalamus at the centre of his patient's brain. At this, Hutchinson's pupils dilate and he screams: "You're going to kill me, you bastard!" Hutchinson's medical records, written by Wall over 30 years ago, confirm that his patient "felt funny - as if he was dying". But as he screamed, Hutchinson recalls Wall leaning in close to his face and leering: "And I thought you were a bit of a tough guy."

His next recollection is of Wall giving orders for surgical implements to be passed. Hutchinson feels the metal pins inserted through nylon balls lodged in cavities bored into the front of his skull being replaced by thicker electrodes he says felt like "broom handles". "After that I started, I start to feel warm all over and quickly feel as if I have fallen into a vat of molten metal, as if I am, quite literally, frying," says Hutchinson, tellingly confusing tenses as he describes the brain surgery he underwent in 1974 yet still relives up to a dozen times a day and in frequent nightmares.

Throughout the surgery, Hutchinson was kept conscious; his head held in a brace, his hands and feet strapped to the operating table. Hutchinson, a 27-year-old father of three at the time of the operation, says he had not given his written consent to the operation being performed; neither had his wife - his next of kin. Instead his mother, an alcoholic, had been visited at home, in the late evening, after she had been drinking, and had been asked to sign the form. "My mother thought doctors were gods," Hutchinson says. "She'd have signed anything they asked."

Hutchinson's excruciatingly detailed recollections are a rare testimony of someone still lucid and intensely angry about a type of brain surgery to which he was subjected - he contends illegally - commonly referred to as a lobotomy. In strict medical terms, a lobotomy - or leucotomy, as the procedure became known in this country - involved the removal of part of the frontal lobes of the brain or the severing of neural fibres connecting the frontal lobes to the limbic system - the part of the brain concerned with emotional response and functions not under conscious control.

From the mid-1930s until the early 1960s this form of "psychosurgery" was heralded as a miracle cure for the mentally ill, before psychotherapy came into vogue and drugs to treat many mental-health problems became widely available. It was pioneered by a maverick Portuguese neurologist, Egas Moniz, who was awarded the Nobel prize in 1949 for developing and promoting the procedure. Lobotomies were seen as the solution to a wide range of mental disorders ranging from profound depression, schizophrenia and advanced neurosyphilis to mild retardation, at a time when half of all hospital beds in many countries were occupied by the mentally ill, and mental institutions were often places of humiliation and horror.

At the height of its popularity in the 1940s and 50s, particularly in the US, some of the most enthusiastic proponents of the procedure promoted it as a way of controlling large numbers of those considered society's worst misfits, including communists and homosexuals. Neurologists, not just in the US but in Japan, Britain and elsewhere, carried out variations of the procedure on tens of thousands of patients - an estimated 50,000 in the UK alone.

Little attention was paid to what happened to those subjected to lobotomies after surgery. John F Kennedy's temperamental sister Rose, who underwent the operation at the age of 23, for instance, spent the next 60 years of her life out of sight in a mental institution. Francis Farmer, the rebellious Hollywood actress and political activist whose outspoken behaviour was also "cured" by a lobotomy, quickly drifted into oblivion and ended her days as a hotel clerk.

But as the number of lives wrecked by such surgery became more widely known, its effect was gradually exposed - most famously in Milos Forman's 1975 film, One Flew over the Cuckoo's Nest. But also earlier, in the 1958 play Suddenly Last Summer, by Tennessee Williams. A close friend of Williams, whose sister Rose was lobotomised as a teenager, recalls how the playwright talked of his sister as "fragile and gentle", someone hurt by "the harshness of life".

"Things alarmed Miss Rose that would not even be noticed by someone less sensitive. She was just awakening to sexuality and knew almost nothing about it Rose came home from school one day and said the nuns were using altar candles for self-abuse. She told mother this," the playwright once confided to his biographer Dotson Rader. To the siblings' mother, known even to her children as "Miss Edwina", human sexuality was "the great unmentionable". She promptly took her daughter to the doctor, demanding the "filth" be cut out of her brain: "Cut it away! Miss Edwina ordered. "Make it clean!" "And he did," recalled the playwright, who said his mother never showed any remorse about reducing her daughter to a human vegetable.

Some now consider such practices to be among the most egregious medical crimes of the last century and have called for Moniz, who was later shot in the back by a dissatisfied patient, to be posthumously stripped of his Nobel prize. The Nobel Foundation rules this out, maintaining that all of its awards can be justified within the historical context that they are given.

By the time Hutchinson had his operation in 1974, the scale on which psychosurgery was being performed was drastically reduced, with more and more mental disorders being treated with drugs and psychotherapy. Crude frontal lobotomies, of the type Moniz promoted, had been phased out. Surgery became targeted at more specific parts of the brain as the neurobiology of emotion became better understood. The surgery performed by Wall on Hutchinson's hypothalamus, for instance, was intended to curb his aggression.

Since then, psychosurgery has become even more refined, the parts of the brain targeted and destroyed to control behaviour ever smaller. Though the name lobotomy persists, the medical profession now refers to any such procedure as NMD (neurosurgery for mental disorder). But Britain is now one of the few countries where this sort of surgery is still permitted. Even here it is only performed for persistent severe depression and anxiety and obsessive-compulsive disorder (OCD) in two places: University Hospital of Wales in Cardiff, and Ninewells hospital, Dundee. Patients must consent to the surgery and ethical and clinical standards committees subject each case to rigid scrutiny before it goes ahead.

If the worst excesses are in the past, the type of surgery now conducted so controlled and the numbers to whom it is given severely limited, some might argue that the subject of lobotomies, psychosurgery, NMD - call it what you will - is only of historical interest. They would be wrong.

In the coming month, parliament is expected to finally debate another hotly contested piece of proposed legislation: the draft Mental Health Bill (2004), which many mental-health experts fear will reduce safeguards for the mentally ill. One provision of the bill is a little-noticed clause that, if passed onto the statute books, would allow doctors to perform NMD without a patient's consent if they were considered so mentally ill they were incapable of giving it.

No matter how refined these latest NMD techniques are, nor how vociferously neurosurgeons who practise it argue it is nowadays employed only as a last resort, its outcome is often unpredictable. Since it is irreversible, some believe it should be banned. At the very least it should only be conducted on those able to give their informed consent, argue campaigners such as the mental-health charity Mind and the Mental Health Alliance, which includes such bodies as the Royal College of Nursing, the Royal College of Psychiatrists, the Law Society and dozens of other organisations in the field of mental health.

With many of those who have undergone such surgery unable to speak for themselves and few of those subjected to the cruder forms of surgery still alive, Derek Hutchinson's is the rare voice of experience. His story serves as a chilling reinforcement of the adage that a society be judged by the way it treats its most vulnerable. With the government proposing legislation that many believe would turn the clock back on the way we treat the mentally ill, what does that say about modern Britain?

As Hutchinson sits talking in the cramped living room of his small terrace house in Leeds, he frequently stretches out his arms to hug his two-year-old grandson, one of 17 grandchildren. While the boy giggles with delight, Hutchinson, 59, talks a little of his own childhood. He recalls how his mother would often lock him, the middle of three brothers, in a coal shed overnight. "Glass were all broken. I'd have to sleep in coal sack, night after night. It went on for years," he says. But he prefers not to dwell on it. "That's all done now, in the past."

On his own admission, Hutchinson grew into a troubled youngster. Though he channelled his aggression into amateur boxing and other sports, he was, he admits, "always in trouble as a lad" and would often get into fights. After a spate of joyriding cars as a teenager, he was sent to a series of borstal schools, then remand homes. Eventually he found work as a welder, married and had three children. When he was 27, however, he suffered a nervous breakdown. After being admitted to a psychiatric hospital, he was given ECT (electroconvulsive therapy) and prescribed strong sedatives. His psychiatrist then recommended that he undergo psychosurgery.

According to Hutchinson, the psychiatrist tried to persuade him such surgery was necessary to curb his aggressive tendencies after asking him how he would feel if Hutchinson were ever to kill one of his own children. "I'd never harmed any of my children. I never would. But when he put it like that, I was scared." Still, Hutchinson was considered incapable of giving consent, as ?he was so heavily sedated. At first his wife agreed to the operation. But after seeing the sizable holes that had been drilled into her husband's skull in preparation for the second part of the operation a week later, she withdrew her consent. It was then that his mother was approached.

In a 1976 TV documentary on the same operation as Hutchinson underwent, being performed on a mother-of-five called Margaret Chapman, the neurosurgeon Wall, who has since died, describes the operation as "quite simple, really". He then casually admits knowledge of psychiatry is "something you pick up as you go along". But far from curing Hutchinson's aggression, which he describes as "within his control" before the operation, the surgery he underwent left him so traumatised that he walked out on his first wife, Ruth, who had recently given birth to twins, fearing he might do his children harm. He subsequently attempted to physically attack the psychiatrist who had referred him to Wall, and several years later tried to commit suicide. Though he eventually resumed work and remarried, he has suffered vivid flashbacks of the operation ever since, and in recent years has been diagnosed as suffering from post-traumatic stress disorder.

However troubling Hutchinson's story is, it is by no means the result of the most cavalier practitioner of psychosurgery in this country. The neurosurgeon reputed to have been Britain's most prolific lobotomist was the former president of the Society of British Neurological Surgeons (SBNS), Sir Wylie McKissock, based at Atkinson Morley's hospital in Wimbledon in the late 1940s and 50s. McKissock is described by those who knew him as a taciturn and difficult man, much feared by his junior staff. He rarely spoke to or met patients before or after surgery. Instead, at weekends, he made regular tours of nursing homes and mental hospitals along the Sussex coast. With the aid of a theatre sister, he would perform, for cash, up to 10 a day of the crude frontal lobotomies pioneered by Moniz. McKissock is understood to have performed around 2,000 such operations.

Few records exist of the reasons they were performed or their outcome; but a 1949 study of 300 of McKissock's lobotomy patients recorded that 16 had died as a direct or indirect result of the operation. It is impossible, therefore, to assess how many of these operations were performed needlessly. But the experience of those such as Hutchinson, and the accounts of relatives of others who underwent earlier forms of psychosurgery, attest to it having been performed for flimsy reasons and to disastrous effect by some British surgeons, just as it was in the US.

One such case is that of Ronald Shaw, whose brother Raymond, a 69-year-old retired painter and decorator from Liverpool, describes as "a very, very clever lad" when he was younger. "He was very good at art. He loved to draw cartoons. Our father was a sign writer and he sent some of Ron's cartoons to a London newspaper when we were still teenagers," Raymond recalls of his elder brother. "They wanted Ron to draw more and were going to pay him quite well. But he suffered with his nerves. He never did it."

When Ronald was in his early teens, his brother remembers he started coming home from school crying and would often wake up screaming in the night. The boy was admitted to hospital and given ECT. It failed to help. "Years later, we discovered, through another boy who was at school with Ron, that there was a teacher who used to regularly take my brother into a back room to cane him. Who knows what else he did to him in that room. I believe now that it was this bullying that caused my brother to behave the way he did."

When he was 17, Ronald volunteered to join the army, but within a year was discharged with a knee injury. In 1955, when Raymond was stationed in the Far East, completing his national service, his brother was admitted to Rainhill hospital in the St Helens district of Liverpool and a frontal lobotomy was performed. "I knew nothing about it. When I came back from the Far East, my brother was destroyed. He did not talk for two years. Eventually he started to speak, but he was never the same again. He was never able to work. My parents spent the rest of their lives looking after him. Their lives were ruined too. After they died he lived alone, though I took him out as much as I could."

Ronald Shaw died last year. His partially skeletal body was found in a field months later. His brother believes he was trying to walk to the Marble Church in Holywell, which had always fascinated him, when he stopped for a rest and died of natural causes. His body had been run over by a tractor after his death and his remains were surrounded by diaries he kept of his daily activities. "I'd been driving all over the country looking for him for months. Then the police called, saying they'd found a body with holes drilled in the front of his skull and I knew it was Ron," says Raymond, his voice cracking. "It's unforgivable what was done to him."

Supporters of modern-day psychosurgery, or NMD, argue it has moved light years from the notorious excesses of such early practices. Yet even the crudest operations, they stress, were effective in alleviating the mental suffering of some patients. One former president of Ireland's Royal College of Surgeons, who is believed to be one of the few surviving neurosurgeons to have carried out the conventional frontal lobotomy on a regular basis, sits sipping a gin and tonic as he demonstrates with a cake knife how he used to sever or core out part of the frontal lobes of his patients to break the nerve "circuits" believed responsible for mental illness. He carried out two operations every Saturday morning, at the request of the Irish Department of Health, for nearly 10 years until 1960.

Immaculately dressed in a tweed suit, he recalls how the operation helped one vet obsessed with a fear of constipation who ate fruit constantly and spent all day in the toilet. After the operation he was able to return to work. He also talks of performing lobotomies on more than 20 priests with perceived personality disorders. But, he says, in his experience the surgery did more to help those who were returned to closed orders rather than allowed to return to the community. Lobotomies, he says, did little to help those with schizophrenia, neurosyphilis or personality disorders other than obsessive-compulsive disorder and severe depression.

Those forms of NMD still being conducted in this country today are targeted at the treatment of severe depression, severe anxiety and OCD. These procedures, which involve minute destructive lesions in parts of the frontal lobe or limbic system, are known as cingulotomies - the cingulum being the part of the frontal lobe associated with OCD - and capsulotomies, which involve making lesions in the capsules: the dense nerve-fibre pathway connecting part of the frontal lobe with the limbic structure. Neurosurgeons at Ninewells hospital in Dundee, for instance, carried out 34 NMD operations between 1990 and 2001. In the past year the hospital has conducted five such operations on patients it describes as "among the most severely ill and disabled who come into contact with any branch of the medical professions". Surgeons at the University Hospital of Wales in Cardiff have conducted 56 NMD operations in the past decade. It was there that the former child singing star Lena Zavaroni, who suffered from anorexia, underwent such surgery in 1999 for severe depression. Though the operation seemed to have been a success, she died of pneumonia less than a month later. According to Brian Simpson, consultant neurosurgeon at Cardiff, the operations his team have conducted have led to a "marked improvement" in roughly half of those being treated for severe depression and OCD. "NMD is not a panacea," Simpson agrees. "It is carefully regulated and only offered to patients for whom all other treatments have failed But in the patients for whom it works well, whose suffering has been indescribable, it transforms their lives."

Some believe the way ahead lies in other forms of brain surgery, such as deep brain stimulation with implantable electrodes, as are increasingly used to treat Parkinson's disease. This they believe could offer an alternative to the ablative operations that have been used to date in psychosurgery. The introduction of modified stem cells into certain parts of the brain has also already had experimental success in treating some neurological conditions and holds out hope for combating psychiatric disease. But it is the irreversible nature of the NMD still practised that concerns opponents. That this type of surgery could be carried out without a patient's consent, according to the proposed legislation, they reject outright. Under the current Mental Health Act of 1983, three independent people, one a doctor, has to certify that any patient undergoing psychosurgery understands the treatment and consents to it. The draft mental-health bill under consideration has broadly the same safeguards for those capable of giving consent. The main difference is that it allows for treatment to be given without the patient's consent, at the request of doctors and on an order of the High Court, providing three conditions are met. The first is if it can be verified that a patient does not have the capacity to consent. The second is if there is no reasonable prospect of them regaining this capacity, and the third is if they are "unlikely to resist treatment".

According to Richard Brook, former chief executive of the mental-health charity Mind, one of the biggest concerns of those who work in mental health is that no leading study has properly assessed the effect of psychosurgery on an individual's personality or sought the views of those undergoing such treatment. "Because of its hazards and the lack of clear evidence for the treatment's benefit, or basis for predicting success in the individual concerned, we believe it should never be given to someone who doesn't have the capacity to consent to it," says Brook.

Doctors at Ninewells hospital in Dundee argue that the lack of a randomised control trial to support NMD applies equally to a range of "cutting edge" medical and surgical procedures. Brian Simpson says that although he appreciates there may be an "understandable fear of returning to the bad old days of lobotomy", he believes it is "not unreasonable in certain circumstances and with adequate legal safeguards" to perform NMD without a patient's consent. "The issue of consent is sensitive and crucially important," warns Simpson, adding that "the more you open it up in this way, the more crucial it becomes to have adequate legal safeguards".

But Christine Johnson, who is behind moves to launch a legal campaign in the US to have Moniz's Nobel prize revoked, believes that there are even wider issues at stake. Johnson's own grandmother was left to languish in a psychiatric institution for 20 years after undergoing a lobotomy. As a result, the medical librarian ?from Levittown, New York state, founded an organisation called Psychosurgery.org, dedicated to the "surgical casualties" of such procedures. "There are a lot of important lessons to be learnt from what happened to our family members," says Johnson.

Many families of those suffering from Alzheimer's disease, she stresses, are now clamouring to have experimental brain surgery performed on them. "But there is a real ethical question about whether you can really do these kind of things to someone who is by definition having problems making decisions. I really hope people will take into consideration the amount of damage that was done in the past when they attempt to push forward with such treatments," Johnson concludes.

Derek Hutchinson has recently tried to sue his local health authority for medical malpractice, but has had to give up because his surgery was carried out so long ago that the statute of limitations on such a claim has expired. West Yorkshire police are now investigating if there is a criminal case to answer over a lack of proper legal consent having been obtained.

Such thoughts are far from his mind, however, as Hutchinson drives me back to the train station in Leeds, warning me that he might have to pull over to the side of the road at any moment because his lobotomy has also left ?him with narcolepsy. Throughout the journey, he talks affectionately about his brood of grandchildren. But by the time we reach the station, he has lapsed into melancholia and tears well in his eyes as he talks about how his own children's lives were damaged when he abandoned them after his operation.

"If nothing else, I want people to understand what these bastards did to me, and thousands of others, so nothing like this is ever allowed to happen again," he says, clutching the steering wheel until his knuckles go white. "What they did was not treatment - it was torture."

Steven Young is consultant neurosurgeon at the Beaumont hospital in Dublin

THE ORIGINS OF MIND-ALTERING SURGERY

Egas Moniz could have afforded to rest on his laurels by the time he attended the Second World Congress of Neurology in London in 1935. The 61-year-old professor of neurology, and dean of Lisbon's Medical School, had already gained an international reputation for pioneering cerebral angiography - a radiological technique for mapping brain vessels. But Moniz was disappointed that this had not won him the Nobel prize. So when he heard two Yale neurologists speak at the London congress about experimental brain research on two chimpanzees called Clyde and Becky, observing how Becky's temper tantrums subsided after surgery, he would go on to pioneer - and relentlessly promote - a procedure that eventually won him the coveted Nobel prize.

The procedure was the lobotomy. Back in Lisbon he ordered that a human brain be brought to him from a morgue, and thrusted a pen through the cortex several times until he was satisfied he knew the approximate angle and depth that would best detach the frontal lobes. He performed the operation on a former prostitute, who afterwards was unable to give her age or say where she was. She was returned to an asylum, never to be seen by him again.

Moniz nonetheless considered this a "clinical cure" and continued operating. The procedure was greeted with enthusiasm by the medical profession and went on to be practised in many countries. After Moniz won the Nobel prize in 1949, the lobotomy's popularity increased. But today many believe the procedure is barbaric, and are campaigning for him to be stripped of the award.

The Nobel Foundation contends that Moniz's prize should be judged in the historical context of a period when there was widespread despair about mental-health treatment. In the 1930s and 40s, patients were often beaten, choked, spat on and humiliated by attendants in state hospitals, where the average duration of confinement was 10 years. Cost was also a factor. In the mid-1930s a lobotomy cost $250 in the US, compared with tens of thousands of dollars to keep a patient incarcerated. The drawback of the operation - that it robbed patients of their personality traits - was considered a small price for emptying hospital beds.

If Moniz brought the lobotomy fame, then the US physician Walter Freeman brought it infamy. A tireless self-publicist, he would perform his variation of Moniz's operation - the "ice pick" lobotomy - before an enthralled audience. This involved driving an ice-pick-like instrument through the roof of the eye and sweeping it across the frontal lobe to scramble neural connections. Freeman once boasted he was "as good as Frank Sinatra" in getting young people to faint at the sight of what he did. One of his patients, Howard Dulley, was 12 when he was lobotomised because his stepmother said he was sullen and refused to bathe.

It was not until the mid-1950s, with the advent of antipsychotic and pacifying drugs such as chlorpromazine, that the lobotomy began to fall out of favour.

The role of psychosurgery came under greater scrutiny in the 1960s and 70s, when social unrest led some sociobiologists to consider it a tool for addressing violence and "psycho-civilising" society through the use of implantable brain electrodes.

Despite growing unease, more refined procedures such as cingulotomies were developed and the modern era of psychosurgery was born. Such procedures remain controversial and have been banned in Germany, Japan and a number of US states. They are still practised in the UK, Finland, India, Sweden, Belgium and Spain.

First proof of the benefits of lobotomy

New survey supports drastic neurosurgery

By Sarah-Kate Templeton, Health Editor

MOST patients given lobotomies at a Scottish hospital made a remarkable recovery, according to the first report into the outcome of their treatment.

The patients suffered from severe depression and many had been in hospital for years. But after the controversial operation, called neurosurgery for mental disorder (NMD), eight of the 14 patients treated could leave hospital and live on their own. Details of the patients' dramatic improvement come as British psychiatrists have called for a moratorium on the treatment.

Professor Keith Matthews, a consultant psychiatrist and director of the Dundee Neurosurgery for Mental Disorder Programme at Ninewells, said: Some of these people had not left hospital for between three and seven years. Often they were in intensive care and needed nurses with them all the time. They are now living independently. Even better, they are out and about and some of them are picking up their careers. Some people do extremely well.

Matthews added that while it is important to recognise that neurosurgery for mental disorder does not help everyone, it has transformed the lives of some severely depressed patients.

Clearly, this surgery isn't fabulous for everyone but it does help some people. If you have people moving from being chronically depressed, hospitalised and needing 24-hour nursing to independent living then that is really dramatic. Given how much neurosurgery for mental disorder has helped these people, I do not think it should be allowed to die out.

Neurosurgery for mental disorder involves using a laser to destroy a tiny part of the brain. The irreversible procedure is carried out on patients suffering from severe depression or obsessive compulsive disorders . It is similar to lobotomy operations performed in the 1940s and 1950s which involved severing the frontal lobes of the brain.

Matthews and Sam Eljamel, consultant neurosurgeon at Ninewells, publish the first information on the outcome of patients treated at the Dundee NMD unit in a biennial report to the Scottish Executive. Since 1990, neurosurgery for mental disorder has been carried out on 37 patients at the Scottish unit. NMD is only performed at two units in the UK, one in Dundee and one in Cardiff. Patients travel to the Dundee centre from England and Ireland as well as from around Scotland.

The study includes 14 patients whom doctors were able to assess 12 months after the operation. Eight managed to leave long-term hospitalisation and live independently . One of the eight did relapse and was awaiting further neuro surgery. Of the other six, three experienced no change and one reported no improvement but was living independently. One patient is still depressed but now responds to electroconvulsive therapy (ECT) and another is able to ignore obsessional thoughts.

The report said: Despite collecting data systematically on potential adverse effects we remain struck by the relative lack of evidence for these.

However, the Scottish Association of Mental Health (SAMH) points out that the long-term risks of neurosurgery are still not known.

Richard Norris, SAMH director of policy, said: What this report indicates is that some people have made a recovery by having neurosurgery for mental disorder. Clearly, it doesn't work for everyone. What needs to be looked at is the longer-term side effects. This does need to be thoroughly researched.

Critics claim patients lose other emotions after neurosurgery. In the September issue of the British Journal of Psychiatry, Dr Raj Persaud, consultant psychiatrist at the Maudsley Hospital in London, calls for an end to the procedure. He writes: There are several reasons why our profession should place a moratorium on neurosurgery for psychological problems until further notice.

First there has never been a prospective, randomised double-blind placebo- controlled trial of any psychosurgical procedure, and none is likely.

He adds: Perhaps most importantly, psychosurgery is based on a flawed and impoverished vision of the relationship between brain tissue and psychological disorder. It is unlikely that any psychiatric problem can be located in one so-called abnormal' brain region.

12 October 2003

Bruised UK