Pioneers of psychosurgery in the UK
The first leucotomies in the UK were carried out at the Burden Neurological Institute in Bristol and were a collaboration between Frederick Golla, director of the Burden Neurological Institute, Effie Hutton, clinical director of the Burden Neurological Institute, surgeon F. Wilfred Willway, and the medical superintendents of Barnwood House in"The operation was carried out with the primary object of relieving the most disturbed patients in the hospital quite independently of their poor prognosis. They formed a large proportion of the most violent, hostile, noisy, excited, destructive or obscene cases in the hospital; the type who distress their relatives, upset the other patients and consume the time and energy which could be put to so much better purpose by the staff".Two died of cerebral haemorrhage, two were discharged (of whom one relapsed); of those remaining in hospital two-thirds had shown at least some improvement, needing less staff time and supervision.
Crudely described the purpose of the operation is to break the connection between the patient’s thoughts and his emotions. It is to relieve the connection between the patient’s thoughts and his emotions. It is to relieve mental tension, to take the sting out of experience and thus to favour improvement or to hasten recovery from mental disorder.Risks were listed as death due to cerebral haemorrhage or infection; epilepsy; and personality changes. A text book of the day went into more detail about personality changes, suggesting that they always occurred to greater or lesser extent and left the patient with diminished judgement, childish behaviour, carelessness, loss of ambition, and generally living at a lower level than previously. There was also the possibility of intellectual deterioration.C Allen 1949 (2nd edition, 1st edition 1937) ''Modern discoveries in medical psychology''. MacMillan: 227. Overall in the Board of Control survey six per cent of patients had died (half of them directly as a result of the operation); 36 per cent had left hospital and 58 per cent remained in hospital (often described as quieter or easier to nurse). Patients who were depressed and had not been ill for long were much more likely to have left hospital than those who had a schizophrenic illness and had been in hospital longer.
Advances in surgical technique
Beginning in the early 1940s, psychiatrists and surgeons experimented with different techniques of psychosurgery, mainly in order to reduce the risk of death, complications and severe personality damage associated with the operation and thus extend its use to depressed and neurotic patients.Transorbital leucotomy
Transorbital leucotomy (transorbital lobotomy in the US) was a technique invented by Italian psychiatrist Amarro Fiamberti and taken up by American neurologist Walter Freeman, with whose name it is particularly associated. Instead of holes being drilled in the skull, a sharp instrument was hammered through the roof of the eye-socket (the orbital plate) and then swung through the white matter in the frontal lobes. The advantages of the method were that the services of a neurosurgeon could be dispensed with (Freeman also dispensed with the services of an anaesthetist, as he used electroconvulsive shock to produce unconsciousness) and the restricted cut produced fewer personality changes.W Freeman 1948 Transorbital leucotomy. ''The Lancet'', 4 September: 371-3. On a visit to England in July 1948 Freeman read a paper on his new technique at the Burden Neurological Institute in Bristol, and in September the paper was published in The Lancet. Transorbital leucotomy did not become widely used in the UK, but a few psychiatrists experimented with it. John Walsh at Tone Vale Hospital in Somerset operated on eight women in 1949, on three occasions (including one as a demonstration at a meeting of the south-western division of the Royal Medico-Psychological Association) using electroconvulsive shock as an anaesthetic. Walsh was disappointed with the results, finding "no definite clinical improvements" in any of the patients. Psychiatrist Alan Edwards atRostral leucotomy
Rostral leucotomy, in which holes were drilled in the top of the skull and the cut made in a downwards direction, was devised by McKissock. Although McKissock approached from the opposite direction, the cut was similar to that of Freeman's transorbital leucotomy, undercutting Brodmann's areas 9 and 10 of the frontal cortex. McKissock was scornful of transorbital operations, considering them an offence "against established aseptic principles". McKissock continued to use the standard prefrontal operation where the aim was to control the behaviour of disturbed patients. In 1957, for example, he performed 125 rostral and 19 standard leucotomies.Cingulotomy
Subcaudate tractotomy
In 1949 Knight at Runwell Hospital started performing the operation of orbital undercutting (called orbital leucotomy in Britain) devised by American surgeon William Beecher Scoville, in which the lower quadrants of the frontal lobes were cut via holes in the forehead. Knight later modified Scoville's operation to restrict the cut to the lower medial quadrants. Further modifications dating from 1961 included the use of a stereotactic frame and brain images to make it easier to navigate in the frontal lobes, and the use of radioactive seeds (up to 20) to destroy tissue in the subcaudate region.PK Bridges et al. 1994 Psychosurgery: stereotactic subcaudate tractotomy, an indispensable treatment. ''British Journal of Psychiatry'' 165: 599–611. The operation was then called stereotactic subcaudate tractotomy and by the mid-1970s, although only used at two neurosurgical units (which by that time had replaced mental hospitals as the sites for psychosurgical operations), it accounted for 30 per cent of operations in the United Kingdom. Knight operated at the Brook Hospital in South London in collaboration with retired psychiatrist Strom-Olsen and then with psychiatrist Paul Bridges. Knight retired in the early 1970s (the unit was named the Geoffrey Knight psychosurgical unit in his honour) and was replaced by John Bartlett. In all, nearly 1300 subcaudate tractotomies were carried out at the Brook Hospital, with one death attributed wholly to the operation. During the 1980s the unit accounted for over 75 per cent of the psychosurgical operations carried out in Britain. The unit ceased operating in 1994. A team at Kings College Hospital under psychiatrist Stuart Checkley took over the work of the unit and performed 23 stereotactic subcaudate tractotomies over the next five years, using radiofrequency to destroy brain tissue.Capsulotomy
Capsulotomy, or anterior capsulotomy, in which part of theLimbic leucotomy
Limbic leucotomy was developed in the early 1970s by surgeon Alan Richardson at Atkinson Morley's Hospital. The operation combines stereotactic subcaudate tractotomy and cingulotomy, with up to 14 cryogenic lesions made in the brain. Limbic leucotomies continued to be performed at Atkinson Morley's Hospital until 1999.C Freeman 1997 Neurosurgery for mental disorder in the UK. ''Psychiatric Bulletin'' 21: 67–9.Multifocal electroleucoagulation
Multifocal electroleucoagulation, in which white matter is gradually destroyed by passing electric current through electrodes implanted in the frontal lobes, was the invention of doctors at the Burden Neurological Institute in 1959. Ten sheaths, each containing six or seven electrodes, were implanted in the brain and connected to a socket on the head. Every week direct currents of 10–20 mA were passed for about 3 minutes through 2–4 selected electrodes to make electrolytic lesions. These experiments continued throughout the 1960s and into the 1970s. In the mid-1990s there were plans to re-introduce multifocal electrocoagulation but they came to nothing.Psychosurgery on the temporal lobe
In most psychosurgical operations the intention is to destroy tissue in the frontal lobes, but a few operations have been done on the temporal lobes. Amygdalotomy, which destroys the amygdala, has been performed on small numbers of people in Britain. A group of Scottish doctors in the early 1970s experimented with the operation in the treatment of aggressive behaviour. Their patients included one as young as eight, and several others aged under 20. In England a few hypothalamotomies, where the hypothalamus is the target, were performed for the same reason.Decline of psychosurgery
The use of psychosurgery in the United Kingdom peaked in the late 1940s and early 1950s, with nearly 1,500 operations a year. Although some mental hospitals never used psychosurgery, or abandoned it after a brief trial, only a few voices were raised against it in the medical literature. Retired professor James MacDonald reminded psychiatrists at the Royal Medico-Psychological Association's March 1943 symposium on pre-frontal leucotomy that the frontal lobes represented the highest form of evolution, that there was no rational basis for leucotomy, and that the operation was of questionable legality. Donald Winnicott in a letter to The Lancet in the early days of leucotomy suggested that those who wanted to perform destructive operations should first establish that mental disorders were actually "brain-tissue diseases". Clifford Allen questioned the ethics of operating on people to make them easier to nurse and said it was little less than criminal to operate on people who were mildly or only recently ill. Several works published in the 1950s drew attention to the damaging and sometimes fatal effects of psychosurgery, though their authors were not opposed to the treatment. Maurice Partridge's follow-up of 300 patients operated on by McKissock revealed a higher death rate than was usually acknowledged, with six per cent of patients dying wholly or partly as a result of the surgery. The book described how many patients, even those whose surgery was considered as success by their doctors, were left with serious disabilities. Walter Maclay, president of the section of psychiatry of the Royal Society of Medicine, chose the subject of "death due to treatment" for his 1952 address. He counted 180 deaths directly resulting from leucotomy over a period of five and a half years. Also mentioned as a "possible lethal complication of leucotomy" were three murders committed by people who had undergone leucotomy. In his book ''Personality changes following frontal leucotomy'' Peter MacDonald Tow, psychiatrist at Runwell Hospital, described his search all over England for "normal subjects" – people who in spite of having been selected for leucotomy did not have severe mental illnesses. Eventually he found sixty subjects. Several died as a result of the operation, or were left too damaged to co-operate with testing. MacDonald Tow's research on the survivors demonstrated that the operation often caused serious intellectual damage. When the Board of Control published their second survey in 1961 the use of psychosurgery had declined by more than half; the decline being attributed to an awareness of the risks of irreversible effects and the introduction in 1955 of neuroleptic drugs. By 1961 nearly half of mental hospitals in the United Kingdom were no longer carrying out leucotomies. Approximately 500 operations were performed a year, and were unevenly distributed over the country. Someone hospitalised in the North East Metropolitan region was more than 15 times more likely to undergo psychosurgery than someone hospitalised in the neighbouring East Anglian region. There were also random differences in the type of operation used and the type of illness treated. Twenty per cent of operations were still standard pre-frontal leucotomies; the rest were new operations, and a few centres used stereotactic techniques. Some hospitals still used psychosurgery to treat chronic schizophrenia, in others the only indications were depression or obsessive illness. Psychosurgery continued to decline during the 1960s and 1970s. In 1976 about 120 operations were carried out in the United Kingdom. There were still a few standard leucotomies, but by the mid-1970s stereotactic subcaudate tractotomy, cingulotomy and stereotactic limbic leucotomy accounted for more than 50 per cent of operations. Depression was the most common diagnosis; people were also operated on for anxiety, violence, obsessive-compulsive disorder, schizophrenia, anorexia and other diagnoses.Legislation
By the early 1980s the number of psychosurgical operations carried out annually in the United Kingdom had fallen to fewer than 70. Most of them were stereotactic subcaudate tractotomies performed at the Geoffrey Knight psychosurgical unit at the Brook Hospital, London. The Mental Health Act 1983 (which covers England and Wales) classified psychosurgery as a treatment that could only be carried out with a patient's consent. Under section 57 of the Act, which applies to both detained and informal patients, a panel of three people appointed by the Mental Health Act Commission has to establish that the patient is consenting. Then the psychiatrist on the panel authorises the operation if it is likely to alleviate or prevent deterioration in the patient's condition. In Scotland, under section 234 of the Mental Health (Care and Treatment) (Scotland) Act 2003, psychosurgery can only be carried out on consenting patients if a panel from the Mental Welfare Commission confirms that the patient's consent is valid and that the operation is in their best interests. It may also be carried out on incapable patients, as long as they are not objecting, with Court of Session approval. Since the law came into force, no non-consenting patients have undergone psychosurgery. Since the introduction of the Mental Health Act 1983 no more than 28 psychosurgical operations have been carried out in the United Kingdom in any year. No operations were performed in England between 1999 and 2009;Well-known people who have undergone psychosurgery in the UK
* Josef Hassid (1923–1950), Polish violinist, came to Britain aged 14 with his father in 1938 to give concert performances and recitals in London, and make recordings for HMV. The outbreak of World War II prevented their return to Poland. In 1941 Hassid had a breakdown and was admitted to St Andrew's Hospital, Northampton, where he was given insulin coma therapy and electroconvulsive therapy. He was later detained in Long Grove Hospital, Epsom, and underwent a leucotomy there in 1950. He died 17 days later of a brain infection. * Ronald Senator, Pulitzer Prize nominated British composer, underwent a leucotomy in St Andrew's Hospital, Northampton, in 1950. He described the experience in his book ''Requiem Letters'' (Marion Boyers Publishers, 1996). * Lena Zavaroni (1963–1999), Scottish child star and singer who had suffered from anorexia and depression for many years, underwent a stereotactic anterior capsulotomy at the University of Wales Hospital in Cardiff in 1999. She died three weeks later from pneumonia (which her doctors considered was not related to the surgery). * The 13th Earl of Galloway was diagnosed as schizophrenic when young and underwent psychosurgery at St Mary's Hospital in London in 1952. His story is told in Louise Carpenter's book ''An Unlikely Countess: Lily Budge and the 13th Earl of Galloway''. (HarperCollins, 2004).Note on terminology
Egas Moniz coined two terms to describe his operation: leucotomy (cutting of the white matter of the brain) and psychosurgery (surgery for psychiatric disorder). The American neurologist Walter Freeman and neurosurgeon James Watts adapted Moniz's techniques and coined a new term: lobotomy (cutting of the lobe). In the United Kingdom, psychiatrists used the Freeman-Watts surgical technique but retained the terminology of Moniz – leucotomy and psychosurgery. In the 1940s, 1950s and 1960s the term leucotomy was used as a generic term with writers distinguishing between the standard, pre-frontal, or Freeman-Watts leucotomy on the one hand and modified leucotomies, such as rostral leucotomy, cingulotomy, etc., on the other. In the 1970s the term psychosurgery became more popular as a generic term, with individual operations being named according to the part of the brain in which tissue is destroyed, for example, cingulotomy, capsulotomy, subcaudate tractotomy, amygdalotomy, etc. The term leucotomy is still used to refer to the standard prefrontal leucotomies of the 1940s, 1950s, 1960s and 1970s, and is occasionally used as a generic term for psychosurgical operations. Some doctors prefer the term neurosurgery for mental disorder (NMD) to psychosurgery. The American term lobotomy has never been used by medical writers in the UK to describe a psychosurgical operation on the frontal lobe. The standard Freeman-Watts operation, called a lobotomy in the US, was called a leucotomy in the UK. Freeman later developed a psychosurgical technique in which an instrument is inserted through the eye-socket. It became known as a transorbital lobotomy in the US and a transorbital leucotomy in the UK (where it was less popular). However the term lobotomy is occasionally used by British journalists synonymously with leucotomy, either to describe the standard operations of former decades or occasionally as a generic term for all psychosurgical operations.References
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