History of psychosurgery in the United Kingdom

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 Gloucester and Brislington House in Bristol, who volunteered their patients as guinea pigs. Frederick Golla was persuaded to undertake the surgery by psychiatrist William Sargant who had seen three of Freeman's patients in the US and tried to introduce leucotomy at the Belmont Hospital in London, only to be refused permission by London County Council.[5][6]

The first operation was carried out in December 1940, a further eight over the next four months – all of them on detained patients. The operations were done with a paper knife, using the standard Freeman-Watts technique. Some were performed under local anaesthesia, some under general.

After nine operations the psychiatrists presented the results of the first eight operations in an article in The Lancet in July 1941, omitting the ninth case where a blood vessel was cut and the patient, a 27-year-old woman, died. Of the eight, one died of a heart attack two days after the operation, three were discharged (two of them still suffering from incontinence) and four remained in hospital. One of the discharged patients, a veteran of World War I who had broken down during the bombing raids on Bristol and had been diagnosed as neurotic, was operated on after just 4 days in hospital. These results were considered sufficiently encouraging for the leucotomy programme to continue at the Burden Neurological Institute, and for Sargant to gain permission to introduce leucotomy at the Belmont Hospital in London.

[13][14][15]

Warlingham Park Hospital, Croydon, Surrey, started to experiment with psychosurgery soon after the Burden Neurological Institute and published the results of their first four operations in the same issue of The Lancet. One patient died.[16] Surgeon John Crumbie designed his own leucotome (instrument for cutting the white matter in the brain) which was constructed by Warlingham's assistant clerk of works, and referred to by Wylie McKissock, who operated with a Cushing brain needle, as a "mechanical egg-whisk".[17] If the patients resisted the surgery they were given electroconvulsive shocks before being anaesthetised.[18]

After the results of at the Burden Neurological Institute and Warlingham Park were published, mental hospitals throughout Great Britain began to use psychosurgery. Pioneering hospitals included:

Crichton Royal Hospital, Dumfries, Scotland: 142 patients had undergone surgery by the end of 1945. Most of them were judged to be "hopeless, chronic invalids" and were selected for surgery on account of being prone to aggressive, destructive and impulsive behaviour.[19]

Graylingwell Hospital, Chichester, West Sussex: 345 patients were operated on between 1942 and 1947.[20]

Belmont Hospital, Sutton, Surrey: mainly neurotic patients who had never been in a mental hospital were treated under the direction of Sargant for disorders such as dermatitis, battle neurosis, anorexia and depression.[21]

Runwell Hospital, Essex: psychiatrist Rolf Strom-Olsen and surgeon Geoffrey Knight formed a psychosurgery partnership that was to last for thirty years. 116 operations had been carried out by the end of 1945, with six deaths. The first few patients had been selected for what Knight called their "low potential", so that harmful effects could be studied before the operation was used in cases of "higher potentiality".[22][23]

Bexley Hospital, Kent: 48 leucotomies, with 3 deaths, had been performed by McKissock by mid 1945. McKissock developed a peripatetic psychosurgery service, visiting hospitals all over the south of England (except for part of Kent, which was the territory of Knight) and Wales on Saturdays and performing thousands of leucotomies.[24]

The North Wales Hospital, Denbigh: Leucotomy was introduced in 1942. The first series of 24 patients operated on 1942–1944 were selected for their failure to respond to other treatments (usually electroconvulsive therapy) and, in at least half the cases, the demands they made on nursing staff. Operations were done by a local GP/general surgeon. One patient died.[25]

Netherne Hospital, Coulsdon, Surrey: in 1942 Eric Cunningham Dax, medical superintendent of Netherne Hospital, called in surgeon Eric Radley Smith to operate on patients. Before the year was out, fifty patients had undergone surgery, and in April 1943 the results were published in the Journal of Mental Science. Cunningham Dax described how he selected patients:

"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".[26]

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.

St Lawrence's Hospital, Caterham, Surrey: in March 1944 a programme of leucotomy was begun on "mental defectives". Crumbie operated on one patient, McKissock and his assistant, McCall, on a further 43 (nine of them under the age of 21). There were five deaths and the majority of patients showed little or no improvement, with twelve of them becoming worse. Doctors at St Lawrence's Hospital decided to abandon the experiment.[27] Rampton Hospital, another mental deficiency institution, began using psychosurgery in January 1947. Twenty patients including a fourteen-year-old underwent surgery in little over a year. One patient died.[28] Superintendent George Mackay found the results sufficiently encouraging to extend the programme to include "a wider group of clinical types". One young woman who underwent a leucotomy turned out to have been detained illegally for eighteen years.[29]

By the end of 1944 about 1,000 psychosurgical operations had been performed in Great Britain, and the Board of Control published the results of a survey in a 30-page booklet.[7] They described the operation in the following terms:

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.[7]

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.[30] 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.[7]

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.[31]

The use of psychosurgery in the United Kingdom peaked in the late 1940s and early 1950s, with nearly 1,500 operations a year.[8] Although some mental hospitals never used psychosurgery,[9] or abandoned it after a brief trial,[27] 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.[53] 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".[54] 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.[55]

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.[56] 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.[10] 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.[57]

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.[8] 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.[9] 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.[11]

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.[47] 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.[58] 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; Frenchay Hospital, Bristol, performed one anterior cingulotomy in 2010.[59] A few stereotactic anterior capsulotomies are performed every year at the University of Wales Hospital, Cardiff. Stereotactic anterior cingulotomies are performed at the Dundee Royal Infirmary in collaboration with the psychiatric unit at Ninewells Hospital. The Cardiff and Dundee units introduced psychosurgery programmes in the early 1990s and have used psychosurgery in the treatment of depression, obsessive-compulsive disorder and anxiety.[47]

• 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.[60][61]
• 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).[62]
• 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).

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.