History of psychosurgery in the United Kingdom

Psychosurgery is a surgical operation that destroys brain tissue in order to alleviate the symptoms of mental disorder.^[1] The lesions are usually, but not always, made in the frontal lobes. Tissue may be destroyed by cutting, burning, freezing, electric current or radiation. The first systematic attempt at psychosurgery is commonly attributed to the Swiss psychiatrist Gottlieb Burckhardt who operated on six patients in 1888.^[2] In 1889 Thomas Claye Shaw reported mental improvement in a case of General Paralysis of the Insane after a neurosurgical intervention. This led to a lively debate in the British Medical Journal on the usefulness of neurosurgery for the treatment of insanity.^[3] In the 1930s the Portuguese neurologist Egas Moniz developed a surgical technique for the treatment of mental illness and called it "leucotomy" or "psychosurgery".^[4] Moniz' technique was adapted and promoted by American neurologist Walter Freeman and his neurosurgeon colleague James W. Watts. They called their operation, where burr holes are drilled in the side of the skull and the white matter is sliced through in order to sever the connections between the frontal lobes and deeper structures in the brain, lobotomy. In the United Kingdom it became known as the standard Freeman-Watts prefrontal leucotomy. British psychiatrist William Sargant met Freeman on a visit to the United States and on his return to England encouraged doctors at the Burden Neurological Institute in Bristol to instigate a programme of psychosurgery.^[5]

The first British psychosurgical operation was performed in Bristol in December 1940,^[6] and by the end of 1944 about 1,000 operations had been carried out in the United Kingdom.^[7] By 1954 that figure had risen to about 12,000 with use peaking in 1949.^[8]

Beginning in the 1940s doctors devised "modified operations" with less extensive cuts or more specific targets (for example, rostral leucotomy and cingulotomy) in an attempt to reduce the damage done by the surgery.^[8] During the 1950s the number of operations declined by more than half, in spite of the fact that Moniz had received a Nobel Prize for psychosurgery in 1949. Reasons for this decline included increasing concern about the deaths and damage caused by the operation, the introduction of neuroleptic drugs, and changing ideas about the nature and treatment of mental illness.^[9][10] By the mid-1970s the use of psychosurgery had declined still further to about 100–150 operations a year, and nearly all were of the modified type.^[11] The Mental Health Act 1983 specified that psychosurgery could only be carried out on consenting patients, and then only with the approval of the Mental Health Act Commission. The decline in psychosurgery has continued to 2007, with the latest figures from the Mental Health Act Commission showing that 5 operations were authorised in Wales in the 2-year period 2005–2007.^[12] A few operations every year are also performed in Dundee, Scotland. No psychosurgical operations were performed in England between 1999 and 2009; one operation was performed in 2010 in Bristol.

In total, over 20,000 people have undergone psychosurgical operations in the United Kingdom. Women have outnumbered men (by about three to two in the early days, and by even more in recent years). The vast majority of operations have been carried out on young and middle-aged adults, although some older people and, in the past, a very small number of children and teenagers have been operated on. Nowadays the operation is used in the treatment of depression, anxiety and obsessive–compulsive disorder. In the past it was also used in the treatment of schizophrenia and a wide variety of other disorders; some patients had been in a mental hospital for years before operation, others only briefly or not at all.