history of psychosurgery in the united kingdom 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. 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. 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. in the 1930s the portuguese neurologist egas moniz developed a surgical technique for the treatment of mental illness and called it "leucotomy" or "psychosurgery". 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. main article: history of psychosurgery the first british psychosurgical operation was performed in bristol in december 1940, and by the end of 1944 about 1,000 operations had been carried out in the united kingdom. by 1954 that figure had risen to about 12,000 with use peaking in 1949. 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. 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. 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. 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. 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. 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 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. 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. 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. 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". if the patients resisted the surgery they were given electroconvulsive shocks before being anaesthetised. 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. graylingwell hospital, chichester, west sussex: 345 patients were operated on between 1942 and 1947. 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. 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". 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. 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. 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".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. 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. 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. 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. 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. 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. 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. 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