A Brief History of Neurosurgery for Mental Disorder

A Renaissance (of sorts)

In the 1960s and 1970s there was a modest revival in interest in psychosurgery, partly as a result of developments in stereotactic technique that moved surgical intervention away from the freehand procedures exemplified by the work of Freeman and Watts. This ‘second wave’ of psychosurgery was undoubtedly not of the scale of the 1950s. A review of psychosurgical activity in the USA by Elliot Valenstein, commissioned by The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1977) was able to estimate that the number of procedures performed annually in the USA in the early 1970s to be 414. Corresponding estimates were 200-250 for the UK and 83 for Australia. It is interesting to note that four surgeons were responsible for 48% of the activity reported in 1973. A questionnaire survey of psychosurgery centres in the USA, inquiring about activity from 1971-1973 revealed that 195 neurosurgeons had performed 1,039 procedures for psychiatric conditions during those three years, supporting Valenstein’s estimate to be reasonably accurate (Donnelly, 1978).

The total number of NMD procedures in the UK from 1979-1995 is given in Figure 1. Although the rate of NMD was clearly decreasing by the late 1970s it is apparent that the introduction of the Mental Health Act 1983 may have had an effect on activity, and helped to keep procedures at a constant level.

Figure 1 : Total number of NMD procedures in the UK (1979-95). From data by Freeman (1997).

 

In the 'third wave' of neurosurgery for mental disorder, stereotactic procedures took over from earlier interventions. Important landmarks in this development include:

• 1962 - Foltz and White: the first open Anterior Cingulotomy.
• 1964 - Geoffrey Knight: develops the subcaudate tractotomy - an extensive lesion of orbitofrontal cortex and frontostriatal thalamic tracts by focal irradiation
• 1968 - Lars Leksell develops the Gamma Knife – a stereotactic method for creating lesions by targeted irradiation without the need for cranial burr holes
• 1972 - Lars Leksell: performs the thermal Anterior Capsulotomy as a focal method of disconnecting ventral and medial frontal cortex from subcortical and limbic structures.
• 1973 - Desmond Kelly and Alan Richardson– Limbic Leucotomy.

Although four procedures were in common use in the past (Anterior capsulotomy, anterior cingulotomy, limbic leucotomy, and subcaudate tractotomy), only the first two are still used in the UK and Europe. The last UK centre offering subcaudate tractotomy - the Geoffrey Knight Centre in London - closed down a number of years ago.

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Donnelly, J. (1978) The incidence of psychosurgery in the United States, 1971--1973. American Journal of Psychiatry, 135, 1476-1480.
Freeman, C. (1997) Neurosurgery for mental disorder in the UK. Psychiatric Bulletin, 21, 67-69.
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1977) Report and Recommendations - Psychosurgery. Washington: U.S. Department of Health, Education, and Welfare.