Abstract

Retired from clinical practice Jan 2014.

Brian qualified from Cambridge University (with Part 2 in Experimental Psychology) and The London Hospital Medical College, 1973. FRCS (England) 1978. Wellcome Trust Research Fellowship – studies on functions of the dopamine systems led to MD (Cantab). Neurosurgical training at the (Royal) London Hospital, with additional special interest in functional neurosurgery. Appointed consultant neurosurgeon at University Hospital of Wales, Cardiff, 1988. Service development: surgical management of intractable pain. Service development: neurosurgery for mental disorder. President, International Neuromodulation Society, 2000–2003. Published widely on therapeutic neurostimulation.

2016 – Senior editor, series of evidence-based guidelines on therapeutic neurostimulation and on intrathecal drug delivery.

The evolution of “psychosurgery”, now better referred to as Neurosurgery for Mental Disorders (NMD), will be reviewed and discussed in relation to historical context and attitudes. Key considerations for the future will be highlighted.

The early history is often regarded now with embarrassment and even horror. The eminent physiologist John Fulton, whose 1935 London lecture triggered the notorious epidemic of radical and relatively indiscriminate frontal lobe surgery, had serious reservations. He knew that intellectual and affective functions could be separated anatomically and was probably the first to advocate more selective procedures, to avoid the sometimes devastating side effects. However, “lobotomy” was given impetus by the eminence of its pioneers, Moniz and Freeman, and by respected neurosurgeons elsewhere, including the UK. The socio-economic benefit of the liberation from asylums of large numbers of indefinite-stay patients for whom, it should be remembered, no drug treatment was available until 1954 (chlorpromazine; antidepressants in 1958), clearly provided great encouragement. However, Walter Freeman’s cavalier approach in the USA helped to close this first chapter.

A technically much more specific approach (“Chapter 2”) became available in 1947 when stereotactic neurosurgery for humans (it had long been used in animal experiments) was introduced. Case-selection also gradually improved, moving away from treating schizophrenia and from “correcting” behaviour, towards relieving affective disorders. Anterior capsulotomy was introduced in 1951 and (stereotactic) cingulotomy in 1962. Developments continued, for example subcaudate tractotomy using yttrium⁹⁰ seeds, of which more than 1300 were performed in London from 1961 until the 1990s. There was still much opposition but when a US Congress Commission was convened in 1974, expecting to ban “psychosurgery”, the evidence of benefit and relative absence of harm was now so compelling that it won official approval. The more refined procedures have continued with demonstrable success but in relatively small numbers.

Between 1993 and 2008, 55 patients underwent bilateral anterior capsulotomy in Cardiff, 45 for depression. The 24 for whom full datasets were available showed an overall improvement of 52%, with a 75% -or-more improvement in 10. There were no significant changes in executive function, attention and concentration, or immediate and delayed memory, and the adverse-effect profile showed it to be safe. However, antagonism continued to be encountered.

Deep brain stimulation (DBS) for psychiatric disorders is not new but it re-emerged in 1999 as a more flexible and superficially more acceptable alternative to traditional lesioning (“Chapter 3 ”). The relative advantages and disadvantages will be discussed.

The future for NMD (“Chapter 4”) for otherwise intractable cases should be exciting, with developments in imaging and other technologies and with increasing understanding of targeted conditions. However, the need to exercise great caution, along with issues of consent and regulation, are paramount. NMD is only one tool and its successful and continuing use depends heavily upon cultural attitudes.