Geoffrey Knight and psychosurgery

The April 2016 edition of the Journal of Neurosurgery (official journal of the American Association of Neurological Surgeons since 1944) has published an article about British neurosurgeon Geoffrey Knight, who was one of the pioneers of psychosurgery in Britain. I was bemused. Why now? Psychosurgery has been largely abandoned in this country, although a few operations are still carried out every year. I don’t think any of them are of the type devised by Knight although I may be wrong (the Care Quality Commission, unlike its predecessor the Mental Health Act Commission publishes numbers but not details of operations). But a little searching reveals recent attempts to claim Knight as the patron saint of deep brain stimulation for psychiatric diagnoses because, presumably, with his particular operation, called a subcaudate tractotomy, he was destroying the same bits of brain as some deep brain stimulation (DBS) surgeons target.

The article is written by a team of five from the Department of Neurosurgery, Kings College Hospital, London. It starts off with a little about the history of psychosurgery, taken largely from an article published five years ago in the journal World Neurosurgery. A few lines about the Ministry of Health survey of psychosurgery in England and Wales 1942-1954 are copied almost word for word, including at least eight errors made by the previous authors, from the World Neurosurgery article.

There follow some biographical details of Knight, including a mention of his work on injuries during World War II, and then the authors relate how he set up a neurosurgical unit at the Brook Hospital, London, in 1950. Why no mention of his leucotomies at Runwell Hospital, Essex? During the war Knight had found time to experiment with psychosurgery on patients at Runwell Hospital, using the Freeman-Watts technique of frontal leucotomy. It was only in 1949 he adopted William Beecher Scoville’s technique of orbital undercutting.

Most of the article is about how Knight developed his technique of stereotactic subcaudate tractotomy at the Brook Hospital. As for his character, that is summed up by a quote from Paul Bridges, from his 1994 obituary of Knight: “greatly talented, innovative, confident, commanding, reassuring and quite unable to tolerate fools in any form.”  Bridges was for many years the psychiatrist at the Brook psychosurgery unit, although he overlapped only briefly, if at all, with Knight. After his retirement Bridges was struck off the medical register by the General Medical Council following his conviction for sexually assaulting two teenage boys.

The article, which had previously been published on-line, prompted a response from Erlick Pereira, rather inappropriately titled: “Stereotactic subcaudate tractotomy: Knight stood on 3 giants’ shoulders.” In fact, Knight and the three surgeons mentioned by Pereira, Hugh Cairns at Oxford who developed the cingulotomy, F. John Gillingham in Edinburgh, and Wylie McKissock in England, were, as Pereira points out, contemporaries with Knight. Pereira refers to McKissock as a “great man” and refers to the fact that he carried out thousands of leucotomies, but does not consider the impact he had on the lives of the people he operated on.

McKissock was not interested in developing techniques that would spare patients the worst effects of leucotomy. Even into the late 1950s he was still using the standard Freeman-Watts frontal leucotomy or his own variation of it, the rostral leucotomy. He used to drive round England, mostly the south but as far north as Northampton, and Wales, carrying out operations in mental hospitals and institutions for people described in those days as mentally defective. It took him as little as 15 minutes to operate. According to the Ministry of Health survey, in the 1940s and early 1950s leucotomy had a four per cent mortality rate, and, according to a later survey by Maurice Partridge, 15 per cent of McKissock’s patients were left with epilepsy. To use McKissock’s own words, a few of his first fifty patients “subsided into a harmless vegetable existence” after surgery.

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