HISTORICAL VIGNETTE J Neurosurg 126:1278–1284, 2017 Geoffrey Knight and his contribution to psychosurgery *Francesco Marchi, MD,1 Francesco Vergani, FRCS,1,2 Iacopo Chiavacci, MD,1 Richard Gullan, FRCS,1 and Keyoumars Ashkan, FRCS1 1Department of Neurosurgery, King’s College Hospital, London; and 2Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom This paper retraces the fundamental achievements of Geoffrey Knight (1906–1994), a British neurosurgeon and a pioneer in the field of psychosurgery. His career developed in the 1950s and 1960s, when—following the unregulated practice of frontal lobotomies—strong criticism arose in the medical community and in the general public against psy- chosurgery. Geoffrey Knight’s clinical research focused on identifying new, selective targets to limit the side effects of psychosurgery while improving the outcome of patients affected by mental disorders. Following the example of William Beecher Scoville, he initially developed restricted orbital undercutting as a less invasive alternative to standard frontal lobotomy. He then developed stereotactic subcaudate tractotomy, with the use of an original stereotactic device. Knight stressed the importance of the anatomy and neurophysiology of the structures targeted in subcaudate tractotomy, with particular regard to the fibers connecting the anterior cingulate region, the amygdala, the orbitofrontal cortex, and the hypothalamus. Of interest, the role of these white matter connections has been recently recognized in deep brain stimulation for major depression and anorexia nervosa. This is perhaps the most enduring legacy of Knight to the field of psychosurgery. He refined frontal leucotomies by selecting a restricted target at the center of a network that plays a crucial role in controlling mood disorders. He then developed a safe, minimally invasive stereotactic operation to reach this target. His work, well ahead of his time, still represents a valid reference on which to build future clinical experience in the modern era of neuromodulation for psychiatric diseases. https://thejns.org/doi/abs/10.3171/2016.3.JNS151756 KEY WORDS Geoffrey Knight; orbital undercutting; subcaudate tractotomy; psychosurgery; deep brain stimulation; depression; history HE birth of modern psychosurgery is usually dat- led many surgeons in Europe and America to become in- ed to November 12, 1935, when Egas Moniz and terested in this field. Fascinated by the ideas of Fulton and Almeida Lima performed the first successful psy- Moniz, Walter Freeman started working on frontal leu- Tchosurgery operation by injecting alcohol into the frontal cotomies with his neurosurgical colleague James Watts.9,45 white matter of a 63-year-old woman with paranoid delu- They performed their first successful frontal lobotomy on sions, anxiety, and melancholia.7,40,45 The work of Moniz September 14, 1936, on Alice Hood Hammatt, a 63-year- and Lima was preceded by earlier neurosurgical interven- old woman with a history of severe depression, insomnia, tions such as topectomies5,19 and corticotomies,44,45 and by and anxiety.32,45 After this case, Freeman and Watts per- the experimental studies of John Farquhar Fulton, who formed 20 lobotomies in a series of patients but they soon noticed a lack of emotional expression and frustration be- became aware of a high rate of symptom recurrence af- havior after bifrontal resection of the frontal association ter the procedure, along with a non-negligible incidence cortex in animals.10,11,45 of complications, including postoperative bleeding (often Building on these preliminary findings, Moniz and leading to death), seizures, or frontal lobe syndrome.8,45 In Lima successfully performed their “frontal leucotomy” an attempt to render his lobotomy intervention less inva- with the centrum semiovale of the frontal lobes as the sive, Freeman rediscovered and modified the transorbital main target and published their results in 1936.7,40,45 This approach described by Amarro Fiamberti and developed ABBREVIATIONS DBS = deep brain stimulation; SCG = subgenual cingulate gyrus. SUBMITTED July 27, 2015. ACCEPTED March 11, 2016. INCLUDE WHEN CITING Published online June 17, 2016; DOI: 10.3171/2016.3.JNS151756. * Drs. Marchi and Vergani contributed equally to this work. 1278 J Neurosurg Volume 126 • April 2017 ©AANS, 2017 Unauthenticated | Downloaded 09/30/21 03:38 PM UTC Geoffrey Knight and his contribution to psychosurgery a procedure in which an ice-pick orbitoclast was inserted with a mallet through the orbital roof to a depth of 7 cm and swept laterally by 15°.43,45 Freeman started a cross- country tour to popularize his technique and performed nearly 4000 procedures in the following years. His surgi- cal practice, in the absence of aseptic techniques, anesthe- sia, and perioperative care, appeared largely deregulated even for the standard of the time. This attracted a growing body of criticism against him, including his former neuro- surgical colleague Watts, who became disillusioned with Freeman’s lobotomies.16,45 Nonetheless, from 1936 to 1956 a total of 60,000 lo- botomies were performed in the US and Europe.45 In terms of the number of operations, the United Kingdom saw the second-most operations performed after the US. A contemporary review, analyzing 10,000 standard fron- tal leucotomies performed in Great Britain between 1943 and 1954, revealed a 6% mortality rate, 1% incidence of seizures, and 1.5% incidence of frontal lobe syndrome. Seventy percent of the patients reported an improvement and 18% could return to a noninstitutional setting.45,50 The Life and Career of Geoffrey Knight It is in this climate that Geoffrey Knight (Fig. 1) started his neurosurgical career. Mr. Knight was born on October 4, 1906, at Lowfield Heath, Surrey, West Sussex, United Kingdom, the only son of Cureton Hope Overbeck Knight, a produce broker, and Ida Emily Norton. He was educated at Wadham House School, Hove and Brighton College, and qualified in 1930 at St. Bartholomew’s Hospital Medi- cal School in London. He subsequently held registrar and chief surgical assistant posts at St. Bartholomew’s before being appointed senior surgeon to the West End Hospi- tal for Nervous Diseases in London, and then Consultant Neurosurgeon to the Royal Postgraduate Medical School, FIG. 1. Original photograph of Mr. Geoffrey Knight in his 50s (October 4, Hammersmith. He held various research scholarships 1906–April 2, 1994). “He was a physically large man, greatly talented, awarded by the Royal College of Surgeons, including the innovative, confident, commanding, reassuring and quite unable to toler- Leverhulme scholarship (1933–1936) and the Meckenzie ate fools in any form.”2 Courtesy of his son, Martin Knight. Mackinnon scholarship (1936–1938). During the Second World War, he was appointed at the “Sector Hospital” for the war-injured in Joyce Green, near Dartford in the South first coiling of intracranial aneurysms in London; and Mr. of England, and he was awarded the Order of the White Northcroft, in the development of postgraduate education 2 Lion of Czechoslovakia for services to Czech aircrew. and spinal neurosurgery. In 1950 he returned to London where he established the In his works, lectures, and papers, Knight appeared South East Metropolitan Regional Neurosurgical Centre as “Geoffrey Knight, F.R.C.S., F.R.C.Psych.” as a testa- based at the Brook Hospital. Thanks to his interests in ment to his clinical commitment to both neurosurgery functional neurosurgery and psychosurgery, Knight was and psychiatry. His affiliation read: “Royal Postgraduate able to create a nationally recognized Psychosurgery Unit. Medical School; Surgeon in Charge, South East Metro- His neurosurgical centre at the Brook Hospital will be, to- politan Regional Neurosurgical Centre, The Brook Hos- gether with the Neurosurgical Unit at the Maudsley Hos- pital, London” often with the specification “Psychosurgi- pital, the nucleus of the current King’s College Hospital cal Department,” confirming the national recognition and London Neurosurgical Unit. the relevance of the Unit of which he was the “Surgeon in During his years at the Brook Hospital, Knight was Charge.” Among the many awards that he received dur- supported by the work of several colleagues, surgeons, ing his career, he was made Hunterian Professor of the and physicians: Mr. John Bartlett, his successor, and Dr. Royal College of Surgeons (United Kingdom) three times, Paul Bridges, his colleague in psychiatry, for his studies an honor very rarely conceded, and he also held the Vice- on functional neurosurgery; Mr. Gibbs, Mr. Neil-Dwyer, Presidency of the International Society of Psychiatric Sur- and Mr. Sharr for the studies on the protective effect of gery. After retiring in 1973, he preferred not to engage in nimodipine against secondary cerebral ischemic dam- clinical practice anymore, but instead “enjoyed many vis- age in aneurysmal subarachnoid hemorrhage and for the its to Spain (…) in his elegant Rolls-Royce.” He died on J Neurosurg Volume 126 • April 2017 1279 Unauthenticated | Downloaded 09/30/21 03:38 PM UTC F. Marchi et al. FIG. 3. Illustrations of the restricted orbital cortex undercutting proce- dure. A: Orbital aspect of right frontal lobe, showing Area 13 in cross- hatch and Area 14 in stipple. B: Orbital aspect of left frontal lobe, showing site of incision used, 1–8 cm wide, situated 1 cm from midline, extending to 6 cm from the frontal pole. The last 2 cm corresponds to Area 13. Re- produced from: Stereotactic tractotomy in the surgical treatment of mental illness, Knight G, J Neurol Neurosurg Psychiatry 28:304–310, Copyright 1965, with permission from BMJ Publishing Group Ltd. FIG. 2. Schematic representation showing Scoville’s operation (left), and the restricted orbital undercutting developed by Knight (right), involving the hair, change of blood pressure, pulse, respiration, and a zone on the inner aspect of the orbital surface. Reprinted from: The gastric motility, and even vocalization. Ward52 confirmed Lancet, 268, Knight GC and Tredgold RF: Orbital leucotomy; a review of that ablation of these areas produced changes in behavior 52 cases, 981–986, Copyright 1955, with permission from Elsevier.