Functional Neurosurgery in Psychiatric Illnesses

Advances in the treatment of psychiatric illnesses have made it possible to use neuropharmacological drugs, in many instances, thus diminishing the need for somatic type of invasive treatment. However there still remains a core of patients with psychiatric illnesses for whom continued attempts at treatment with psychotherapy and drugs have not yielded good results. Such cases deserve consideration for treatment by other methods. One of the areas where such treatment is available for these intractable patients is in the field of functional neurosurgery. All psychiatrists are familiar with the history of prefrontal leucotomy proposed by Moniz in 1935 and later popularised by Freeman and Watts (1952). A large number of operations were performed in the forties and fifties of this century. Govindasami and Rao (1944) published the first series of leucotomies in India. Kolb (1953) reviewed 10,000 cases and f reported that the success of such surgery was dependent on the adequacy of the postoperative care and the attitude of relatives. Elithorm and Slater (1956) reported the views of relatives and of patients who had undergone prefrontal leucotomy. They found that in a series of 103 patients, 65 were happy to have had the operation, 11 regretted it, three thought it was a mistake and 23 were indifferent. Of 93 relatives interviewed, 72 thought the patient was better off. Miller (1967) in a ten-year followup of patients who underwent leucotomy for mental illness between 1948 and 1952 found that 6 1 % were working in the community. However it was obvious that, though about 60% of the patients improved, there were many who showed deterioration in their intellect and some who were reduced to a vegetable state. This led to a large scale condemnation of the type of surgery that produced such large lesions in the brain. Efforts were made to limit the ablation to only the effective and concerned areas of the brain. As early as 1949, Scoville devised modified leucotomies to obviate the unsatisfactory side effects. Sargant (1953) pleaded for confining the leucotomy to only the medial inferior quadrant of the frontal lobe. Lesions in this area divide the froiitohypothalamic connections which run just above area 13 (Knight and Tredgold 1955). Fulton (1947) suggested cingulumotomy as a form of restricted leucotomy (Ballantine et al. 1967). Since then our knowledge of the indications for cingulumotomy and the precision of our techniques have increased. Cingulumotomy for drug addiction was initiated and popularised in India by Balasubramaniam et al. (1974). With the advancement in our knowledge of the functional tracts in the human brain and with the advances that have taken place in the stereotactic techniques of brain surgery, it is now possible to place a small lesion in any desired area of the brain accurately and with great precision. This has proved to be a great benefit in the