Controlled multifocal frontal leucotomy for psychiatric illness.

There have been two important developments in the surgical treatment of mental disorders during the last 12 years, and one of these is in the selection of patients. No longer is the chronic schizophrenic the principal type of patient selected for cerebral surgery. The patients now considered for surgical treatment are usually chronic depressives and those with anxiety states, and obsessional syndromes whose symptoms have proved intractable. These cases include young and intelligent people, some with potentially promising futures and many with heavy responsibilities. In such cases it is particularly important to preserve as much as possible of intellectual capacity, sense of responsibility, and social judgment. The need for more discriminating intervention in cerebral function has been reflected in the variations in operative techniques used in cerebral surgery in recent years. The second important change, then, has been the introduction of methods for the selection and limitation of the site of the destruction so as to do the least damage that will bring significant and prolonged relief of symptoms to the patient. Many attempts have been made to achieve the goal of most relief with least damage. Frontal topectomy was described by Pool (1949), anterior cingulectomy by Whitty, Duffield, Tow, and Cairns (1952), electro-coagulation of limited areas in the thalamic nuclei by Spiegel and Wycis (1949), orbital undercutting by Scoville (1949), frontal electro-coagulation by Grantham (1951), bimedial leucotomy by Greenblatt and Solomon (1952), transorbital leucotomy by Freeman (1948), lower quadrant leucotomy by Thorpe and Hardman (1952), and rostral leucotomy by McKissock (1951). White, Sweet, and Hackett (1959) have described a method of leaving coagulating electrodes in the frontal lobes of brain for prolonged periods to allow the lesion to be enlarged at a later date if the clinical state indicates the need. They used one or two large electrodes and coagulated by diathermy. This technique was used in cases of intractable pain (usually caused by cancer). These methods have two limitations: first, however well controlled the lesion is anatomically, they are functionally 'blind' and irreversible; second, being essentially acute operations it is difficult to grade the lesion to match the illness of the patient. Greater delicacy and control of coagulation of frontal white matter can be achieved by using a large number of small, chronically indwelling, intracerebral electrodes.