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Orbital Leucotomy
LEADING ARTICLES
THE
LANCET
LONDON:: SATURDAY, MAY 14, 1955
Orbital
Leucotomy
STANDARD leucotomy, or lobotomy, developed by FREEMAN and WATTS, in which a large part of the prefrontal areas is severed from the rest of the brain, has of late been carried out only in cases of longstanding mental illness with severe behaviour disorder. Apart from the unpredictability of its anatomical results, it commonly causes undesirable personality changes. These changes, it was observed, were more likely to occur when the operation had been extensive, and attempts were therefore made to limit it to a minimum. Clinical observation of patients with frontal-lobe injuries, as well as experimental work, suggested that a regional factor was important. Several workers reported satisfactory results from " lower quadrant operations aimed at the orbital of the frontal lobes. isolating only part These, like the standard leucotomy, were still blind procedures, lacking in precision. With the hrcreasing use of open operations various selective-methods have of these been developed. One of the most is the undercutting of, certain parts of. the frontal cortex first proposed by ScoviLLE,1 who compared three cortical areas with the effects of those of standard leucotomv. The areas chosen were the superior surface of the frontal pole, the orbital surface, and the medial surface of the cingulate gyrus. He found that in schizophrenia and the affective states undercutting the superior or the orbital surface brought about the same results as the standard operation, but with less personality defect. He regarded undercutting of the orbital surface " as the ideal operation for psychoneuroses and the milder mood disturbances, because of the almost complete absence of personality changes." There was much to recommend the choice of that particular area for patients with otherwise intractable anxiety and "
interesting
undercutting
depression. The importance
of this area as part of the cerebral substrate of emotional integration is now generally recognised. Tow and LEWIN2 described the results of undercutting the orbital surface in twenty patients with various mental disorders who were subsequently 1.
Scoville, W. B. J. Neurosurg. 1949, 6, 65 ; Proc. 1949, 42, suppl. p. 3. 2. Tow, P. M., Lewin, W. Lancet, 1953, ii, 644.
1007
followed up for two years. The effects were comparable with those of the standard operation, but the personality changes were less pronounced. Two reports on earlier pages of this issue appear to confirm the value of the method. Dr. STRÖM-OLSEN and’ Mr. NORTHFIELD have applied it to a group of patients with chronic neurotic tension states ; in each of these patients, including one with pronounced paranoid ideas, depression was prominent. More than half recovered from their symptoms ; and personality changes were slight. Another group, suffering from long-standing schizophrenia with personality Mr. KNIGHT and deterioration, did less well. Dr. TREDGOLD report on a series of fifty-two patients subjected to a slight modification of cortical undercutting. Their results are almost as impressive as those of STRÖM-OLSEN and NORTHFIELD. They also found that improvement was most striking in patients with anxiety and depression. Patients with hysterical symptoms did not respond favourably. The two reports confirm the beneficial effect of orbital undercutting and the absence of severe postoperative personality changes, but it is difficult to compare the results in detail since these were differently assessed. KNIGHT and TREDGOLD eschew the term recovered " used by the other group of workers ; but it can be assumed that the majority, if not all, of their " much improved " patients would -have been classed among the " recovered" by STRÖMOLSEN and NORTHFIELD. Evaluation and classification of therapeutic results is a serious problem in psychiatry, and communication between workers in the same field is often bedevilled by the pitfalls of semantics. The fact that an operation as limited as orbital undercutting can produce a substantial and often dramatic change in the mental state seems at first to contradict the view held by earlier workers that the degree of improvement depends chiefly on the amount of brain substance isolated. MEYER and BECK3 suggest that, though the extent of the opera.tion is important, regional localisation of the cut within the frontal lobe also influences the- effects. They point out that some very limited regional cuts may in fact, by severing the thalamofrontal projection, isolate large areas of cortex. The question, therefore, whether the frontal lobe functions by mosaic or mass action has still not been finally answered. In their experience, the extent of the cut, wherever localised, is correlated with improvement. But various types of improvement follow surgical interference with frontal-lobe function : one is the complete disappearance of symptoms, especially of depression, immediately after the operation; almost any operation on the frontal lobe, however limited, has sometimes resulted in this dramatic change. In such instances, at any rate, improvement or even recovery does not seem to have been bought at the price of a severe personality change, The results of cortical so obvious in other patients. that show notoriously reversible sympundercutting such as toms, depression and anxiety, can be removed sometimes by a very limited operation-an effect which, though profound, is clearly unrelated to the "
personality change.
R. Soc. Med. 3.
Meyer, A., Beck, E. Prefrontal Leucotomy and Related Operations. Edinburgh, 1954.
1008 In what type of patient can one expect such a distinct improvement ? Here we are still in the dark. STROM-OLSEN and NoRTHFiELD consider that neuropathology may some day provide the answer. Some workers believe that it will eventually be possible to produce lesions to suit every condition and every patient. The fact that the results of a precise and limited operation, such as orbital undercutting, are still inconstant, suggests that the effect does not depend only on the extent and localisation of the lesion. The patients’ personality-the sum total of his response patterns, innate and acquired-must be of considerable importance. Only when we know more about the reactions of the personality to sudden alterations in the emotional charges shall we be able to predict the effects of surgical treatment in individual cases. The psychiatrists, it is true, have been aware of this, and have generally accepted that in wellintegrated personalities the likelihood of undesirable postoperative behaviour features, even after extensive operations, is small; but beyond this we know very little. Naturally, clinicians are more interested in their successes, especially when a method has still to be established. But the time comes when careful and systematic study of failures and partial failures is at least as important as that of This is particularly true in the present successes. of the stage surgical treatment of mental disorders. Such studies would also act as a wholesome corrective to the danger of a reversal to atomistic " concepts of cerebral function. The effects of localised operations on mental states have contributed to a revival of concepts reminiscent of those so persistently criticised by HuGHLiNGS JACKSON, and a language has crept back into medical writings which not so long ago seemed almost extinct. What would JACKSON have thought of the " intellectual pathways" referred to by KNIGHT and TREDGOLD ? The passage from LE GROS CLARK cited by these workers, and MEYER and BECK’S3 recent warning against too atomistic an interpretation of the effects of brain operations, show that at least some of those most familiar with cerebral structure and functions are opposed to a return to the old-fashioned rigid localisation of functions. Only by taking into consideration the undamaged parts of the brain and the reactions of the whole personality shall we reach a fuller understanding of the scope and limitations of the surgical treatment of mental disorders. "
Estimation of Blood-loss THE most important cause of shock after surgical or accidental injury is loss of blood into and from the damaged tissues, or of plasma in cases of burns and scalds, or of crushing. Such shock usually responds to the rapid replacement of the lost fluid ; but measurement of the amount lost, even at operation, is not easy. Estimates based
the opera,when reinforced low, usually by collection of the swabs, towels, and gowns. Surgeons who have not submitted themselves to the discipline of direct measurement of blood-loss usually find it hard to believe the figures obtained in this way. Sometimes-for example, when the operation is for extensive clearance of viscera in the pelvis or of a tion
are
on
too
impressions during even
large block of organs in the upper abdomen-estimates based on impressions are of hardly any value; and when, in addition,the operation lasts many hours and is accompanied by transfusion to replace lost blood, direct measurement is especially necessary. To be useful the method of direct measurement must provide an accurate answer shortly after the operation has ended. Probably the simplest way is to wash out all the swabs, towels, gowns, and instriiments in a known volume of water, to which is added the contents of the suction-bottle. The haemoglobin level of this fluid is then measured either directly1 or after conversion to acid hoomatin. 23 This, together with the haemoglobin level of the patient’s blood before and immediately after operation, gives a fairly accurate guide to the volume of blood lost. PAQUIN et al.4 have devised a method suitable for cases in which blood or other intravenous fluids are being administered. The difference between preoperative and postoperative weight is corrected on the one hand for additions (including dressings and transfused blood or other fluids), and on the other hand for depletion by bleedings, estimated insensible water-loss, resected tissue, and excreted urine and other lost body-fluids. As a check they also measure blood-loss directly,by weighing the towels, swabs, They have found close gowns, and suction-fluid. between results the by these two methods, agreement even for operations lasting ten hours with a bloodloss of over 4 litres. But they point out that serious errors may arise from the accumulation of shed blood in ‘’ deal spaces "-for example, the pelvis—and from excretion of urine or, in operations on the urinary tract, from contamination of blood with urine. Furthermore the method of PAQUIN et al. cannot be expected to give really reliable results until we know more about the possibly wide variation in insensible water-loss during different types of anoesthesia; and they themselves emphasise that their method should be combined with clinical examination before
deciding
on
treatment.
Fortunately operations lasting
for more than three hours are rare, and the amount of blood lost at operation seldom exceeds 2 litres. Measurement of blood or plasma lost by accidental injury is even less easy. Theoretically such loss would be best measured by estimating the amount of blood remaining in the circulation and subtracting this from the normal volume, which, as GIBSON and EVANS6 showed, is closely related to bodyweight. But this approach is so studded with pitfalls7 that others have been tried. NoBLE and GREGERSErr found that in civilian injuries blood-loss depended largely on the extent of muscle damage and the8 number of fractures ; and GRANT and REEVE showed that in limb injuries the volume of damaged tissue was a good guide to the volume of blood lost. Mr. RUSCOE CLARKE and his colleagues9 have 1.
2. 3. 4. 5. 6.
7. 8. 9.
Oppenheim, A., Pack, G. T., Abels, J. C., Rhoads, C. P. Ann. Surg. 1944, 119, 865. Gatch, W. D., Little, W. D. J. Amer. med. Ass. 1924, 83, 1075. White, M. L., Buxton, R. W. J. thorac. Surg. 1942, 12, 198. Paquin, A. J., Marshall, V. F., Nathanson, B. Ann. Surg. 1955, 141, 53. Wangensteen, O. W. Minnesota Med. 1942, 25, 783. J. clin. Invest. 1937. Gibson, J. G. jun., Evans, W. A. jun. 16, 317. Noble, R. P., Gregersen, M. I. Ibid, 1946, 25, 158, 172. Grant, R. T., Reeve, E. B. Spec. Rep. Ser. med. Res. Coun., Lond. 1951, no. 277. Clarke, R., Topley, E., Flear, G. G. T. Lancet, March 26, 1955, p. 629.
THE
LANCET
LONDON:: SATURDAY, MAY 14, 1955
Orbital
Leucotomy
STANDARD leucotomy, or lobotomy, developed by FREEMAN and WATTS, in which a large part of the prefrontal areas is severed from the rest of the brain, has of late been carried out only in cases of longstanding mental illness with severe behaviour disorder. Apart from the unpredictability of its anatomical results, it commonly causes undesirable personality changes. These changes, it was observed, were more likely to occur when the operation had been extensive, and attempts were therefore made to limit it to a minimum. Clinical observation of patients with frontal-lobe injuries, as well as experimental work, suggested that a regional factor was important. Several workers reported satisfactory results from " lower quadrant operations aimed at the orbital of the frontal lobes. isolating only part These, like the standard leucotomy, were still blind procedures, lacking in precision. With the hrcreasing use of open operations various selective-methods have of these been developed. One of the most is the undercutting of, certain parts of. the frontal cortex first proposed by ScoviLLE,1 who compared three cortical areas with the effects of those of standard leucotomv. The areas chosen were the superior surface of the frontal pole, the orbital surface, and the medial surface of the cingulate gyrus. He found that in schizophrenia and the affective states undercutting the superior or the orbital surface brought about the same results as the standard operation, but with less personality defect. He regarded undercutting of the orbital surface " as the ideal operation for psychoneuroses and the milder mood disturbances, because of the almost complete absence of personality changes." There was much to recommend the choice of that particular area for patients with otherwise intractable anxiety and "
interesting
undercutting
depression. The importance
of this area as part of the cerebral substrate of emotional integration is now generally recognised. Tow and LEWIN2 described the results of undercutting the orbital surface in twenty patients with various mental disorders who were subsequently 1.
Scoville, W. B. J. Neurosurg. 1949, 6, 65 ; Proc. 1949, 42, suppl. p. 3. 2. Tow, P. M., Lewin, W. Lancet, 1953, ii, 644.
1007
followed up for two years. The effects were comparable with those of the standard operation, but the personality changes were less pronounced. Two reports on earlier pages of this issue appear to confirm the value of the method. Dr. STRÖM-OLSEN and’ Mr. NORTHFIELD have applied it to a group of patients with chronic neurotic tension states ; in each of these patients, including one with pronounced paranoid ideas, depression was prominent. More than half recovered from their symptoms ; and personality changes were slight. Another group, suffering from long-standing schizophrenia with personality Mr. KNIGHT and deterioration, did less well. Dr. TREDGOLD report on a series of fifty-two patients subjected to a slight modification of cortical undercutting. Their results are almost as impressive as those of STRÖM-OLSEN and NORTHFIELD. They also found that improvement was most striking in patients with anxiety and depression. Patients with hysterical symptoms did not respond favourably. The two reports confirm the beneficial effect of orbital undercutting and the absence of severe postoperative personality changes, but it is difficult to compare the results in detail since these were differently assessed. KNIGHT and TREDGOLD eschew the term recovered " used by the other group of workers ; but it can be assumed that the majority, if not all, of their " much improved " patients would -have been classed among the " recovered" by STRÖMOLSEN and NORTHFIELD. Evaluation and classification of therapeutic results is a serious problem in psychiatry, and communication between workers in the same field is often bedevilled by the pitfalls of semantics. The fact that an operation as limited as orbital undercutting can produce a substantial and often dramatic change in the mental state seems at first to contradict the view held by earlier workers that the degree of improvement depends chiefly on the amount of brain substance isolated. MEYER and BECK3 suggest that, though the extent of the opera.tion is important, regional localisation of the cut within the frontal lobe also influences the- effects. They point out that some very limited regional cuts may in fact, by severing the thalamofrontal projection, isolate large areas of cortex. The question, therefore, whether the frontal lobe functions by mosaic or mass action has still not been finally answered. In their experience, the extent of the cut, wherever localised, is correlated with improvement. But various types of improvement follow surgical interference with frontal-lobe function : one is the complete disappearance of symptoms, especially of depression, immediately after the operation; almost any operation on the frontal lobe, however limited, has sometimes resulted in this dramatic change. In such instances, at any rate, improvement or even recovery does not seem to have been bought at the price of a severe personality change, The results of cortical so obvious in other patients. that show notoriously reversible sympundercutting such as toms, depression and anxiety, can be removed sometimes by a very limited operation-an effect which, though profound, is clearly unrelated to the "
personality change.
R. Soc. Med. 3.
Meyer, A., Beck, E. Prefrontal Leucotomy and Related Operations. Edinburgh, 1954.
1008 In what type of patient can one expect such a distinct improvement ? Here we are still in the dark. STROM-OLSEN and NoRTHFiELD consider that neuropathology may some day provide the answer. Some workers believe that it will eventually be possible to produce lesions to suit every condition and every patient. The fact that the results of a precise and limited operation, such as orbital undercutting, are still inconstant, suggests that the effect does not depend only on the extent and localisation of the lesion. The patients’ personality-the sum total of his response patterns, innate and acquired-must be of considerable importance. Only when we know more about the reactions of the personality to sudden alterations in the emotional charges shall we be able to predict the effects of surgical treatment in individual cases. The psychiatrists, it is true, have been aware of this, and have generally accepted that in wellintegrated personalities the likelihood of undesirable postoperative behaviour features, even after extensive operations, is small; but beyond this we know very little. Naturally, clinicians are more interested in their successes, especially when a method has still to be established. But the time comes when careful and systematic study of failures and partial failures is at least as important as that of This is particularly true in the present successes. of the stage surgical treatment of mental disorders. Such studies would also act as a wholesome corrective to the danger of a reversal to atomistic " concepts of cerebral function. The effects of localised operations on mental states have contributed to a revival of concepts reminiscent of those so persistently criticised by HuGHLiNGS JACKSON, and a language has crept back into medical writings which not so long ago seemed almost extinct. What would JACKSON have thought of the " intellectual pathways" referred to by KNIGHT and TREDGOLD ? The passage from LE GROS CLARK cited by these workers, and MEYER and BECK’S3 recent warning against too atomistic an interpretation of the effects of brain operations, show that at least some of those most familiar with cerebral structure and functions are opposed to a return to the old-fashioned rigid localisation of functions. Only by taking into consideration the undamaged parts of the brain and the reactions of the whole personality shall we reach a fuller understanding of the scope and limitations of the surgical treatment of mental disorders. "
Estimation of Blood-loss THE most important cause of shock after surgical or accidental injury is loss of blood into and from the damaged tissues, or of plasma in cases of burns and scalds, or of crushing. Such shock usually responds to the rapid replacement of the lost fluid ; but measurement of the amount lost, even at operation, is not easy. Estimates based
the opera,when reinforced low, usually by collection of the swabs, towels, and gowns. Surgeons who have not submitted themselves to the discipline of direct measurement of blood-loss usually find it hard to believe the figures obtained in this way. Sometimes-for example, when the operation is for extensive clearance of viscera in the pelvis or of a tion
are
on
too
impressions during even
large block of organs in the upper abdomen-estimates based on impressions are of hardly any value; and when, in addition,the operation lasts many hours and is accompanied by transfusion to replace lost blood, direct measurement is especially necessary. To be useful the method of direct measurement must provide an accurate answer shortly after the operation has ended. Probably the simplest way is to wash out all the swabs, towels, gowns, and instriiments in a known volume of water, to which is added the contents of the suction-bottle. The haemoglobin level of this fluid is then measured either directly1 or after conversion to acid hoomatin. 23 This, together with the haemoglobin level of the patient’s blood before and immediately after operation, gives a fairly accurate guide to the volume of blood lost. PAQUIN et al.4 have devised a method suitable for cases in which blood or other intravenous fluids are being administered. The difference between preoperative and postoperative weight is corrected on the one hand for additions (including dressings and transfused blood or other fluids), and on the other hand for depletion by bleedings, estimated insensible water-loss, resected tissue, and excreted urine and other lost body-fluids. As a check they also measure blood-loss directly,by weighing the towels, swabs, They have found close gowns, and suction-fluid. between results the by these two methods, agreement even for operations lasting ten hours with a bloodloss of over 4 litres. But they point out that serious errors may arise from the accumulation of shed blood in ‘’ deal spaces "-for example, the pelvis—and from excretion of urine or, in operations on the urinary tract, from contamination of blood with urine. Furthermore the method of PAQUIN et al. cannot be expected to give really reliable results until we know more about the possibly wide variation in insensible water-loss during different types of anoesthesia; and they themselves emphasise that their method should be combined with clinical examination before
deciding
on
treatment.
Fortunately operations lasting
for more than three hours are rare, and the amount of blood lost at operation seldom exceeds 2 litres. Measurement of blood or plasma lost by accidental injury is even less easy. Theoretically such loss would be best measured by estimating the amount of blood remaining in the circulation and subtracting this from the normal volume, which, as GIBSON and EVANS6 showed, is closely related to bodyweight. But this approach is so studded with pitfalls7 that others have been tried. NoBLE and GREGERSErr found that in civilian injuries blood-loss depended largely on the extent of muscle damage and the8 number of fractures ; and GRANT and REEVE showed that in limb injuries the volume of damaged tissue was a good guide to the volume of blood lost. Mr. RUSCOE CLARKE and his colleagues9 have 1.
2. 3. 4. 5. 6.
7. 8. 9.
Oppenheim, A., Pack, G. T., Abels, J. C., Rhoads, C. P. Ann. Surg. 1944, 119, 865. Gatch, W. D., Little, W. D. J. Amer. med. Ass. 1924, 83, 1075. White, M. L., Buxton, R. W. J. thorac. Surg. 1942, 12, 198. Paquin, A. J., Marshall, V. F., Nathanson, B. Ann. Surg. 1955, 141, 53. Wangensteen, O. W. Minnesota Med. 1942, 25, 783. J. clin. Invest. 1937. Gibson, J. G. jun., Evans, W. A. jun. 16, 317. Noble, R. P., Gregersen, M. I. Ibid, 1946, 25, 158, 172. Grant, R. T., Reeve, E. B. Spec. Rep. Ser. med. Res. Coun., Lond. 1951, no. 277. Clarke, R., Topley, E., Flear, G. G. T. Lancet, March 26, 1955, p. 629.