Anatomical Correlates of Improvement After Leucotomy

The Surgical Uncertainties of Prefrontal Topectomy and Leucotomy (Observations on 100 Cases)

Three is no branch of neuro-surgery in which the assessment of results is more difficult than in psycho-surgery. The main sources of uncertainty are:

(a)

Some Reflections on the Nature of Affective Disorders, Arising from the Results of Prefrontal Leucotomy

For the use of the term “affective disorder” there is good literary warrant. Shakespeare, writing in the last decade of the sixteenth century, or just before it, uses the word thus:

Post-Operative Syndromes in Selective Prefrontal Surgery

The prefrontal region lies in front of the motor and premotor areas of the frontal lobe. In Brodmann's terminology this corresponds to areas 8, 9, 10, 45 and 46 on the convexity; 11, 47 and 13 on the orbital surface; 24, 32 and 12 on the mesial surface. When speaking of selective prefrontal surgery, we mean topectomy or cortical undercutting or partial leucotomy of one or several of these areas.

Anatomical Comments on Psychosurgical Procedures

There has recently been a plethora of new methods of psychosurgery. This has, we believe, created considerable bewilderment in the minds both of the clinical psychiatrists who have to decide which of the methods to choose and of the neurosurgeons who have to practise them. The aim of the present paper is to clarify and disentangle the situation as far as this can be done from the anatomical angle.

Hallucinations as top-down effects on perception

The problem of whether and how information is integrated across hierarchical brain networks embodies a fundamental tension in contemporary cognitive neuroscience, and by extension, cognitive neuropsychiatry. Indeed, the penetrability of perceptual processes in a 'top-down' manner by higher-level cognition-a natural extension of hierarchical models of perception-may contradict a strictly modular view of mental organization. Furthermore, some in the cognitive science community have challenged cognitive penetration as an unlikely, if not impossible, process. We review the evidence for and against top-down influences in perception, informed by a predictive coding model of perception and drawing heavily upon the literature of computational neuroimaging. We extend these findings to propose a way in which these processes may be altered in mental illness. We propose that hallucinations - perceptions without stimulus - can be understood as top-down effects on perception, mediated by inappropriate perceptual priors.

Altered functional connectivity in lesional peduncular hallucinosis with REM sleep behavior disorder

Brainstem lesions causing peduncular hallucinosis (PH) produce vivid visual hallucinations occasionally accompanied by sleep disorders. Overlapping brainstem regions modulate visual pathways and REM sleep functions via gating of thalamocortical networks. A 66-year-old man with paroxysmal atrial fibrillation developed abrupt-onset complex visual hallucinations with preserved insight and violent dream enactment behavior. Brain MRI showed restricted diffusion in the left rostrodorsal pons suggestive of an acute ischemic stroke. REM sleep behavior disorder (RBD) was diagnosed on polysomnography. We investigated the integrity of ponto-geniculate-occipital circuits with seed-based resting-state functional connectivity MRI (rs-fcMRI) in this patient compared to 46 controls. Rs-fcMRI revealed significantly reduced functional connectivity between the lesion and lateral geniculate nuclei (LGN), and between LGN and visual association cortex compared to controls. Conversely, functional connectivity between brainstem and visual association cortex, and between visual association cortex and prefrontal cortex (PFC) was significantly increased in the patient. Focal damage to the rostrodorsal pons is sufficient to cause RBD and PH in humans, suggesting an overlapping mechanism in both syndromes. This lesion produced a pattern of altered functional connectivity consistent with disrupted visual cortex connectivity via de-afferentation of thalamocortical pathways.

Failed leucotomy with misplaced cuts: a clinico-anatomical study of two cases

Failure of treatment does not necessarily mean inappropriate treatment; it must first be ascertained that the treatment has been carried out. Increasing attention is being paid to this question in regard to drug therapy with estimations of blood and urine levels. Patients who fail to get better after leucotomy may have been unsuitably chosen; they may also fail to get better because the aim of the operation, namely to sever the thalamo-frontal radiations, has not been achieved. Neuro-anatomical studies have long suggested that not only do many patients remain with these tracts intact following a blind operative approach but that there is also great variability in the size and position of the lesions produced, a consequence of unreliable surface markings, brain fibre elasticity, complicating haemorrhages and progressive gliosis. The blind approach is no ideal surgical method, since it results in a largely fortuitous lesion (Meyer and McLardy, 1948, 1949; Beck, McLardy, and Meyer, 1950; Eie, 1954; Meyer and Beck, 1954). There is even a gross discrepancy between the actual and desired point of insertion of the leucotome (Dax, 1943). Whilst the effects of misplaced cuts have been studied by these workers, one can only guess what proportion of clinical failures can be attributed to misplaced cuts and what proportion of successes follow misplaced cuts (Meyer and Beck, 1954). Appeals for further studies with post-mortem correlates have been made by these authors.

RESTRICTED ORBITAL UNDERCUTTING; A STUDY OF ITS EFFECTS ON 350 PATIENTS OVER THE TEN YEARS 1951-1960

“The great majority of physicians, including our own specialty, have written off frontal lobe surgery as a therapeutic weapon for any illness short of chronic major psychosis.”

Bilateral vs. bimedial lobotomy. Social evaluation of outcome of operation in two matched groups of 60 patients

A sample of 60 cases operated on by the bimediallobotomy approach was compared with a similar number operated on by the standard bilateral technique. These two groups were stratified in terms of diagnosis and duration of hospitalization before operation. The status of the group for other variables still differed sufficiently to require more refined statistical breakdown of these unstratified variables.

The outcome following operation was determined by the use of discharge probabilities up to the period of 4 years and by a classification of adjustment at the time of observation in terms of good, moderate or poor, determined by the score on an objective social rating scale.

It was not possible to demonstrate any measurable and consistent statistical difference between the outcome of the following of two lobotomy procedures by the various techniques employed.

These results would support the suggestion of Fulton” that the medial aspect of the section is the crucial one physiologically and would not support the suggestion of McLardy and Meyer” that improvement was related to the amount of prefrontal cortex isolated from its white matter.

Although this method of comparison shows the outcome by the two techniques to be similar, one technique may be preferred over the other because of other factors not considered in this study. If such is the case, then one can come to this decision with the knowledge that the results in terms of social outcome are identical. Certainly it would appear to the authors that the bimedial approach, producing similar results in terms of social recovery, might well be preferred to the standard procedure on the basis of its more limited destructive nature.

Anterior cingulectomy in schizophrenia and other psychotic disorders; clinical results

Recent interest in the surgical alleviation of mental disorders has centred in the trial of new and different operations. Fairly early in the development of the subject Freeman and Watts (1944) themselves reported the fairly constant observation that under local anaesthesia gross mental change did not occur until certain stab incisions had been made deep in the infero-medial quadrants. Marked mental change, with confusion, unresponsiveness and disorientation, seemed to occur on section of a small bundle of fibres located interiorly close to the midline. Most of the modifications of Moniz's original procedure have, however, been made on an essentially empirical basis.