[Dr. H. Thomas Ballantine:] I think there might be general agreement that it
is somewhat difficult to present a clear account of four
years of work upon a controversial topic,
a new surgical approach to the treatment of mental illness,
in 10 minutes.
In an attempt to accomplish this task,
I would like to read an abstract from a paper
schedule for presentation of the Harvey Cushing society
at its annual meeting in St. Louis, Missouri
on April the 19th, 1966.
I will then illustrate its content
and add as much to it as time allows.
The abstract will read as follows,
quote, the beneficial effects of interruption
of cingulate fibers upon certain psychiatric illnesses
have been well-documented over the last 20 years
by Cairns, Lewin, Poole, and Lebeau among others.
These surgeons have, however, preferred a direct attack
on the cingulum.
In 1961, Foltz and White presented
to this society, that is the Harvey Cushing
society, a series of 16 patients suffering
from intractable pain in whom lesions were placed
in the cingulum by stereotactic-electrode
placement for the relief of pain.
Using a slight modification of their,
technique we began in 1962 an investigation of this procedure
for the treatment of mental illness, primarily
manic depressive psychosis.
To date, 51 psychiatric patients have
been operated upon 75 times.
10 have had cingulotomy performed
for the intractable pain of incurable cancer.
There have been no operative or post-operative complications,
no patients have, to date, suffered
undesirable alterations of personality or intelligence.
36 of 40 psychiatric patients, followed three months
to four years post-operatively, have shown
varying degrees of improvement.
And in 30, this has been useful improvement.
Seven of the 10 cancer patients have
had satisfactory pain relief.
That's the end of the abstract.
Now, if we may have the illustrative material.
May I have the first slide, please?
This is the area under attack, the limbic system.
More specifically, the cingulum.
This fiber bundle, the cingulum bundle,
seems to be the main link between the frontal lobes
and the limbic lobe.
The latter is thought to be in animals, at least,
a prime regulator of behavior and emotion,
if I may be permitted to use the term emotion in respect
to animals.
May we have the next slide, please?
A word about technique, bilateral burr holes
are placed 9.5 centimeters posterior
to the nasion and 1.3 to 1.5 centimeters
to either side of the midline.
Specially designed, the number 17 ventricular needles,
insulated except for the distal centimeter,
are inserted into the ventricles and air is injected.
If the ventricular needles have pierced
the cingulum appropriately, they are
withdrawn until the bear ends lie in the cingulate region
and then the radiation is carried out.
May I have the next slide, please?
Initially, the lesions were replaced
2.5 centimeters posterior to the anterior
tips of the frontal horns.
And you can see the needles in the cingulum in this slide,
this is according to the method of Foltz and White.
Experience and a suggestion from Paul Yakovlev, a very famous
neuropathologist, has induced us to select a target
four centimeters back at the tips of the frontal horns
in our more recent operations.
Using a radiofrequency lesion generator,
a current of eight watts is applied
to the electrodes for 60 seconds,
two contiguous lesions are placed vertically
in each cingulum.
May I have the next slide, please?
This is a whole brain section stained by the Loyez method.
It has been taken at about the locus of our lesions
and is presented for orientation purposes.
The shaded areas show the area of the cingulate destruction.
May I have the next slide, please?
This is an example of the destruction produced.
This brain section comes from a man with intractable pain
who died from his lung cancer.
Note, the relatively large size of the lesions.
We believe that adequate destruction
is vital to surgical success.
10 cancer patients with severe pain
have been subjected to cingulotomy,
adequate pain relief was obtained in 7
for periods up to three months.
Our main purpose, however, has been
to investigate cingulotomy as a method
of treating the mentally ill.
And the remainder of my remarks will
be concerned with 40 psychiatric patients who
have been followed three months to four years
after their last operation.
Let me have the next slide, please.
These are the major symptoms of the 40 psychiatric patients,
34 are thought to have had a severe mood
disturbance of the manic depressive type and six,
the diagnosis is in doubt.
All of the group have been treated with talk and medicine.
39 of the 40 had preoperative electroshock therapy.
Note also, that 35 of the 40 were totally disabled,
that's the second line in that slide.
These patients represent a refractory 5%
of the total patient load at the hospital
which had been treating them.
May I have the next slide, please.
This chart shows the age at onset and at operation.
We have been dealing mostly with a younger group of patients,
many of whom might have been called schizophrenic
by other psychiatrists and all of whom
represent a difficult treatment problem.
Our youngest patient was 15, the oldest 80.
The average preoperative duration of illness
was about 10 years.
May I have the next slide, please?
Now, these are our results.
The eight patients called well are currently symptom free.
The markedly improved group are functioning effectively
in society, although psychiatric supervision
and some form of treatment are still necessary.
The improved patients are still disabled but at the time
of the presentation of this paper,
they do not require hospitalization.
The slightly improved and unimproved
require no further categorical delineation.
We might try to excuse this lack of useful improvement
on the grounds of errors in psychiatric diagnosis,
improper lesion placement, inadequate lesion size, and so
forth.
But I will resist this temptation.
May I have the next slide, please.
This is a comparison of the results of surgery
for mental illness as recorded by different observers
scrutinizing different operations.
The degree of improvement is about the same in all three
groups and is surprisingly similar to that reported
by August Moniz 30 years ago.
In his first article published 1936,
Moniz stated that 14 of 20 psychiatric patients subjected
to frontal lobotomy were better post-operatively
and that five of the six failures
occurred in patients suffering from schizophrenia.
In one respect, however-- and I refer you to the last column.
In one respect however, the cingulotomies
and cingulectomies are different from the leucotomy series,
the operation seems to be much safer.
Now, a word about multiple operations, 10 of the 40
psychiatric patients have had more than one operation
and one patient has had seven.
His IQ remains about 130.
In this latter respect, I want to make it clear
that I do not believe that cingulotomy
can turn a moron into a genius.
But it is true that if nine patients who
had cortical function tests before and after operation,
none was worse post-operatively, and six
had slightly higher scores.
May I have the next slide, please?
This short bibliography has two virtues.
The articles listed are excellent in themselves
and they also contain copious additional references
for the serious student of the subject of operative attempts
to influence the course of mental illness.
In conclusion then, we have carried
out 85 bilateral cingulotomies on 61 patients,
10 of these operations have been for pain.
And we have been able to confirm the findings of Foltz and White
that cingulotomy is a value in controlling
otherwise intractable pain.
75% of these operations have been done for mental illness,
primarily, those conditions characterized
by profound and chronic disorders of affect.
30 or 40 patients followed three months to four years
after operation have shown useful improvement.
These good results could be due to chance,
to the so-called non-specific effects of surgery,
or to other factors than surgical intervention.
Naturally, we prefer to think that there
is a specific operative effect.
But we have no concrete proof of this.
The operation does seem to be safe, however.
And this, despite the fact, that our lesions have been large.
We believe that it is necessary to destroy the most
medial cingulate fibers bilaterally
and of re-operated patients to be certain of this destruction,
as well as to enlarge the lesion.
Finally and most importantly, I, as a neurosurgeon
do not believe that this operation
is a panacea for mental illness, not even
for effective disorders such as manic-depressive
disease or psychosis.
Cingulotomy should be considered an incident
in the total treatment of the severely disabled patient.
And any neurosurgeon who performs it
will be disappointed in his results
unless he is able to work with psychiatrists who will treat
these patients intensively before and after surgery
with all of the chemical and physical agents
available for the biological approach
to the therapy of mental illness.