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PREFRONTAL LEUCOTOMY

THE LANCETLONDON: : SAT IIRD9.Y, JULY 5, 1941

THE suggestion that some cases of mental illnessmight benefit by division of the association fibres ofthe frontal lobe of the brain was first put forward byProf. EGAS MoNiz of Lisbon five years ago. He

argued that in such disorders the functional connexionsbetween the cortical cells, instead of being variable,become fixed, giving rise to obsessions and delusions ;and that by cutting the fibres concerned it might bepossible to release the patients from their symptoms.Any proposal that mental disorders should betreated surgically is bound to arouse criticism,probably not untinged with emotion. The psycho-logical and physiological hypotheses on which MoNizfounded his operation seem at first sight to be opposedto much current thought in psychological medicine,and particularly to the modern holistic view of thenervous system which has replaced earlier conceptionsof localisation. Our knowledge of the anatomy andphysiology of the cerebrum is so scanty that we canonly indicate generally the possible results of structuraldamage. But this need not deter us from acceptingany empirical treatment if it should prove valuable ;indeed our ignorance should make us chary of

rejecting any treatment merely because it conflictswith psychological preconceptions.That surgical interference is not devoid of risk can-

not be a complete argument against it ; in generalmedicine, if non-operative methods fail, we weigh thedangers and disadvantages of operation against thosecaused by the disease and choose the lesser of the twoevils. Insanity often carries worse consequences forthe patient and his relatives and dependants thanbodily disease, and many cases of insanity must stillooregarded as being incurable. In many of its forms

cl’!’ntal disease is chronic, not endangering the life ofthe patient ; but surgery is often used in the treat-ment of chronic bodily disorders, and few wouldhesitate to advise an operation with a low mortalityfor the relief of chronic distressing symptoms. Yetin the treatment of all disease (as distinct fromstructural defect) surgery must be regarded to someextent as a makeshift, marking the incomplete stateof our knowledge; and this is specially true of the brain.The original mental patients operated upon by MoNiz

and by RIzzATTI and his colleagues were all cases

with a poor or hopeless prognosis, who had failed torespond to other mothods of treatment and whocould, indeed, be accepted as incurable. As yet wehave had no opportunity in England of judging thevalue of the treatment, but the latest reports from theUnited States seem to support the original contentionsof MoNiz and the Italian school that the operationproduces something like a cure in a large percentage ofcases resistant to other therapeutic methods. Anyclaim to therapeutic success in the cases reported inthis issue by MCGREGOR and CRUMBIE and by HUTTON,FLEMING and Fox is naturally impossible after so shortan interval ; but it is noteworthy that in these twoseries of cases, treated, entirely independently, nogrossly harmful effects followed operation and therewere, in some cases, signs of mental improvement.

LANGE has recently reviewed cases submitted tofrontal lobectomy and concludes that the patientsshow some loss of initiative and possibly of prevision.The disturbance to the adjacent nervous structurescaused by the Moniz leucotomy is certainly less severethan in lobectomy but further study of leucotomisedpatients may reveal similar blunting of these faculties.Whether this will be found too high a price to pay forthe benefits claimed, and whether such benefits arelasting, remains to be seen. From the evidence sofar submitted it seems that the operation has mostchance of being useful in cases of acute anxiety andin obsessional states.

WAR FORMULARYIT is three months since the Medical Research

Council issued its War Memorandum No. 3,1 callingfor economy in drugs and setting out lists of thosewhich we can or must use fairly freely (A), those withwhich we must be careful (B), and those which we mustgive up altogether (C), but as Dr. PAPPWORTH makesclear in his letter on another page the response hasbeen disappointing. Various authorities and theE.M.S. have asked their hospitals to follow theM.R.C. advice, but hardly anyone seems to havetaken the requests very seriously, and most practi-tioners have made no changes at all in their prescribinghabits. After a few years in practice the doctorknows what effects he may expect from certain drugsand mixtures of drugs, what are the snags to beavoided in prescribing them, and which are speciallysuitable for particular patients ; it may take himmonths to become as familiar with alternatives, andhe will get no thanks from his patients for makingchanges. Moreover, some of the drugs we are askedto economise in still seem to be plentiful-bismuth andiodine, for example-and it is not encouraging tofind rows of proprietary syrups in the chemists’ shopswhen " sucrosum " and syrups appear in list B.The hospital dispenser, too, who can remind thestaff of the need for care, sometimes takes the viewthat there is no point in limiting the prescriptionof substances of which he has a large stock.The reason for economy is not always easy to grasp ;we have to remember both the need for reserving allthe cargo space and foreign exchange we can for foodand war materials, and also, in the case of drugs madeat home, that their constituents may be more usefulas food or munitions, and that their manufacture andtransport mean diverting labour from war industries.

This is a grand opportunity for us not only to helpthe war effort but also to throw off unworthy traditionsand rationalise our prescribing. In peace-time drugs,natural and synthetic, pour into our ports from everyquarter of the globe, and if some are inactive andothers could well be replaced by cheaper ones whocares ? 1 Doctors and patients have their fancies andcould afford to humour them. Thus the width of ourworld trade has widened our materia medica, andtraditional medicines have come to contain ingredientswhose very presence most prescribers have forgottenand few could justify. Polypharmacy must alwayshandicap progress in therapeutics by obscuring theaction of active ingredients, and now there can be noexcuse for it. We must now be in no doubt what weare prescribing and why; ; when we are ordering1. Economy in the Use of Drugs in War-time. H.M. Stationery

Office. Pp. 18. 3d.