Selective Partial Ablation of the Frontal Cortex

This is an ambitious and exhaustive study of a small number of patients.Its purpose is stated in the preface as follows: "We were attempting to discover whether technically improved and less drastic neurosurgical approaches to the therapy of the mentally ill would yield results as satisfactory as, or better than, those obtained by lobotomy."One begins to fear, at the onset of his examination of this report, that the authors will fail to answer their questions when one learns in the next paragraph that the 24 control patients were not operated on.It is true that, later on, six control patients had lobotomies but one fails to understand, in view of the statement of the problem, why they were not all lobotomized by the same operator, and studied under the same conditions and by the same observers, as were those subj ected to topectomy.The details of these experiments are given in profusion, but the number is too limited for valid conclusions to be drawn from them.Of this difficulty the authors are well aware.Such as they are, however, these data will be useful to subsequent experimenters and are given in sufficient detail so that anyone may use them.Section I contains introductory chapters concerning the nature of the project, the prognostic expectations of the patients under ordinary institutional care, the institutional management, the social implications, the surgical procedure, and the cytoarchitecture of the frontal part of the brain.As Mettler points out, "study of the succeeding pages will indicate many ways in which such an investigation could and should be improved."One improvement would be better selection of patients since "the degree of divergence one ultimately found in our group was surprising and seriously complicated the interpretation of the subsequent data."Another improvement would be to increase the number of cases, especially in certain categories.Another, that suggests itself, would be to remove all areas by subpial suction, since the method adopted must remove also a lot of fibers coming from other areas.It might be objected that the suction method would prevent the tissue removed from being examined microscopically.This is not a serious objection since the provenience of any segment removed anterior to the agranular cortex cannot be identified anyway.This the authors halfheartedlyadmit."Until the specimen is sectioned, and perhaps not even then, it is, of course, impossible to know exactly what area is removed from a brain if that area is not electrically excitable."Mettler's task in the present study was certainly a thankless one.It is interesting to note that the only photographs which he gives are of the dysgranular portion of the inferior frontal gyrus (fig.68) which is the easiest of all to recognize.It would have been interesting to see photographs of the so-called areas 9-10-46.The choice of areas to remove is unfortunate, particularly as to area 9. Nobody subsequent to Brodmann has been able to identify any area in the frontal lobe with uniform characteristics which has the situation and shape of Brodmann's area 9. Lying as it does athwart the boundary between agranular and granular frontal cortex, its removal is ideally calculated to interfere with the region lying anterior to it.In other words, removal of area 9 makes a partial lobotomy .Moreover, if it were possible to identify area 9, it would have the shape given to it by Brodmann only on the brain he studied, because of the extreme variability of the gyral pattern of the frontal lobe.The impossibility of determining the position of these supposed areas on any brain exposed at operation, and the impossibility of identifying them by examination of the removed cortex make any talk of removal of areas 9-10-46 futile.The authors are uncomfortably aware of these difficulties as one may learn from perusal of their text.The only sure guide to topography on a brain exposed at operation is the central sulcus located by electrical stimulation.This guide was used in only three cases, as noted on page 47.Section II is a relatively unimportant account of studies of the general medical condi-348