Summary It seems fundamentally improbable that different mental symptoms and personality disorders should be relieved by one single form of operation on the brain. The present paper describes five operations which can be performed with benefit to different types of psychiatric abnormality; namely, unilateral temporal lobectomy, unilateral or bilateral temporal lobotomy, inferior quadrant pre-frontal leucotomy, paramedian frontal leucotomy and posterior cingulectomy. The symptoms that represent an indication for these various operations and the results of the operations on the symptom complexes are described. The proposition is put forward that only operations suitable for the precise psychiatric diagnosis should be used. A new form of analysis of sphenoidal lead examinations is described which is of primary importance in conjunction with psychiatric examination in deciding which operation a particular patient would or would not benefit from. A concept of diencephalic instability is introduced in connection with this EEG analysis to supplement the usual concept of centrencephalic epilepsy. Diencephalic instability as defined here seems to respond specifically to paramedian lobotomy, provided of course the clinical condition justifies such a step.

The treatment of choice for craniopharyngioma is still controversial and probably ought to vary in individual cases. Where the histological structure is benign a total removal has seemed an ideal to aim at. The lesion is, however, frequently adherent to the hypothalamus, to main cerebral vessels, and to the optic tracts as well as to the pituitary stalk, and attempts at total removal have resulted in a forbidding operative mortality even when the attempt was abandoned because the operation proved technically impossible. When apparently complete removal was achieved there was still a substantial recurrence rate (35 %) in the survivors (Gordy, Peet, and Kahn, 1949). In many instances histological examination showed anaplastic cell growth and mitotic figures, malignant changes which precluded any serious attempt at surgical extirpation. The lesion usually consists of one or more cysts, though about one in 10 is a solid tumour. After incomplete removal of a cyst wall and aspiration of contents in most of the surviving patients the lesion recurred in three to six months (Ingraham and Scott, 1946), although an occasional patient survived longer, even up to 13 years. Russell and Pennybacker (1961) Although craniopharyngioma has frequently been regarded as radio-resistant, several workers have reported a useful result from radiotherapy on a small number of cases (Love and Marshall, 1950) with periods of survival up to eight years. Ingraham and Scott (1946) advocated irradiation instead of decompression for a later recurrence. Carpenter, Chamberlin, and Frazier (1937) in four cases aspirated the cyst and then irradiated it with doses between 1,000 and 3,500r over a long period. In their cases there was no recurrence in 17 to 30 months, whereas before irradiation the cysts required aspiration at intervals of three weeks to six months. Kramer, McKissock, and Concannon (1961) used two million volt rays by a rotation technique to irradiate the craniopharyngioma with doses of 5,500r over six weeks in children and of 7,000r over seven weeks in adults. Their results were startling. Nine out of 10 patients, including six children, were well after six years or more. One case had required re-aspiration. None showed clinical evidence of damage to the brain due to irradiation.Our work was started before these last results were published. One aim of radiation therapy is to destroy the secretory epithelium so that a cystic craniopharyngioma does not re-form. Consequently we decided to use an isotope material whose effect would be largely restricted to the cyst lining whilst having insufficient penetrating radiation to affect nearby hypothalamic structures. One argument against this technique is that the craniopharyngioma is not always a unilocular cyst, but may consist of a number of thin-walled cysts, a complex multilocular cystic mass with some solid material, or a solid mass with no cystic spaces at all. Nevertheless the majority of cases do have one or more large cysts which can be emptied through a single aspirating cannula, and...

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In most instances presenile dementia is based on well-defined organic diseases and it is not necessary to resort to cerebral biopsy to establish a diagnosis. These organic disorders cover a wide spectrum and include cerebro-vascular disease, tumours, trauma and well-defined degenerative states such as Huntington's chorea, vitamin deficiencies, endocrine disturbances, infections (bacterial and viral) and poisons such as alcohol, lead, barbiturates, bromides and carbon monoxide. The effects of liver and kidney failure as well as the hypercapnia of pulmonary insufficiency account for others.

SUMMARY A method of local cerebral hypothermia with circulatory arrest of one or more of the major vessels of the neck is described. Ten clinical cases have been operated upon, and much has been learned of the operative difficulties including an increased operating time and a high complication rate. There were four post-operative deaths, in one (case 1) there was some evidence that the technique protected the perfused part of the brain from anoxic damage. In case 9 the method itself caused particularly bad operating conditions and eventually the patient died. Case 2 and case 4, like case 1, were patients who were severely ill and who might well have died whatever technique had been used in operating upon them. Of the survivors, one patient (case 3) had a post-operative intracerebral clot which developed during closure and another (case 6) had an intracerebral clot which required removal after 24 hours. Another patient (case 8) had some delay in return to full mental function. In the light of this experience we cannot regard the method in its present form as satisfactory for general use. In our view, its further development requires the discovery of a more effective means of neutralizing the anticoagulants, or doing without anticoagulants altogether. It is also necessary to develop a method of monitoring parts of the brain distant from those directly perfused to give warning of threatened anoxia. Until such time as these problems can be solved we have returned to other procedures but are publishing our results in the hope that other workers will be able to improve upon them.Since the work of Drew (1959), neurological surgeons have been interested in using the ability of the brain to withstand complete circulatory arrest for over 30 minutes at temperatures of the order of 15°C, on the basis that the difficult aneurysm or arteriovenous malformation might be easier to treat under such conditions.From the beginning it seemed probable that the full Drew technique might be too much for a patient who had sustained one or more recent subarachnoid haemorrhages. Despite the difficulties, a large number of neurosurgical operations were carried out in the early 1960s and clinical reports came from