Grey Matter

Grey Matter Psychosurgery is older than the pyramids, though ancient man didn't call it psychosurgery. When he picked up flint and mallet and cut a hole in his brother's skull, he was often just looking for a way to let the evil spirits out. Modern medical science not only has better tools and a sounder vocabulary, but believes it knows where to look for the trouble, i.e., in the front part of the brain.

In the last 14 years psychosurgeons have performed thousands of operations on the frontal lobes. They still do not agree on just where or how to open the skull or what tissues to cut.

In the current issue of Surgery, Gynecology and Obstetrics, half a dozen top U.S. psychiatrists and surgeons set out to compare methods and results. Columbia University's Dr. Lothar B. Kalinowsky points out a few things the experts are agreed on, notably that the frontal lobes are the seat of anxiety feelings, and that cutting nerve fibers in, or connected with, the lobes can reduce anxiety feelings when they occur with pathological intensity.

After Shock Fails. Psychiatrists and surgeons are also agreed, says Dr. Kalinowsky, that surgery is a last resort in mental cases, a measure not to be taken until all other treatments, including shock, have failed. Reason: psychosurgery in some cases has "undeniable side effects" (chiefly damage to the personality such as apathy and irresponsibility). Schizophrenics are the usual subjects, largely because nothing else seems to help them much.

What actual surgical procedures work best? Washington's Dr. Walter Freeman, who (with Dr. James Watts) pioneered psychosurgery in the U.S., staunchly defends two operations in which he has specialized. Freeman and Watts performed 624 prefrontal lobotomies. In this operation (see diagram), a hole is drilled through the skull back of each temple, and a dull, rounded knife is inserted to cut white nerve fibers connecting the frontal lobe with the thalamus, a neural relay station at the base of the brain. Freeman reports good results in 41% of such cases and fair in 34%, admits poor results in 22% (deaths in 3%).

This is a radical operation, difficult even when performed by highly skilled specialists. So Freeman and Watts tried something simpler: the transorbital lobotomy, so called because the instrument is inserted through the eye socket. Freeman reports good results in 47% of 316 cases, fair results in 23%, poor in 28% (deaths in 2%).

A Look Inside. Many doctors were not satisfied that it was safe or wise to make these "blind" cuts inside the brain. Some of them developed "open" operations, in which, for example, the surgeon saws out a wide piece of skull above the middle of the forehead, or two smaller pieces over each temple, so that he can see what he is cutting. Boston's Dr. Harry C. Solomon reports on hundreds of such cases and on still more variations. Sometimes only one lobe was cut (this seemed to be less successful) ; in other cases both lobes were cut near the midline of the brain, leaving the part near the temples.

Columbia's Dr. Paul H. Hoch tells of his group, which took a different tack. They tried to spare the long white fibers, and actually cut out a piece of the brain's grey matter, catching only a few white fibers. Usually they took out about an ounce on each side, in an operation called a topectomy.

Since important impulses to & from the frontal lobes must pass through the thalamus, a Philadelphia team headed by Dr. Ernest A. Spiegel decided to operate on this central clearinghouse. They drilled a hole through the top of the skull, sank a hollow needle through the brain. When its electric tip touched the thalamus, it seared some of the nerve nuclei. Few other U.S. surgeons have taken up this difficult operation (thalamotomy). Dr. Spiegel reports on 43 patients, about half of whom were improved.

The Price Paid. None of the reporting doctors was more concerned with the side effects of psychosurgery than Dr. Edward K. Wilk of Taunton, Mass. "Personality blunting," he says, "has been the inevitable price paid for a complete lobotomy operation [and] reveals itself in the higher realms of creative imagination, foresight, ambition and social sensitivity." Some long-confined schizophrenics are so tar gone that this damage might hardly show. But the less severe the case, the greater the risk. And if psychosurgery is to be used in other psychoses, and even in neuroses, says Dr. Wilk, personality damage cannot be tolerated.

He favors still another type of operation, developed by Yale's Dr. William B. Scoville. Called "selective cortical undercutting," it involves choosing one of the three main areas of the frontal lobes and making a local cut where the grey matter joins the major white fibers. Weighing results in 150 cases, Dr. Wilk considers them as good as those from complete lobotomies. And personality damage was vastly reduced, to the point where he thinks the selective operation might be used for serious neuroses.

In all the experts' reports there was an unreality about comparisons. The very nature of mental illness makes it impossible to grade patients like fruit. "Improvement" can be a matter of opinion. Some hospitals will discharge patients that others would keep. The best estimate: one-third of psychosurgery patients get well enough to be sent home, one-third are improved but have to be kept in the hospital, one-third get no benefit at all.

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