SURGICAL PSYCHOTHERAPY (PSYCHOSURGERY). - One of the most recent branches of modern medicine; it comprises a whole series of neurosurgical interventions aimed at curing or alleviating mental disorders to which, at least until now, it has not been possible to apply an etiological therapy. Some authors distinguish a "lesional" and a "functional" p.: interventions for cerebral tumors and traumas would fall under the first form, while the functional one would constitute p. c. properly so called.
The history of p., properly understood, goes back to the Swiss psychiatrist G. Burckhardt, who was the first to carry out, more than 60 years ago, such a type of intervention. In 1935 the Portuguese Egas Moniz, a Nobel laureate, described at the Second International Congress of Neurology, in London, his "prefrontal leucotomy": by means of an instrument called a "leucotome" one proceeds to interrupt a part of the nerve pathways that connect the frontal lobes with the rest of the brain; in this way those particular modifications of the nervous "connections," those peculiar fixed neuronic patterns on which, according to Moniz, the mental symptoms would depend, would be interrupted. The lobotomy is prefrontal because this region of the brain is considered today as a set of association fields
(areas 8-9-10-11-44-46 etc. of Brodmann) in which the various cortical sensory and motor representations converge, along with the emotional processes that take on the imprint of the Ego. From these principles there developed, within a few years, numerous operative techniques and a most fertile field of neurophysiological, anatomo-clinical and psychological research. From the technical point of view, there are currently practiced, in relation to the extent and topography of the intervention: lobotomy and lobectomy, leucotomy, gyrectomy, topectomy, thalamotomy, selective subcortical excisions, etc. The interventions, even the most extensive, are not burdened by a significant operative mortality; today, however, there is a tendency to operate with an open field, both because one can act bilaterally on a single operative field (unilateral lobotomy is much less effective), and because the danger of hemorrhagic complications and of late deaths from uremia and trophic disturbances is avoided (McLardy); the most feared and most frequent complication is, generically, the epileptogenic one.
The literature on technique and neurosurgical evaluation is very extensive; many authors consider lobotomy more effective in the "anxious," whether reactive or primary (Horányi), while in the "excited" topectomy would be more useful; in the "delusional" topectomy would fail, while lobotomy would often overcome even the most deeply rooted delusions (Singer). As can be seen, these are indications of a more symptomatic than nosological order. Operative requirements, in any case, oscillate between two extremes: either to carry out an extensive intervention, e.g., a radical, bilateral lobotomy, attaining the therapeutic goal only at the price of a deterioration of the psychic potential; or to perform too limited an intervention and thus fail to obtain the intended result. Some authors, taking into account the preponderant role of areas 9 and 10 in emotional integration, of the pericallosal areas in psychomotor impulsivity, of the orbital areas in the control of instinctual-affective tone, have recourse to leucotopectomies, judging them generically more suitable than the other types of intervention.
Leucotomy produces in the first place deficit phenomena (attributable mainly to the impairment of the fronto-thalamo-hypothalamic circuits) affecting emotional excitability and, more rarely and mildly, affecting certain higher psychic functions of the intellective, noetic type. The majority of the more recent authors agree in admitting that the decay of the highest intellectual and ethical powers can be considered negligible in practice, taking into account both re-education and the previous state in which the patients on whom p. c. is performed generally find themselves (Gomirato).
The deficit phenomena are followed by a series of "positive repercussions," especially in the sphere of the thymopsyche (affectivity) and of behavior (p. c. has been defined as the "surgery of behavior"): anxious states, hyperemotive states and emotional imbalances are influenced; maladjustment to the environment, inertia, negativism are modified (Puca). The result is a tendency toward a new psychic equilibrium, produced by a series of compensatory and perhaps also reintegrative processes, presumably favored by the diminution of neurovegetative reactivity.
The central problem of p. c., perfectly framed in the contribution of Freeman and Watts (1950), lies entirely in the evaluation of the lasting, stable modifications of the personality. Such an evaluation, which demands a strictly specialized technique, cannot be obtained with precision and certainty in the severe forms of schizophrenia (which provide the highest contribution to psychosurgical interventions), in which one can always doubt whether the symptoms are the result of the operation or, instead, an autonomous form of final stabilization.
On the other hand, alterations of the personality can be accurately specified when p. c. is employed in severe painful conditions, refractory to every treatment, e.g., in the atrocious pains of the phantom limb of amputees, in trigeminal neuralgias, causalgias, thalamic pains (in such cases the best results seem to be obtained, according to Fulton, with the section of the infero-medial quadrants of the frontal lobes; the pain may remain, but its psychic realization [Horányi] and the emotional reaction to it disappear). Here, precisely, there would be no deficits in the standard tests of intelligence, while a real reduction would become evident in the capacity to maintain an attitude and an attention and to make an effective plan; the personal characterological and reactive tendencies fade, an impairment of the functions of synthesis and an impoverishment of the creative imagination are observed (Hoch).
The most recent experience would instead speak in favor of slight changes of the personality (Mossa, 1950; Gillies, 1952; Freeman, 1952), so that it would seem that the much-feared disorders of the personality do not constitute a serious problem. "Religious indoctrination" (Levine and Albert, 1951) can persist efficiently, even if with varying degrees of intensity. "It is increasingly clear," says Freeman, "that these operations are a practical and useful method." Opinions, however, are by no means in agreement; in the Soviet Union, indeed, lobotomy has been abolished by an official decree (1951), because it is theoretically incompatible with Pavlov's discoveries. The disagreement, especially as regards schizophrenics, is notable above all between neurosurgeons and psychiatrists. One may admit about 40% of good results, with social readjustment (maxima of 80%, minima of 15%).
A very important problem is constituted by "readjustment to the environment," which occurs rather rapidly for patients with intelligent and understanding families; more often, however, a long and severe re-education is necessary, in particular to prevent patients from settling into inertia and indifference. In the United States of America, centers of occupational therapy, established also for this purpose, are very common.
It is not easy at present to give an absolute judgment of the beneficial results and the possible collateral damages of surgical psychotherapy; "new facts multiply every day, often contradict one another, but the complexity of the problems posed is so vast that these apparent contradictions are never absolute" (Puech). No method has so far given an indisputable proof, even though all of them count good successes to their credit. Surgical psychotherapy cannot be applied systematically to all mentally ill patients considered incurable, but only to well-studied and carefully selected subjects; the decision on the intervention remains, case by case, with the specialist psychiatrist alone.
From the standpoint of moral licitness, it must be borne in mind that p. constitutes an injury to the highest levels of the subject's personality, coming to modify, in a manner that is hardly reversible and grave, its intellectual and moral characteristics. In judging the legitimacy of the intervention, one must therefore take into account the starting point and the presumable point of arrival; the gravity of the mental state and the extent of the damage already produced by the illness justify the intervention: one chooses the lesser evil, rather than abstention, all the more so since the modified personality is superior to the one existing before the intervention.
Caso per caso, possono presentarsi gravi problemi di coscienza in rapporto agli infiniti gradi di passaggio tra individuo normale e alienato. Il giudizio potrà essere assai dibattuto per i soggetti le cui condizioni mentali siano normali e la p. c. venga applicata per distruggere la realizzazione psichica e la grave reazione emotiva di dolori non altrimenti vincibili.
Bibliography13 works
1950; J. S. Fulton, Frontal lobotomy and affective behavior. A neurophysiological analysis, Nuova York 1951; G. Comitato, G. Padovani, Russ. studi psichiat., 40 (1951), p. 205; Ministero della Sanità - U.R.S.S. = Nevropat. psichiat., 20 (1951), p. 17; A. Puca, Annali nevropat., 57 (1951), p. 341; L. Singer, La psychochirurgie des névroses et des psychoses, Strasburgo 1951; M. Yahn e altri, Trattamento chirurgico das molestias mentais (Leucosoma), São Paulo 1951; W. Freeman, in Amer. Journ. Psychiatr., 108 (1952), p. 521; H. Gillies, in Brit. med. Journ., fasc. 4757 (1952), p. 527; B. Callieri, in Studium, 48 (1952), p. 182.