SURGICAL PSYCHOTHERAPY (PSYCHOSURGERY). — One of the most recent branches of modern medicine; it comprises a whole series of neurosurgical procedures intended to cure or alleviate mental disorders to which, at least thus far, it has not been possible to apply etiological therapy. Some authors distinguish a “lesional” and a “functional” p.; the first form would include procedures for tumors and cerebral traumas, whereas the functional form would constitute s. p. properly so called.
The history of p., properly understood, goes back to the Swiss psychiatrist G. Burehardt, who was the first to carry out this type of operation more than 60 years ago. In 1935 the Portuguese Egas Moniz, Nobel laureate, described his “prefrontal leucotomy” at the Second International Congress of Neurology in London: by means of an instrument called a “leucotome,” part of the nerve pathways connecting the frontal lobes with the rest of the brain is interrupted; those particular modifications of the nervous “connections,” those peculiar fixed neuronic patterns on which, according to Moniz, the mental symptoms would depend, would thus be interrupted. The lobotomy is prefrontal because this region of the brain is now regarded as a set of association fields
(areas 8-9-10-11-44-46, etc., of Broadmann) in which the various sensitive and motor cortical representations converge, together with the emotional processes that bear the imprint of the Ego. Numerous operative techniques and a highly fertile field of neurophysiological, anatomoclinical, and psychological research have developed from these principles in only a few years. From the technical point of view, the following are currently performed, according to the extent and topography of the intervention: lobotomy and lobectomy, leucotomy, girectomy, topectomy, thalamotomy, selective subcortical excisions, etc. The procedures, even the most extensive, are not burdened by significant operative mortality; today, however, there is a tendency to operate with the skull open, both because it is possible to act bilaterally through a single operative field (unilateral lobotomy is much less effective), and because this avoids the danger of hemorrhagic complications and late deaths from uremia and trophic disorders (Mc Lardy); the most feared and most frequent complication is, generally, epileptogenic in nature.
The literature on neurosurgical technique and evaluation is extremely extensive; many authors consider lobotomy more effective in the “anxious,” both reactive and primary (Horanyi), whereas in the “excited” topectomy would be more useful; in the “delusional,” topectomy would fail, whereas lobotomy would often overcome even the most deeply rooted delusions (Singer). As can be seen, these are indications more symptomatic than nosological in nature. Operative requirements, nevertheless, oscillate between two extremes: either carrying out an extensive procedure, e.g., a radical bilateral lobotomy, achieving the therapeutic goal only at the cost of a deterioration of psychic potential; or performing an intervention that is too limited and thus failing to obtain the intended result. Some authors, taking into account the predominant role of areas 9 and 10 in emotional integration, of the pericallosal areas in psychomotor impulsivity, and of the orbital areas in the control of instinctive-affective tone, resort to leucotopetomies, judging them generally more suitable than other types of intervention.
Leucotomy first produces deficit phenomena (attributable mainly to impairment of the fronto-thalamo-hypothalamic circuits) affecting emotional excitability and, more rarely and mildly, certain higher psychic functions of the intellectual, noetic type. Most of the more recent authors agree in admitting that the decline of the highest intellectual and ethical powers may be regarded as negligible in practice, taking into account both re-education and the preceding condition in which the patients undergoing s. p. are generally found (Gomirato).
The deficit phenomena are followed by a series of “positive repercussions,” especially in the sphere of thymopsychism (affectivity) and behavior (s. p. has been defined as the “surgery of behavior”): anxious and hyperemotional states and emotional imbalances are influenced; maladjustment to the environment, inertia, and 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 a reduction in neurovegetative reactivity.
The central problem of s. p., perfectly framed in the contribution of Freeman and Watts (1950), lies entirely in the evaluation of the enduring, stable modifications of the personality. This evaluation, which requires a strictly specialized technique, cannot be obtained with precision and certainty in severe forms of schizophrenia (which provide the largest proportion of candidates for psychosurgical procedures), in which it is always possible to question whether the symptoms are the result of the operation or, instead, an autonomous form of final stabilization.
By contrast, alterations of the personality can be accurately specified when s. p. is employed in severe painful conditions resistant to every treatment, e.g., in the atrocious phantom-limb pains of amputees, trigeminal neuralgias, causalgias, and thalamic pains (in such cases, according to Fulton, the best results seem to be obtained by sectioning the inferomedial quadrants of the frontal lobes; the pain may remain, but its psychic realization disappears [Horanyi], as does the emotional reaction to it). Here, precisely, there would be no deficits in standard intelligence tests, whereas a genuine reduction would become evident in the capacity to maintain an attitude and attention and to formulate an effective plan; personal characterological and reactive tendencies fade, and impairment of synthetic functions and impoverishment of creative imagination are observed (Hoch).
The most recent experience, on the other hand, would point to slight changes in personality (Mossa, 1950; Gillies, 1952; Freeman, 1952), so that the much-feared personality disorders would not appear to constitute a serious problem. “Religious indoctrination” (Levine and Albert, 1951) may remain effective, even if with varying degrees of intensity. “It is becoming increasingly clear,” says Freeman, “that these operations are a practical and useful method.” Opinions, however, are by no means unanimous; in the Soviet Union, indeed, lobotomy was abolished by an official decree (1951), because it was theoretically incompatible with Pavlov’s discoveries. The disagreement, especially regarding schizophrenic patients, is particularly marked between neurosurgeons and psychiatrists. Approximately 40% good results, with social readjustment, may be admitted (maximum 80%, minimum 15%).
A very important problem is constituted by “readjustment to the environment,” which occurs fairly rapidly in patients with intelligent and understanding families; more often, however, lengthy and rigorous re-education is necessary, particularly to prevent patients from settling into inertia and indifference. In the United States of America, occupational therapy centers, established for this purpose as well, are very common.
Non è facile attualmente dare un giudizio assoluto dei risultati benefici e degli eventuali danni collaterali della p. c.; «i fatti nuovi si moltiplicano ogni giorno, si contraddicono spesso gli uni rispetto agli altri, ma la complessità dei problemi posti è così vasta che queste apparenti contraddizioni non sono mai assolute» (Puech). Nessun metodo ha dato finora una prova indiscutibile, anche se tutti contano buoni successi al loro attivo. La p. c. non può venir applicata sistematicamente a tutti gli ammalati mentali considerati incurabili, ma solo a soggetti ben studiati e accuratamente selezionati; soltanto allo specialista psichiatra rimane volta per volta la decisione dell'intervento.
Sotto l'aspetto della liceità morale, va tenuto presente che la p. costituisce lesione dei livelli più elevati della personalità del soggetto, giungendo a modificarne, in maniera difficilmente reversibile e grave, le caratteristiche intellettuali e morali. Nel giudizio di legittimità dell'intervento, bisogna quindi tener conto del punto di partenza e di quello presumibile di arrivo; la gravità dello stato mentale e la vastità dei danni già prodotti dalla malattia giustificano l'intervento: si sceglie il male minore, piuttosto che l'astensione, tanto più che la personalità modificata è superiore a quella esistente prima dell'intervento.
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.
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.