PSYCHOSURGERY (PSYCHOSURGERY). — One of the most recent branches of modern medicine; it comprises a series of neurosurgical interventions aimed at curing or alleviating mental disorders for which, at least until now, an etiological therapy has not been possible. Some authors distinguish between “lesional” and “functional” psychosurgery: the former would include interventions for tumors and cerebral traumas, while the latter would constitute psychosurgery in the proper sense.
The history of psychosurgery, properly speaking, dates back to the Swiss psychiatrist G. Burckhardt, who was the first to perform such an operation more than 60 years ago. In 1935, the Portuguese Egas Moniz, now a Nobel laureate, described his “prefrontal leucotomy” at the International Neurology Congress in London. Using an instrument called a “leucotome,” he severed part of the nerve pathways connecting the frontal lobes with the rest of the brain, thereby interrupting those particular modifications of “nerve connections,” those peculiar fixed neuronic patterns upon which, according to Moniz, mental symptoms depend. The lobotomy is called prefrontal because this region of the brain is now considered a complex of association areas (Brodmann areas 8-9-10-11-44-46, etc.) where various cortical sensory and motor representations converge, along with emotional processes that bear the imprint of the ego.
From these principles, numerous surgical techniques and a highly fertile field of neurophysiological, anatomical, and psychological research have developed within a few years. From a technical standpoint, the following are currently practiced, depending on the extent and topography of the intervention: lobotomy and lobectomy, leucotomy, gyrectomy, topectomy, thalamotomy, selective subcortical incisions, etc. The interventions, even the most extensive ones, do not entail significant operative mortality; however, there is now a tendency toward open-skull procedures, both because bilateral action can be taken on a single operative field (unilateral lobotomy is much less effective) and because the danger of hemorrhagic complications and late deaths from edema and trophic disorders is avoided (McLardy). The most feared and frequent complication is, generally speaking, epileptogenic.
The technical and neurosurgical evaluation literature is extensive. Many authors consider lobotomy more effective in “anxious” patients, whether reactive or primary (Horanyi), while in “excited” patients, topotomy would be more useful; in “delusional” patients, topotomy would fail, whereas lobotomy would often overcome even deeply rooted delusions (Singer). As can be seen, these are indications based more on symptomatic than nosological grounds. The surgical requirements, however, oscillate between two extremes: either performing a broad intervention, e.g., a radical bilateral lobotomy, achieving the therapeutic goal only at the cost of a deterioration of psychic potential; or performing an overly limited intervention and thus failing to achieve the proposed result. Some authors, taking into account the predominant role of areas g and io in emotional expression, of dangerous areas in psychomotor impulsivity, and of orbital areas in the control of instinctive-affective tone, resort to leucotopectomies, judging them generally more suitable than other types of interventions.
Leucotomy primarily produces deficit phenomena (attributable mainly to the impairment of fronto-thalamo-hypothalamic circuits) affecting emotional excitability and, more rarely and mildly, certain higher psychic functions of an intellectual, noetic nature. Most recent authors agree in admitting that the decline of higher intellectual and ethical faculties can be considered negligible in practice, given both re-education and the pre-existing state in which patients undergoing psychosurgery generally find themselves (Gomirato).
Following the deficit phenomena, a series of “positive repressions” ensues, particularly in the sphere of thymospheria (affectivity) and behavior (psychosurgery has been defined as “behavioral surgery”). Anxious states, hyperemotionality, and emotional imbalances are influenced; maladaptability 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 possibly even reintegrative processes, likely facilitated by a reduction in neurovegetative reactivity.
The central problem of psychosurgery, perfectly framed in the contribution of Freeman and Watts (1950), still lies in the evaluation of lasting, stable personality changes. Such an evaluation, which requires a strictly specialized technique, cannot be precisely and reliably obtained in severe cases of schizophrenia (which contribute the most to psychosurgical interventions), where one can always doubt whether the symptoms are the result of the operation or, instead, an autonomous form of final stabilization.
However, personality alterations can be accurately assessed when psychosurgery is employed in severe, intractable painful conditions, e.g., in the agonizing pain of phantom limb in amputees, in trigeminal and causal neuralgias, thalamic pain (in such cases, the best results seem to be obtained, according to Fulton, by sectioning the inferomedial quadrants of the frontal lobes; the pain may remain, but its psychic realization and emotional reaction to it disappear [Horanyi]). In these cases, there would be no deficits in standard intelligence tests, while a real reduction in the ability to maintain an attitude and attention and to make effective plans would be evident; personal character and reactive tendencies fade, and a compromise of synthetic functions and impoverishment of creative imagination is observed (Hoch).
Recent experience, however, seems to indicate only slight changes in personality (Mossa, 1950; Gillies, 1952; Freeman, 1952), suggesting that the much-feared personality disorders do not constitute a serious problem. Religious indoctrination (Levine and Albert, 1951) can remain effective, albeit to varying degrees of intensity. It is increasingly clear, as Freeman states, that these operations are a practical and useful method. Opinions, however, are by no means unanimous; in the Soviet Union, in fact, lobotomy was abolished by an official decree (1951) as theoretically incompatible with Pavlov’s discoveries. The disagreement, particularly regarding schizophrenics, is notable especially between neurosurgeons and psychiatrists. One can admit to about 40% of good results, with social readaptation (ranging from a maximum of 80% to a minimum of 15%).
A very important problem is constituted by “readaptation to the environment,” which occurs quite rapidly in patients with intelligent and understanding families; more often, however, long and severe re-education is necessary, particularly to prevent patients from lapsing into inertia and indifference. In the United States, occupational therapy centers are very common, established for this very purpose.
It is not easy at present to render an absolute judgment on the beneficial results and any possible side effects of psychosurgery; "new facts multiply every day, often contradicting one another, but the complexity of the problems raised is so vast that these apparent contradictions are never absolute" (Puech). No method has yet provided irrefutable proof, even though all can claim good successes. Psychosurgery cannot be systematically applied to all mentally ill patients deemed incurable, but only to subjects who have been carefully studied and meticulously selected; the decision to intervene must be left each time to the psychiatrist specialist.
From the standpoint of moral legitimacy, it must be borne in mind that the procedure involves the destruction of the highest levels of the subject’s personality, bringing about, in a hardly reversible and serious manner, changes in intellectual and moral characteristics. In judging the legitimacy of the intervention, therefore, one must take into account both the starting point and the probable outcome; the severity of the mental state and the extent of the damage already caused by the illness justify the intervention: one chooses the lesser evil rather than mere custodial care, especially since the modified personality is superior to that existing before the intervention.
Case by case, serious problems of conscience may arise in relation to the infinite degrees of transition between the normal individual and the mentally alienated. The judgment may be hotly debated in the case of subjects whose mental conditions are normal and for whom psychosurgery is employed to destroy psychic realization and the severe emotional reaction of pain that cannot otherwise be overcome.