Medicine: Grey Matter

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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.