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Fall 1998, Vol.5, No.2
Bilateral Frontal Resection for Psychoses Revisted Edgar M. Housepian, M.D. Professor Emeritus of Clinical Neurological Surgery When I was first asked to write a commentary on Heath and Pool's article in Journal of Nervous and Mental Disease on psychosurgery I hesitated and then declined because I have never performed a psychosurgical procedure and basically have only a cultural knowledge of the development of psychosurgery and its decline in neurosurgery. I then re-read the article and was captivated by the clear descriptive style which is no longer evident in many scientific reports. This led me to look up Dr. Pool's other contributions to the field of psychosurgery and I found eleven articles written by him and his colleagues from the period of 1948 to 1959. As I reviewed this material it seemed to fall into an historical context. What factors forced the development of psychosurgery and what contributed to its demise? The relations of brain and behavior have been know for centuries, the development of neurosurgical techniques in the late 19th century and refinements in the early 20th century led to clinical investigation justified by a great need. Remember that at the time of these studies there were no good pharmacologic agents for the treatment of severe mental illness. I remember some of the daily treatments for psychotic patients who were chronically ill and severely incapacitated when I worked as a college student on the "Disturbed Ward" at Cornell's Westchester division [earlier known as Bloomingdale's Insane Asylum]. There were patients with manic depressive psychosis and schizophrenia in its various forms, including paranoid schizophrenia and catatonia, and general paretics. The treatments which I witnessed were limited to electro-shock, insulin shock and continuous tepid tubs. Patients were also wrapped in wet sheets and some subjected to hydrotherapy. Clearly psychotherapy was not working for this group of patients. With the introduction of frontal and pre-frontal lobotomy by Edgar Moniz and popularized by Freeman and Watts, it was apparent early on that, though sedative, there were many side affects which were not acceptable even to control the most violent patients. This included the now well known organic mental syndrome with flat affect and incontinence. It is in this setting that the work of Dr. Pool and his associates Drs. Heath, Ransohoff, Glusman and others who worked in the study known as the Columbia-Greystone Associates deserves great credit. Their attempt to refine the surgical treatment of these disorders while studying brain function was commendable. Eight years after the initiation of the project which Dr. Pool described in his 1948 article, he published a follow-up report of 106 cases treated by topectomy wherein he clearly described the limited beneficial effects and some of the major disadvantages of the operation. The procedure of circumscribed superficial cortical ablation was attended by zero mortality and had a much lower risk of impaired intellectual function and personality change and incontinence when compared to the white matter disruption of lobotomy. He ascribed this to the fact that the volume and area of the superficial cortical excision could be critically determined at operation unlike the blind cutting of tracts in lobotomy. He also showed conclusively that this was not a suitable procedure for chronically deteriorated schizophrenics and that there was a slightly higher incidence of seizures in topectomy patients than in patients under going lobotomy. Pool and his colleagues also made observations regarding electrical stimulation parameters as well as relating topographical information in an attempt to understand the physiology of topectomy. They found no relation between the site of frontal ablation and beneficial results but there was a definite relation to the quantity of cortical tissue excised. They concluded that the cortical ablation of portions of Broadman's area 10 at the rostral frontal pole and the rostral portion of area 11 was most effective. Subsequently Pool and his colleagues as well as other neurosurgeons around the world began to limit their psychosurgical procedures to the more successful treatment of obsessive compulsive neurosis and refined the operation to the cingulum with considerable salutary effects. Soon after, several events first slowed and then completely halted psychosurgery. The advent of psychotropic drugs had arrived and improvements in understanding the actions of these drugs and experience in treating patients with psychopharmacological agents was growing. At the same time by the end of the 1960's and certainly by the beginning of the middle of the 1970's there was a growing worldwide public outcry against "destructive" neurosurgery initially as a response to the deleterious effects of lobotomy but also conceptually. By this time not only was psychosurgery rarely done but stereotactic lesioning for a variety of conditions also began to lose favor. The simultaneous introduction of L-dopa signaled a temporary cessation of stereotactic surgery for movement disorders, particularly Parkinsonism, and it is only now that there has been a resurgence of interest in stereotactic surgery for the treatment of Parkinsonism and other movement disorders. Modern stereotactic surgery employs vastly improved technology for the required localization utilizing computerized tomography. A recognition that although pharmacological treatment for movement disorders has advanced a great deal, it has not abolished the problem but has provided further impetus to the return of stereotactic functional surgery. While re-reading Dr. Pool's article I was reminded that I owe my development as a young neurosurgeon in his department between 1955 and 1961 to him. He was a wonderful role model and gifted surgeon. His keen and inquiring mind led to many advances in neurological surgery and set the stage for still more. I am personally grateful to have had the privilege of growing up professionally under his guidance.
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