General Articles

The Cut That Makes Men Sane

Surgery has a new weapon against madness — an operation that reaches into the brain to snip the mental knots that cripple it

M. C. DINBERG, M.D.,GERALD ANGLIN March 1 1948
General Articles

The Cut That Makes Men Sane

Surgery has a new weapon against madness — an operation that reaches into the brain to snip the mental knots that cripple it

M. C. DINBERG, M.D.,GERALD ANGLIN March 1 1948

The Cut That Makes Men Sane

Surgery has a new weapon against madness — an operation that reaches into the brain to snip the mental knots that cripple it

M. C. DINBERG, M.D.

GERALD ANGLIN

JOHN’S SIX-FOOT frame lay immobile under the white drapes of the operating table, wasted away to a gaunt skeleton from an original 180 pounds. For many months he had refused to eat more than a mouthful at a time, barely enough to keep alive. Under the glare of a sharply focused lamp, his face was a mass of hollows and deep shadows. It showed no trace of emotion as a -doctor related John’s strange history to an expectant audience of medical specialists.

Discouraged when he had been turned down by the three armed services because of a heart murmur, he had suffered a further blow to his pride when his fiancée suddenly broke off their engagement and married one of his chums. This run of personal tragedy had been too much for him. Instead of developing new interests and new friends, he began to withdraw into himself. For several months forced gaiety had alternated with periods of depression and seclusion. This erratic behavior had cost him his job.

Then he began to hear compelling, mysterious voices, directing him to peculiar, antisocial actions. In a short time, he had lost contact altogether with the realities of life; had become a human robot, living in a fanciful dreamworld of his own creation. The doctors diagnosed John’s mental illness as schizophrenia. For three years medicine had battled to return John’s mind to normal. Deep coma, produced by insulin injections, had been tried over and over again. Metrazol shock treatments had also been used, producing convulsions. But for John these drastic, sometimes curative measures had failed, leading to the pitiful verdict that he was a hopeless mental cripple.

Release from Madness

NOW, WHILE the interested gallery of specialists looks on, John is going to have his last chance—a radical brain operation reserved for cases not helped by any other means.

Even as the surgeon injects a local anaesthetic into John’s shaven scalp and proceeds to drill two small holes through the temple bones to expose the brain the mental cripple remains inert and unflinching.

Then the surgeon introduces a small, sharp instrument directly into John’s brain and makes two steady, sure incisions, first on one side, then on the other. It is hard to believe but, with the last incision the young man relaxes visibly, as though released from a tight vise.

More than 2,000 persons have been released, like John, from the living hell of mental illness by this operation first known as a prefrontal lobotomy, now more correctly called a bilateral frontal lobe leucotomy.

Authentic reports from England, the U. S. and Canada, vouched for by reputable physicians, prove that leucotomy is neither a Hollywood brand of surgical wizardry nor yet a temporary, false-hope measure. No character of fiction ever underwent more amazing transformation than have many inmates of mental institutions after this treatment.

Often the only anaesthet ic used is a “local” into the scalp over the areas of operation. Many patients have conversed with their surgeons even while the incisions were being made into the brain tissue.

In some cases the operation has no beneficial efleet. But most patients sit up and eat well within 12 hours; often at this point they recognize and talk freely with relatives and friends to whom they have acted as strangers for months. They develop insatiable appetites and it is common for them to gain from 15 to 20 pounds in the first six months. This increased weight and the return of normal facial expression produce start ling before-and-after pictures.

But the greatest change is mental. Sullenness, confusion and other symptoms of mental disturbance give way to a more reasonable disposition. The morbid thoughts and fears which formerly dominated the deranged mind are abolished—or, if they still linger for a while, are so reduced as to be of little concern.

A new sense of personal satisfaction is born and, as a result, even the violent become more rational. Those cases which must remain under hospital supervision usually recover enough to be employed at simple tasks. In the more successful cases the patients are able to take their place again in it is as though they have

emerged from a bad dream or from under a dark cloud, with only vague recollections of their abnormal behavior. Sometimes this change for the better comes within a period of days or weeks, hut maximum improvement may not be reached for several months.

Continued on page 32

The Cut That Makes Men Sane

Continued from page 23

Swift and miraculous as are the results, the leucotomy operation must he recognized as a last-ditch tactic in the medical war on mental disease. There is little risk of the patient’s death; fatalities in all cases to date have totalled not more than one per cent, and the technique is constantly being improved. But leucotomy is still a major operation, and the surgeon operates only on the most hopeless mental cases, and only after all other means of treatment have failed, just as he wouid hesitate to remove an inflamed appendix unless it would not respond to other treatment.

Which mental cases will be helped by the leucotomy operation is usually decided by an expert psychiatrist and skilled neurosurgeon, working in close consultation. From experience they now know that leucotomy may help people suffering from depressed mental states and some types of schizophrenia. But the psychiatrist will recommend for the operation only patients whose dominant symptom is fear—persons who are so plagued by all manner of imaginary fears, worries and premonitions of disaster that: they are unable to lead anything like normal lives. And this is leucotomy’s great triumph: the startling change seen in patients almost immediately after the operation occurs, because these fears have been greatly reduced, if not completely banished.

Thus, the team of psychiatrist and surgeon have found in leucotomy a means of literally cutting away fear from an afflicted mind. To appreciate how this wonder is accomplished you must understand something of how the brain operates.

The Policeman in Your Brain

One part of your brain receives impressions of what you see, taste, hear, smell or touch. In another part, these impressions are stored away for future reference—your memory. How you act upon receiving such impressions determines what the psychologist calls your behavior pattern—your ability to get along with people, to face and find solutions for your problems.

Take a simple example: when you pull your fingers back from a hot light bulb, your nervous system has responded with a reflex action—the “decision” is an automatic one. But when you awake to find your house on fire, the decision whether to rush panicstricken down the stairs into the flames or to take refuge on a window ledge and wait for the fireman’s ladder must be referred to a more complex mechanism.

Your senses send a shout of “fire!” up to your brain, where several things happen almost simultaneously. Your memory prompt ly produces vivid recollections of what fires are like. Thus, abetted by experience, a primitive part of the brain called the thalamus and hypothalamus registers a blind impulse of self-preservation and shouts an order to flee—in any direction. But the same signal also flashes to another part of the brain—the frontal lobes.

This amazing group of cells takes a second look at the situation. It refers hack to the memory files and locates a stray hit of information you read somewhere about the right and wrong way to act in a fire. It considers whether there are other people in the house who may also be in danger and estimates the chances of a safe drop from the window if that ladder doesn’t arrive soon enough.

I n a flash it thinks over all these considerations, then signals its opinion hack to the thalamus and hypothalamus. Here thought and feeling combine to produce an order to the brain’s “motor area” which sends you more or less calmly to the window instead of in mad flight into the flames.

Place the heel of your palm just above one eyebrow and curve your hand back over your head. Directly beneath your hand, within the skull, lie oneofthetwo frontal lobes,man’s exclusive evolutionary achievement. In no animal are these lobes so well developed. Here are located your powers of discrimination, foresight, judgment and your ability to associate past experience with present situations.

This important maze of nervous tissue is intricately linked with all other parts of the brain, particularly the central lower portion where are located the thalamus and hypothalamus. Yet life is possible if the frontal lobes are missing.

Human beings who lost these lobes through accident or for neurosurgical reasons (such as the removal of tumors) act as if intoxicated—without the stagger. They become boastful, careless and lack both judgment and initiative; they can perform most normal tasks but can’t think things through or grasp complicated problems. But one thing struck medical men as most significant — such persons are incapable of feeling fear.

In a person mentally deranged the brain’s normal signal system is out of kilter. Fear impulses, for instance, can arise without any cause for fear being received by the senses. Normally the hypothalamus guards the delicate balance of human emotions—but suppose the wires become crossed and false fear signals are received from the frontal lobes. The person in whom that happens is so hounded by groundless fears that he becomes emotionally unstable.

If a surgeon were to sever some of the many connections between the frontal lobes and the hypothalamus, might this not do away with most of the false fear signals yet leave the lobes themselves intact and with sufficient connections for the brain to operate with near-normal powers of intellect and judgment?

Such reasoning led psychiatrists and surgeons to attempt the operation known as leucotomy — literally a cutting of white fibres.

It’s a Portuguese Idea

Even before history was written, primitive surgeons drilled crude holes through the skull to relieve brain injuries and presumably to permit the evil spirits of insanity to escape. In the ancient ruins of Peru and among the remains of early Indians of British Columbia, archaeologists have found numerous skulls with unmistakable surgical openings in them. In more recent times, certain visionary surgeons came to believe that the way to cure mental diseases was through direct attack upon the brain itself.

Several brain surgeons, more daring than others, operated upon the brains of the mentally ill as long as 50 years ago. Because they cut only one side of the brain, the results were unsuccessful. But where others had failed, in 1935 a Portuguese psychiatrist , Egas Moniz, and neurosurgeon, Almeida Lima, succeeded. They made incisions into both the right and left frontal lobes.

Continued on page 35

Continued, from page 32

Cold, polite scepticism greeted the first report of their unorthodox operation upon the master organ of the body, even when they told how 14 out of 20 patients had been either cured or greatly improved. Wary medical men knew too well how a distorted brain may seemingly recover only to suffer a relapse.

It remained for two neurospecialists from the George Washington University School of Medicine in the American capital, Doctors Walter Freeman and James W. Watts, to improve upon the original operation and to show that the Portuguese doctors were right. Soon other neurosurgeons and psychiatrists came from all over the world to see and marvel and learn the new technique.

Among these were two Canadian doctors, one a psychiatrist, the other a surgeon, who were eager to bring the benefits of the new treatment to mental patients in Canada. After studying the methods of Freeman and Watts the Canadian psychiatrist began his careful selection of cases, the surgeon developed a further refinement of the operative technique, and as a result they were recently able to report in the Canadian Medical Association Journal a highly successful series of 27 bilateral frontal lobe leucotomies.

While in certain earlier operations the skull had been entered from the temples the Canadian surgeon decided to reach the lobes through the top of the skull. Above each lobe he drills two tiny holes an inch and a half apart, then removes the thin intervening blocks of bone. After opening the dura, the heavy membrane which covers the brain inside the skull, the surgeon first determines the exact place for cutting the brain by inserting a “brain needle” through the lobe. Then he is ready to perform the actual cutting of the desired proportion of the white fibres which link the lobe with the hypothalamus—but for this he uses not a knife or other familiar cutting instrument but a device of his own design.

This is a long, slim,'round instrument, itself not unlike a large needle, but having a groove down one side in which a fine wire lies concealed. As an assistant removes the brain needle the surgeon inserts his special leucotomy device. When it is in position he depresses a lever which forces a loop of the wire to push out at one side—and the wire neatly severs the fibres in its path. This is done in each lobe.

This procedure cuts approximately three fifths of the white fibres (the doctor calls them “association tracts”) linking the frontal lobes with the thalamus and hypothalamus.

Idiocy Not the Outcome

“Won’t he be an idiot after this brain operation?” is often the worried question of relatives concerned about what may happen after any tampering with the brain. But such fears are groundless.

■In the more successful cases the return to normal is so nearly complete that only with special tests could any difference in intelligence be discovered, say psychiatrists who have worked with leucotomy patients. In cases where the mental illness has lasted many years, they point out that the brain may be somewhat impaired before the operation. And in the serious type of cases chqsen for operation it is usually difficult to measure intelligence before the leucotomy is performed.

Typical operations in the Canadian group have been performed on men and women past middle age who have reached the change of life, a period sometimes accompanied by mental breakdown. One case was that of a woman approaching 50 who became steadily more emotionally upset. She criticized everything and everyone in the, home until family life became unbearable. As her mental state became more serious she took to pacing the room, moaning, and repeating that something terrible was going to happen to her. She had gone on this way for more than a year, despite electroshock treatments.

Then the leucotomy was performed. She recovered and returned to her family.

The difference in her outlook completely changed the atmosphere of the home. She was able to supervise its operation, instruct her help as to what to have for dinner and direct the housekeeping chores. There was no more of the carping criticism which had previously made life miserable for everyone; instead, she was easy-going. And no longer was she haunted by fear.

Full recovery doesn’t come overnight, psychiatrists warn. For a time the old fears may persist—but because the patient is no longer wrought up and excited the old phobias don’t bother him. He may still think semeone’s waiting to pounce on him from the closet—but his attitude is “so what?” And gradually the false fears no longer persist.

Twenty-three of the 27 patients operated on in the Canadian group showed marked improvement ranging from loss of violent behavior to complete recovery. Ten of these recovered so fully as to be able to leave hospital. Only four of the 27 cases showed no beneficial results.

At a time when the cost of treatment and institutional care for mental patients has become a mounting factor in the national medical bill, it is interesting to note that the recoveries effected in this one small group of patients represent an estimated saving of $70,000—the cost of future care they will no longer need.

In another series of leucotomies done in England, the results exceeded any ever before obtained by other means. The operation removed or relieved the mental symptoms almost without exception in 44 cases of manic-depressive psychosis, that mental illness in which there are alternating periods of depression and boisterous exhilaration.

Typical of the many who have regained a normal life is Mrs. C. B., a 62-year-old housewife who was mentally deranged for six years. During this time she would sit for hours with legs drawn up, her body bent over, the blankets over her head. The morning after leucotomy she rested comfortably in ht d. Less than one month later she returned to her own home and took over all household work.

Before leucotomy, chances of recovery for all those Toronto and English patients had been remote. There were not merely neurotic or hysterical or simply peculiar people— each and every one was certifiable as a hopeless mental case. Ten years ago all of them likely would have spent the remainder of their lives in a mental hospital.

Today, thanks to surgical vision and skill, the veil which overhangs 50,000 mentally ill persons in Canada and other thousands throughout the world has been partially drawn aside. Leucotomy can help to decrease the multit ude of pathetic creatures who walk aimlessly in barren wards or lie helpless in restraining sheets, useless to themselves, unwanted by others. For these people, for their families and for society, there is a kindling of new hope. if