Skeptics about pallidotomy often cite the false hopes raised in 1987 by a=
=0AMexico City surgeon named Ignacio Madrazo.  He reported helping patien=
ts by=0Atransplanting into their brains cells from adult adrenal glands, =
which were=0Athought to spew chemicals offsetting a neuronal deficiency. =
 Patients rushed=0Ato get the transplants, but U.S.  researchers in 1989 =
quashed the fad by=0Areporting that careful evaluations of such patients =
showed minimal, short-=0Alived benefits and a high rate of complications.=
  (The effectiveness of=0Aanother kind of brain transplant for Parkinson'=
s disease - of brain tissue=0Afrom aborted fetuses - isn't yet establishe=
d.  A study of the technique is=0Aexpected to begin within weeks.)
Surgery can cause a placebo effect.  In a 1950s study, heart patients giv=
en=0Asham artery bypass operations - incisions without bypasses - reporte=
d as much=0Arelief from the pain of angina as those who got bypasses.  Wi=
th Parkinson's,=0Athe risk of overestimating an operation's benefits is h=
eightened by the=0Asubjective nature of many of the disease's symptoms, s=
ays Chicago neurologist=0AHarold Klawans.  "A patient's mood can affect h=
ow much he can do" in=0Aovercoming the disease's lack of muscle control, =
he says.
While acknowledging that pallidotomies can help some people, the doubters=
 say=0Adesperate patients may rush to get the operation from surgeons who=
 don't have=0Amuch experience doing it, with potentially disastrous resul=
ts.  Indeed, Dr.=0ALaitinen reported that six of his first 38 pallidotomy=
 patients had permanent=0Ablind spots in their visual fields after the su=
rgery.  The problem no longer=0Aoccurs, he says, because he has figured o=
ut how to avoid damaging neurons that=0Acarry visual signals.
The skeptics also note that before L-dopa, neurosurgeons often tried, wit=
h=0Aonly limited success, to help by destroying parts of the pallidum.  T=
he idea=0Aarose from the observation that Parkinson's patients who had mi=
nor strokes=0Asometimes lost their tremor.  The strokes apparently had di=
sabled misfiring=0Aneurons that were responsible for the quivering.
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First Efforts
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Beginning in the 1930s, surgeons tried to nick the same brain area hit by=
 the=0Abeneficial strokes.  The results were promising - and appalling.  =
One pioneer,=0ARussell Meyers, reported that after he cut nerve tracts ne=
ar the pallidum in=0A38 patients, 25 had lessened Parkinson's symptoms bu=
t six died soon afterward.
Later, surgeons improved the precision of probes and did better.  By=0Ade=
stroying part of the pallidum, an area that helps control movement, they=
=0Aalleviated some of the muscle rigidity.  But the surgery reportedly di=
d little=0Afor tremor and the inability to make voluntary movements.
Then researchers learned that the brains of Parkinson s patients were=0Ad=
eficient in dopamine, a neurotransmitter that carries signals between=0An=
eurons.  In the late 1960s, they found that oral doses of a dopamine=0Apr=
ecursor, L-dopa, could ease the deficiency, mitigating symptoms.  That=0A=
killed off most surgery for the disease.
Unknown to most doctors, however, a noted Swedish surgeon named Lars Leks=
ell=0Ahad found that by knocking out part of the pallidum not usually tar=
geted, he=0Acould dramatically improve all Parkinson's symptoms.  The lat=
e Dr. Leksell=0Adidn't publish his finding "because he believed that a ne=
urosurgeon was biased=0Ain reporting his own results," says Dr. Laitinen,=
 one of his prot=E9g=E9s.  Less=0Aold-fashioned, Dr. Laitinen issued his =
startling 1992 report on the procedure=0Aafter trying it on 38 patients w=
ho were failing on L-dopa.
"Neurologists were extremely surprised by the results," says Dr. Laitinen=
.  He=0Asays he has now performed about 350 pallidotomies with similar re=
sults.=0A"Younger patients do particularly well.  We recently checked the=
 first 10=0Apatients who got pallidotomies in 1985 and 1986," he says, "a=
nd nine of them=0Aare doing well."
----- -----
How It Might Work
----- -----
Medical textbooks say brain surgery can help the tremor of Parkinson's bu=
t not=0Athe freezing.  Rethinking that in light of the new pallidotomy re=
sults,=0Ascientists theorize that lack of dopamine incites furious firing=
 by certain=0Aneurons that normally help suppress undesired movement.  Th=
at causes=0AParkinson's patients to freeze up.  Pallidotomy appears to cu=
t these=0Aoveractive "inhibitory" brain pathways, as well as ones that in=
duce tremors.
But the jury is still out on crucial issues: how effective the surgery is=
, how=0Amuch risk it poses, precisely what part of the pallidum to destro=
y for maximum=0Abenefit and how long the benefit lasts.  An Emory Univers=
ity team in Atlanta=0Ahas begun a federally funded study to answer these =
questions, but its results=0Aaren't expected for years.  A report on 126 =
patients given pallidotomies by=0ADr. Iacono is expected to be published =
soon.
Meanwhile, patients are getting some answers via the Internet and support=
=0Agroups.  After flying to Stockholm for a pallidotomy, Alan Bonander, o=
f San=0ARamon, Calif., recently produced a videotape on the surgery that =
is now=0Acirculating in the Parkinson's-disease network.  In a moving seg=
ment, Mr.=0ABonander is shown with immobile limbs just before the surgery=
.  then flexing=0Ahis limbs with fluid speed just after - calling to mind=
 the "Wizard of Oz"=0Ascene in which Dorothy oils the rusted tin man.  Mr=
. Bonander say he still has=0Asome problems with tremor and rigidity, but=
 "my quality of life" has improved.
----- -----
Outcomes Research
----- -----
David Devor, a Jerusalem resident whose wife has Parkinson's, recently po=
sted=0Aon the Internet what may be the most comprehensive report so far o=
n=0Apallidotomy outcomes.  After being advised against the surgery by his=
 wife's=0Adoctor, he asked Dr. Iacono for evidence that it works.  "I hea=
rd a lot of=0Aneurologists call him a charlatan," Mr. Devor says.
Dr. Iacono responded by sending him the names of all his pallidotomy pati=
ents=0Afrom late 1993 to late 1994.  Running up a $1,000 phone bill, Mr. =
Devor=0Ainterviewed 113 of the patients or their spouses.  Nine said they=
 hadn't been=0Ahelped, including five who said they got worse, Mr. Devor =
reported; but about=0A80% said the surgery gave them "marked improvement,=
" with symptoms lessened by=0A20% to 100%.
Many described the surgery with words like "miraculous," he added in the=
=0Areport.  Most typical were the expressions of relief to be again able =
to turn=0Aover in bed, shower and dress alone, eat normally .  .  ., to w=
alk, write and=0Awork normally or almost normally, and even drive a car."=
  Mr. Devor concluded=0Aby asking, "Would I fly in a shuttle that had a 9=
2% reliability of getting me=0Asome distance away from hell on earth, 8% =
of doing me some harm and well under=0A1% of killing me?"
His wife, Aviva, is scheduled to have a pallidotomy next week.

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