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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. ----- ----- First Efforts ----- ----- 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. ----- ----- END ----- -----