AHP readers may be interested in a recent special issue from Neurosurgical Focus on “Neurosurgery, Psychiatry, and Function: The History of Altering Behavior, Thought, and Function Through Neurosurgery.” Full titles, authors, and abstract follow below.
“Introduction. Neurosurgery, psychiatry, and function: the history of altering behavior, thought, and function through neurosurgery,” by Mark C. Preul, MD, T. Forcht Dagi, MD, Charles J. Prestigiacomo, MD, and Chris A. Sloffer, MD, MBA. No abstract.
“Sanger Brown and Edward Schäfer before Heinrich Klüver and Paul Bucy: their observations on bilateral temporal lobe ablations,” by Prasad S. S. V. Vannemreddy, MD, and James L. Stone, MD. Abstract:
Fifty years before a report on the complete bitemporal lobectomy syndrome in primates, known as the Klüver-Bucy syndrome, was published, 2 talented investigators working at the University College in London, England—neurologist Sanger Brown and physiologist Edward Schäfer—also made this discovery. The title of their work was “An investigation into the functions of the occipital and temporal lobes of the monkey’s brain,” and it involved excisional brain surgery in 12 monkeys. They were particularly interested in the then-disputed primary cortical locations relating to vision and hearing. However, following extensive bilateral temporal lobe excisions in 2 monkeys, they noted peculiar behavior including apparent loss of memory and intelligence resembling “idiocy.” These investigators recognized most of the behavioral findings that later came to be known as the Klüver-Bucy syndrome. However, they were working within the late-19th-century framework of cerebral cortical localizations of basic motor and sensory functions.
Details of the Brown and Schäfer study and a glimpse of the neurological thinking of that period is presented. In the decades following the pivotal work of Klüver and Bucy in the late 1930s, in which they used a more advanced neurosurgical technique, tools of behavioral observations, and analysis of brain sections after euthanasia, investigators have elaborated the full components of the clinical syndrome and the extent of their resections.
Other neuroscientists sought to isolate and determine the specific temporal neocortical, medial temporal, and deep limbic structures responsible for various visual and complex behavioral deficits. No doubt, Klüver and Bucy’s contribution led to a great expansion in attention given to the limbic system’s role in action, perception, emotion, and affect—a tide that continues to the present time.
“Editorial. The Klüver-Bucy syndrome and the golden age of localization,” by Chris A. Sloffer, MD, MBA. No abstract.
“The early argument for prefrontal leucotomy: the collision of frontal lobe theory and psychosurgery at the 1935 International Neurological Congress in London,” by Lillian B. Boettcher, BA, and Sarah T. Menacho, MD. Abstract:
The pathophysiology of mental illness and its relationship to the frontal lobe were subjects of immense interest in the latter half of the 19th century. Numerous studies emerged during this time on cortical localization and frontal lobe theory, drawing upon various ideas from neurology and psychiatry. Reflecting the intense interest in this region of the brain, the 1935 International Neurological Congress in London hosted a special session on the frontal lobe. Among other presentations, Yale physiologists John Fulton and Carlyle Jacobsen presented a study on frontal lobectomy in primates, and neurologist Richard Brickner presented a case of frontal ablation for olfactory meningioma performed by the Johns Hopkins neurosurgeon Walter Dandy. Both occurrences are said to have influenced Portuguese neurologist Egas Moniz (1874–1955) to commence performing leucotomies on patients beginning in late 1935. Here the authors review the relevant events related to frontal lobe theory leading up to the 1935 Neurological Congress as well as the extent of this meeting’s role in the genesis of the modern era of psychosurgery.
“Editorial. London 1935: the frontal lobe, insanity, and a brain surgery,” by Mark C. Preul, MD, and T. Forcht Dagi, MD, DMedSc, DHC. No abstract.
“Psychosurgery, ethics, and media: a history of Walter Freeman and the lobotomy,” by James P. Caruso, BS, and Jason P. Sheehan, MD, PhD. Abstract:
At the peak of his career, Walter J. Freeman II was a celebrated physician and scientist. He served as the first chairman of the Department of Neurology at George Washington University and was a tireless advocate of surgical treatment for mental illness. His eccentric appearance, engaging personality during interviews, and theatrical demonstrations of his surgical techniques gained him substantial popularity with local and national media, and he performed more than 3000 prefrontal and transorbital lobotomies between 1930 and 1960. However, poor patient outcomes, unfavorable portrayals of the lobotomy in literature and film, and increased regulatory scrutiny contributed to the lobotomy’s decline in popularity. The development of antipsychotic medications eventually relegated the lobotomy to rare circumstances, and Freeman’s reputation deteriorated. Today, despite significant advancements in technique, oversight, and ethical scrutiny, neurosurgical treatment of mental illness still carries a degree of social stigma.
This review presents a historical account of Walter Freeman’s life and career, and the popularization of the lobotomy in the US. Additionally, the authors pay special attention to the influence of popular literature and film on the public’s perception of psychosurgery. Aided by an understanding of this pivotal period in medical history, neurosurgeons are poised to confront the ethical and sociological questions facing psychosurgery as it continues to evolve.
“Topectomy versus leukotomy: J. Lawrence Pool’s contribution to psychosurgery,” by Ryan Holland, MD, David Kopel, MD, Peter W. Carmel, MD, MedSci, and Charles J. Prestigiacomo, MD. Abstract:
Surgery of the mind has a rather checkered past. Though its history begins with the prehistoric trephination of skulls to allow “evil spirits” to escape, the early- to mid-20th century saw a surge in the popularity of psychosurgery. The 2 prevailing operations were topectomy and leukotomy for the treatment of certain mental illnesses. Although they were modified and refined by several of their main practitioners, the effectiveness of and the ethics involved with these operations remained controversial.
In 1947, Dr. J. Lawrence Pool and the Columbia-Greystone Associates sought to rigorously investigate the outcomes of specific psychosurgical procedures. Pool along with R. G. Heath and John Weber believed that nonexcessive bifrontal cortical ablation could successfully treat certain mental illnesses without the undesired consequences of irreversible personality changes. They conducted this investigation at the psychiatric hospital at Greystone Park near Morristown, New Jersey.
Despite several encouraging findings of the Columbia-Greystone project, psychosurgery practices began to decline significantly in the 1950s. The uncertainty of results and ethical debates related to side effects made these procedures unpopular. Further, groups such as the National Association for the Advancement of Colored People and the American Civil Liberties Union condemned the use of psychosurgery, believing it to be an inhumane form of treatment. Today, there are strict guidelines that must be adhered to when evaluating a patient for psychosurgery procedures. It is imperative for the neurosurgery community to remember the history of psychosurgery to provide the best possible current treatment and to search for better future treatments for a particularly vulnerable patient population.
“The origins and persistence of psychosurgery in the state of Iowa,” by Francis J. Jareczek, BS, BA, Marshall T. Holland, MD, Matthew A. Howard III, MD, Timothy Walch, PhD, and Taylor J. Abel, MD. Abstract:
Neurosurgery for the treatment of psychological disorders has a checkered history in the United States. Prior to the advent of antipsychotic medications, individuals with severe mental illness were institutionalized and subjected to extreme therapies in an attempt to palliate their symptoms. Psychiatrist Walter Freeman first introduced psychosurgery, in the form of frontal lobotomy, as an intervention that could offer some hope to those patients in whom all other treatments had failed. Since that time, however, the use of psychosurgery in the United States has waxed and waned significantly, though literature describing its use is relatively sparse. In an effort to contribute to a better understanding of the evolution of psychosurgery, the authors describe the history of psychosurgery in the state of Iowa and particularly at the University of Iowa Department of Neurosurgery. An interesting aspect of psychosurgery at the University of Iowa is that these procedures have been nearly continuously active since Freeman introduced the lobotomy in the 1930s. Frontal lobotomies and transorbital leukotomies were performed by physicians in the state mental health institutions as well as by neurosurgeons at the University of Iowa Hospitals and Clinics (formerly known as the State University of Iowa Hospital). Though the early technique of frontal lobotomy quickly fell out of favor, the use of neurosurgery to treat select cases of intractable mental illness persisted as a collaborative treatment effort between psychiatrists and neurosurgeons at Iowa. Frontal lobotomies gave way to more targeted lesions such as anterior cingulotomies and to neuromodulation through deep brain stimulation. As knowledge of brain circuits and the pathophysiology underlying mental illness continues to grow, surgical intervention for psychiatric pathologies is likely to persist as a viable treatment option for select patients at the University of Iowa and in the larger medical community.
“History of psychosurgery at Sainte-Anne Hospital, Paris, France, through translational interactions between psychiatrists and neurosurgeons,” by Marc Zanello, MD, MSc, Johan Pallud, MD, PhD, Nicolas Baup, MD, PhD, Sophie Peeters, MSc, Baris Turak, MD, Marie Odile Krebs, MD, PhD, Catherine Oppenheim, MD, PhD, Raphael Gaillard, MD, PhD, and Bertrand Devaux, MD. Abstract:
Sainte-Anne Hospital is the largest psychiatric hospital in Paris. Its long and fascinating history began in the 18th century. In 1952, it was at Sainte-Anne Hospital that Jean Delay and Pierre Deniker used the first neuroleptic, chlorpromazine, to cure psychiatric patients, putting an end to the expansion of psychosurgery. The Department of Neuro-psychosurgery was created in 1941. The works of successive heads of the Neurosurgery Department at Sainte-Anne Hospital summarized the history of psychosurgery in France.
Pierre Puech defined psychosurgery as the necessary cooperation between neurosurgeons and psychiatrists to treat the conditions causing psychiatric symptoms, from brain tumors to mental health disorders. He reported the results of his series of 369 cases and underlined the necessity for proper follow-up and postoperative re-education, illustrating the relative caution of French neurosurgeons concerning psychosurgery.
Marcel David and his assistants tried to follow their patients closely postoperatively; this resulted in numerous publications with significant follow-up and conclusions. As early as 1955, David reported intellectual degradation 2 years after prefrontal leucotomies.
Jean Talairach, a psychiatrist who eventually trained as a neurosurgeon, was the first to describe anterior capsulotomy in 1949. He operated in several hospitals outside of Paris, including the Sarthe Psychiatric Hospital and the Public Institution of Mental Health in the Lille region. He developed stereotactic surgery, notably stereo-electroencephalography, for epilepsy surgery but also to treat psychiatric patients using stereotactic lesioning with radiofrequency ablation or radioactive seeds of yttrium-90.
The evolution of functional neurosurgery has been marked by the development of deep brain stimulation, in particular for obsessive-compulsive disorder, replacing the former lesional stereotactic procedures.
The history of Sainte-Anne Hospital’s Neurosurgery Department sheds light on the initiation—yet fast reconsideration—of psychosurgery in France. This relatively more prudent attitude toward the practice of psychosurgery compared with other countries was probably due to the historically strong collaboration between psychiatrists and neurosurgeons in France.
“Pneumoencephalography in the workup of neuropsychiatric illnesses: a historical perspective,” by Mariam Ishaque, PhD, David J. Wallace, MD, and Ramesh Grandhi, MD. Abstract:
Throughout history, neurosurgical procedures have been fundamental in advancing neuroscience; however, this has not always been without deleterious side effects or harmful consequences. While critical to the progression of clinical neuroscience during the early 20th century, yet, at the same time, poorly tolerated by patients, pneumoencephalography is one such procedure that exemplifies this juxtaposition. Presented herein are historical perspectives and reflections on the role of the pneumoencephalography in the diagnosis and treatment of neuropsychiatric illnesses.
“Neuroplasticity and the brain connectome: what can Jean Talairach’s reflections bring to modern psychosurgery?,” by Pierre Bourdillon, MD, Caroline Apra, MSc, MD, Marc Lévêque, MD, and Fabien Vinckier, MD, PhD. Abstract:
Contrary to common psychosurgical practice in the 1950s, Dr. Jean Talairach had the intuition, based on clinical experience, that the brain connectome and neuroplasticity had a role to play in psychosurgery. Due to the remarkable progress of pharmacology at that time and to the technical limits of neurosurgery, these concepts were not put into practice. Currently, these concepts are being confirmed by modern techniques such as neuroimaging and computational neurosciences, and could pave the way for therapeutic innovation in psychiatry.
Psychosurgery commonly uses a localizationist approach, based on the idea that a lesion to a specific area is responsible for a deficit opposite to its function. To psychosurgeons such as Walter Freeman, who performed extensive lesions causing apparently inevitable deficit, Talairach answered with clinical data: complex psychic functions cannot be described that simply, because the same lesion does not provoke the same deficit in different patients. Moreover, cognitive impairment did not always follow efficacious psychosurgery. Talairach suggested that selectively destructing part of a network could open the door to a new organization, and that early psychotherapy could encourage this psychoplasticity. Talairach did not have the opportunity to put these concepts into practice in psychiatric diseases because of the sudden availability of neuroleptics, but connectomics and neuroplasticity gave rise to major advances in intraparenchymal neurosurgery, from epilepsy to low-grade glioma. In psychiatry, alongside long-standing theories implicating focal lesions and diffuse pathological processes, neuroimaging techniques are currently being developed. In mentally healthy individuals, combining diffusion tensor imaging with functional MRI, magnetoencephalography, and electroencephalography allows the determination of a comprehensive map of neural connections in the brain on many spatial scales, the so-called connectome. Ultimately, global neurocomputational models could predict physiological activity, behavior, and subjective feeling, and describe neuropsychiatric disorders.
Connectomic studies comparing psychiatric patients with controls have already confirmed the early intuitions of Talairach. As a striking example, massive dysconnectivity has been found in schizophrenia, leading some authors to propose a “dysconnection hypothesis.” Alterations of the connectome have also been demonstrated in obsessive-compulsive disorder and depression. Furthermore, normalization of the functional dysconnectivity has been observed following clinical improvement in several therapeutic interventions, from psychotherapy to pharmacological treatments. Provided that mental disorders result from abnormal structural or functional wiring, targeted psychosurgery would require that one be able: 1) to identify the pathological network involved in a given patient; 2) to use neurostimulation to safely create a reversible and durable alteration, mimicking a lesion, in a network compatible with neuroplasticity; and 3) to predict which functional lesion would result in adapted neuronal plasticity and/or to guide neuronal plasticity to promote recovery. All these conditions, already suggested by Talairach, could now be achievable considering modern biomarkers and surgical progress.
“Dr. Robert G. Heath: a controversial figure in the history of deep brain stimulation,” by Christen M. O’Neal, BS, Cordell M. Baker, BS, Chad A. Glenn, MD, Andrew K. Conner, MD, and Michael E. Sughrue, MD. Abstract:
The history of psychosurgery is filled with tales of researchers pushing the boundaries of science and ethics. These stories often create a dark historical framework for some of the most important medical and surgical advancements. Dr. Robert G. Heath, a board-certified neurologist, psychiatrist, and psychoanalyst, holds a debated position within this framework and is most notably remembered for his research on schizophrenia. Dr. Heath was one of the first physicians to implant electrodes in deep cortical structures as a psychosurgical intervention. He used electrical stimulation in an attempt to cure patients with schizophrenia and as a method of conversion therapy in a homosexual man. This research was highly controversial, even prior to the implementation of current ethics standards for clinical research and often goes unmentioned within the historical narrative of deep brain stimulation (DBS). While distinction between the modern practice of DBS and its controversial origins is necessary, it is important to examine Dr. Heath’s work as it allows for reflection on current neurosurgical practices and questioning the ethical implication of these advancements.
“A brief note on the history of psychosurgery in Japan,” by Jiro Nudeshima, PhD, and Takaomi Taira, MD, PhD. Abstract:
In Japan, there has been no neurosurgical treatment for psychiatric disorders since the 1970s. Even deep brain stimulation (DBS) has not been studied or used for psychiatric disorders. Neurosurgery for psychiatric disorders has been thwarted by social taboos for many years, and psychiatrists today seem to simply ignore modern developments and therapies offered by neurosurgery such as DBS. As a result, most patients and their families do not know such “last-resort” options exist.
Historically, as in other countries, frontal lobotomies were widely performed in Japan in the 1940s and 1950s, and some Japanese neurosurgeons used stereotactic methods for the treatment of psychiatric disorders until the 1960s. However, in the 1960s and 1970s such surgical treatments began to receive condemnation based on political judgment, rather than on medical and scientific evaluation. Protest campaigns at the time hinged on the prevailing political beliefs, forming a part of the new “left” movement against leading authorities across a wide range of societal institutions including medical schools. Finally, the Japanese Society for Psychiatry and Neurology banned the surgical treatment for psychiatric disorders in 1975. Even today, Japan’s dark history continues to exert an enormous negative influence on neurosurgery for psychiatric disorders.
“Exploring the brain through posterior hypothalamus surgery for aggressive behavior,” by Michele Rizzi, MD, Andrea Trezza, MD, Giuseppe Messina, MD, Alessandro De Benedictis, MD, PhD, Angelo Franzini, MD, and Carlo Efisio Marras, MD. Abstract:
Neurological surgery offers an opportunity to study brain functions, through either resection or implanted neuromodulation devices. Pathological aggressive behavior in patients with intellectual disability is a frequent condition that is difficult to treat using either supportive care or pharmacological therapy. The bulk of the laboratory studies performed throughout the 19th century enabled the formulation of hypotheses on brain circuits involved in the generation of emotions. Aggressive behavior was also studied extensively. Lesional radiofrequency surgery of the posterior hypothalamus, which peaked in the 1970s, was shown to be an effective therapy in many reported series. As with other surgical procedures for the treatment of psychiatric disorders, however, this therapy was abandoned for many reasons, including the risk of its misuse. Deep brain stimulation (DBS) offers the possibility of treating neurological and psychoaffective disorders through relatively reversible and adaptable therapy. Deep brain stimulation of the posterior hypothalamus was proposed and performed successfully in 2005 as a treatment for aggressive behavior. Other groups reported positive outcomes using target and parameter settings similar to those of the original study. Both the lesional and DBS approaches enabled researchers to explore the role of the posterior hypothalamus (or posterior hypothalamic area) in the autonomic and emotional systems.
“The hypothalamus at the crossroads of psychopathology and neurosurgery,” by Daniel A. N. Barbosa, Ricardo de Oliveira-Souza, MD, PhD, Felipe Monte Santo, MD, Ana Carolina de Oliveira Faria, MSc, PhD, Alessandra A. Gorgulho, MD, MSc, and Antonio A. F. De Salles, MD, PhD. Abstract:
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The neurosurgical endeavor to treat psychiatric patients may have been part of human history since its beginning. The modern era of psychosurgery can be traced to the heroic attempts of Gottlieb Burckhardt and Egas Moniz to alleviate mental symptoms through the ablation of restricted areas of the frontal lobes in patients with disabling psychiatric illnesses. Thanks to the adaptation of the stereotactic frame to human patients, the ablation of large volumes of brain tissue has been practically abandoned in favor of controlled interventions with discrete targets.
Consonant with the role of the hypothalamus in the mediation of the most fundamental approach-avoidance behaviors, some hypothalamic nuclei and regions, in particular, have been selected as targets for the treatment of aggressiveness (posterior hypothalamus), pathological obesity (lateral or ventromedial nuclei), sexual deviations (ventromedial nucleus), and drug dependence (ventromedial nucleus). Some recent improvements in outcomes may have been due to the use of stereotactically guided deep brain stimulation and the change of therapeutic focus from categorical diagnoses (such as schizophrenia) to dimensional symptoms (such as aggressiveness), which are nonspecific in terms of formal diagnosis. However, agreement has never been reached on 2 related issues: 1) the choice of target, based on individual diagnoses; and 2) reliable prediction of outcomes related to individual targets. Despite the lingering controversies on such critical aspects, the experience of the past decades should pave the way for advances in the field. The current failure of pharmacological treatments in a considerable proportion of patients with chronic disabling mental disorders is reminiscent of the state of affairs that prevailed in the years before the early psychosurgical attempts.
This article reviews the functional organization of the hypothalamus, the effects of ablation and stimulation of discrete hypothalamic regions, and the stereotactic targets that have most often been used in the treatment of psychopathological and behavioral symptoms; finally, the implications of current and past experience are presented from the perspective of how this fund of knowledge may usefully contribute to the future of hypothalamic psychosurgery.