From theory to practice: the unconventional contribution of Gottlieb Burckhardt to psychosurgery

Gottlieb Burckhardt (1836-1907): 19th-Century Pioneer of Psychosurgery

Gottlieb Burckhardt was a 19th-century Swiss psychiatrist who introduced the psychosurgical method known as topectomy as a means to relieve the symptoms of aggression and agitation in individuals diagnosed with mental disease. Specifically, he performed topical excision of part of the cerebral cortex on 6 patients with chronic schizophrenia. Most of these patients became more approachable and easier to manage, but they also showed signs of aphasia or seizures, and 2 died soon after the surgery. Burckhardt's presentation of the results of his surgical procedures to the Berlin Medical Congress in 1890 caused an enormous controversy within the European medical community and resulted in his ostracism from it. He continued practicing, however and dispensing advice in his role as a mental hospital director, though he soon gave up his surgical endeavours. His innovative theory of higher cerebral functions anticipated the lobotomy procedure that was developed nearly half a century later by the neurologist Egas Moniz (1874-1955).

The Co-evolution of Neuroimaging and Psychiatric Neurosurgery

The role of neuroimaging in psychiatric neurosurgery has evolved significantly throughout the field's history. Psychiatric neurosurgery initially developed without the benefit of information provided by modern imaging modalities, and thus lesion targets were selected based on contemporary theories of frontal lobe dysfunction in psychiatric disease. However, by the end of the 20th century, the availability of structural and functional magnetic resonance imaging (fMRI) allowed for the development of mechanistic theories attempting to explain the anatamofunctional basis of these disorders, as well as the efficacy of stereotactic neuromodulatory treatments. Neuroimaging now plays a central and ever-expanding role in the neurosurgical management of psychiatric disorders, by influencing the determination of surgical candidates, allowing individualized surgical targeting and planning, and identifying network-level changes in the brain following surgery. In this review, we aim to describe the coevolution of psychiatric neurosurgery and neuroimaging, including ways in which neuroimaging has proved useful in elucidating the therapeutic mechanisms of neuromodulatory procedures. We focus on ablative over stimulation-based procedures given their historical precedence and the greater opportunity they afford for post-operative re-imaging, but also discuss important contributions from the deep brain stimulation (DBS) literature. We conclude with a discussion of how neuroimaging will transition the field of psychiatric neurosurgery into the era of precision medicine.

Geoffrey Knight and his contribution to psychosurgery

This paper retraces the fundamental achievements of Geoffrey Knight (1906-1994), a British neurosurgeon and a pioneer in the field of psychosurgery. His career developed in the 1950s and 1960s, when-following the unregulated practice of frontal lobotomies-strong criticism arose in the medical community and in the general public against psychosurgery. Geoffrey Knight's clinical research focused on identifying new, selective targets to limit the side effects of psychosurgery while improving the outcome of patients affected by mental disorders. Following the example of William Beecher Scoville, he initially developed restricted orbital undercutting as a less invasive alternative to standard frontal lobotomy. He then developed stereotactic subcaudate tractotomy, with the use of an original stereotactic device. Knight stressed the importance of the anatomy and neurophysiology of the structures targeted in subcaudate tractotomy, with particular regard to the fibers connecting the anterior cingulate region, the amygdala, the orbitofrontal cortex, and the hypothalamus. Of interest, the role of these white matter connections has been recently recognized in deep brain stimulation for major depression and anorexia nervosa. This is perhaps the most enduring legacy of Knight to the field of psychosurgery. He refined frontal leucotomies by selecting a restricted target at the center of a network that plays a crucial role in controlling mood disorders. He then developed a safe, minimally invasive stereotactic operation to reach this target. His work, well ahead of his time, still represents a valid reference on which to build future clinical experience in the modern era of neuromodulation for psychiatric diseases.

Surgery of the mind, mood, and conscious state: an idea in evolution

Since the beginning of recorded history, humans have sought a physical means of altering disordered behavior and consciousness. This quest has spawned numerous innovations in neurosurgery and the neurosciences, from the earliest prehistoric attempts at trepanation to the electrocortical and anatomic localization of cerebral function that emerged in the 19th century. At the start of the 20th century, the overwhelming social impact of psychiatric illness intersected with the novel but imperfect understanding of frontal lobe function, establishing a decades-long venture into the modern origin of psychosurgery, the prefrontal lobotomy. The subsequent social and ethical ramifications of the widespread overuse of transorbital lobotomies drove psychosurgery to near extinction. However, as the pharmacologic treatment of psychiatric illness was established, numerous concomitant technical and neuroscientific innovations permitted the incremental development of a new paradigm of treating the disordered mind. In this article, we retrospectively examine these early origins of psychosurgery and then look to the recent past, present, and future for emerging trends in surgery of the psyche. Recent decades have seen a revolution in minimalism, noninvasive imaging, and functional manipulation of the human cerebrum that have created new opportunities and treatment modalities for disorders of the human mind and mood. Early contemporary efforts were directed at focal lesioning of abnormal pathways, but deep-brain stimulation now aims to reversibly alter and modulate those neurologic activities responsible for not only psychiatric disorders, but also to modulate and even to augment consciousness, memory, and other elements of cerebral function. As new tools become available, the social and medical impact of psychosurgery promises to revolutionize not only neurosurgery, but also humans' capability for positively impacting life and society.

Modern psychosurgery before Egas Moniz: a tribute to Gottlieb Burckhardt

The history of modern psychosurgery has been written in several ways, weaving around many pioneers in the field during the 19th century. Often neglected in this history is Gottlieb Burckhardt (1836–1907), who performed the first psychosurgical procedures as early as 1888, several decades before the work of Egas Moniz (1874–1955). The unconventional and original case series of Burckhardt, who claimed success in 50% of patients (3 of 6), had met with overt criticism from his contemporary medical colleagues. The authors describe 2 illustrative cases of cortical extirpation performed by Burckhardt and review his pioneering case series for surgical outcome, despite the ambiguity in postoperative evaluation criteria. Although Burckhardt discontinued the project after publication of his surgical results in 1891, neurosurgeons around the world continued to investigate psychosurgery and revitalized his ideas in 1910; psychosurgery subsequently developed into a full-fledged neurosurgical specialty.

Psychosurgery: past, present, and future

Psychosurgery, the neurosurgical treatment of psychiatric disease, has a history dating back to antiquity, and involves all of the clinical neurosciences. This review discusses the history of psychosurgery, its development in the 19th century, and the conditions of its use and abuse in the 20th century, with a particular focus on the frontal lobotomy. The transition to the modern era of psychosurgery is discussed, as well as the neurobiology underlying current psychosurgical procedures. The techniques of stereotactic cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leukotomy are described, as well their indications and side effects. Due to the past abuse of psychosurgery, procedures are currently under strict control, and the example of the Cingulotomy Committee at the Massachusetts General Hospital is discussed. Finally, future directions of psychosurgery and somatic therapies are explored, including transcranial magnetic stimulation, vagal nerve stimulation, deep brain stimulation, gene therapy, and stem cell therapy. In summary, this review provides a concise yet comprehensive introduction to the history, current practice, and future trends of neurosurgery for psychiatric disorders.

Should neurosurgery for mental disorder be allowed to die out? For

The persistence of psychosurgery within the therapeutic armamentarium of psychiatry is something of an anachronism in the current era of evidence-based medicine. Robust evidence for efficacy does not exist and, indeed, can never realistically be gathered because of the extreme ethical difficulties of carrying out randomised controlled trials in this area. Yet there are undoubtedly patients who remain resistant to all conventional forms of treatment. Should they be denied what is possibly their last hope of recovery? Although the evidence is not watertight, modern neurosurgery is safer than ever before and appears to offer clinically meaningful symptom relief for ‘untreatable’ patients with chronic severe depression or obsessive–compulsive disorder (Matthews & Eljamel, 2003). The debate this month poses the question, ‘Should neurosurgery for mental disorder be allowed to die out?’ Dr Raj Persaud, consultant psychiatrist at the Maudsley hospital, argues in favour of the motion. The case in favour of retaining neurosurgery is made by two consultant psychotherapists, Dr David Crossley (Wrexham) and Dr Chris Freeman (Edinburgh).

Psychosurgery: a historical overview

Neurosurgical treatment for psychiatric disorders has a long and controversial history. From the Stone Age use of trephining to release the demons of the spirit to the millimeter accuracy of stereotactic instruments currently used in the operating room, psychosurgery has enjoyed enthusiastic support as well as experiencing scorn. Today, psychosurgery is a minimally invasive and highly selective treatment that is performed for only a few patients with severe, treatment-refractory, affective, anxiety, or obsessive-compulsive disorders. Recent advances in technology and functional neuroanatomic techniques, as well as economic pressures to decrease the costs of caring for chronically ill patients, may provide an opportunity for psychosurgery to become a more attractive option for the treatment of psychiatric diseases. In this historical overview, the rise and fall of psychosurgery are described. A better understanding of the colorful history of this interesting topic should enable modern neurosurgeons and other health care professionals to meet the social, ethical, and technical challenges that are sure to lie ahead.