Against the Current: Wilder Penfield, the Frontal Lobes and Psychosurgery

Happy Birthday "One Flew Over the Cuckoo's Nest": A Momentous Tale in the Quest for an Effective and Ethical Approach to Psychosurgery

The anniversary of the publication of 'One Flew Over the Cuckoo's Nest' by Ken Kesey offers an opportunity for reflection on the use of neurosurgery in psychiatry. We used a narrative, historical and dialectical method to deliver an account of the controversial subject. A balanced representation of the negative and positive aspects, acknowledging some of the questionable ethical practices while describing well-reasoned applications is provided. It includes neurosurgeons, psychiatrists who have embraced these procedures with unwarranted enthusiasm and those who have opposed. Neurosurgical techniques for the treatment of severe mental disorders have evolved from rudimentary procedures which were used to 'correct' unwanted behaviours associated with a wide range of severe mental disorders to more refined and selective approaches used as a last resort to treat specific mental health conditions. In the absence of specific aetiological models to guide ablative surgical targets, non-ablative, stimulatory techniques have more recently been developed to allow reversibility when surgical treatment fails to obtain a sizeable improvement in quality of life. The subject is concretely illustrated by two eloquent clinical images: one on a series of brain computed tomography scans carried out on a Canadian population of subjects, who underwent leukotomy decades ago, and the other more contemporary on an implantation surgery to epidural stimulation. Alongside technical advances in psychosurgery, a regulatory framework has gradually developed to ensure vigilance in the appropriateness of patients' selection. Nevertheless, harmonisation of protocols around the world is necessary to ensure consistency in obtaining and maintaining the highest possible ethical standards for the benefit of patients. If the neurosciences promise today, in their new, better framed, and reversible applications, to provide answers to unmet therapeutic needs, we still must remain attentive to drifts linked the introduction of intrusive technologies for purposes of domination or behaviour modification that would impede our individual freedom.

The birth of experimental neurosurgery: Wilder Penfield at Montreal's Royal Victoria Hospital, 1928-1934

Wilder Penfield is well known as the founder of the Montreal Neurological Institute (MNI), the site of his most important contributions to the investigation and treatment of epilepsy and to our understanding of the structure-function relationship of the brain. The seeds of the MNI were sown 6 years before its opening in 1934, when Penfield accepted the position of head of the Subdepartment of Neurosurgery at McGill University's Royal Victoria Hospital (RVH). Penfield took this position because of the facilities made available to him to pursue the neuropathological research that he had undertaken with Pío del Río Hortega in Madrid, and to continue his investigation into the nature and treatment of posttraumatic epilepsy that he began with Otfrid Foerster in Breslau. Penfield and his first neurosurgical research fellows Joseph Evans, Jerzy Choróbski, Nathan Norcross, Theodore Erickson, Isadore Tarlov, and Arne Torkildsen studied the substrate of focal epilepsy, the innervation of cortical arteries, the function of the diencephalon, the microscopic structure of spinal nerve roots, and the ventricular system in health and disease. In his 6 years at the RVH, Penfield and his fellows effected a paradigm shift that saw neurosurgery pass from empirical practice to scientific discipline.