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The loss of sadness of the human being: the beginnings of psychosurgery (Part I).

"Doctors are different by nature. One kind adheres to the oid principie: first, do no harm (primum non nocere); the other one says: it is better to do something than do nothing (meiius anceps remedium quam nuiium). I certainly belong to the second category."

Gottlieb Burckhardt, the father of psychosurgery (1836-1907)

FROM ANCIENT TREPANATION TO WERNICKE AND BROCA'S COGNITIVE FUNCTIONS

The history of psychosurgery is as old as the history of neurosurgery, and the trepanation holes discovered in the prehistoric human skull are living testimony to the fact that these surgeries have been performed since ancient times.

There is no doubt that trepanation is one of the oldest surgical procedures, as well as the oldest neurosurgical intervention made by humans (1). The practice of trepanation has evolved from its mystical and ritualistic content from primitive African and later pre-Columbian Mesoamerican cultures, to a potentially therapeutic destination in the Egyptian, Greek and Roman civilizations, who left behind tools and instructions to perform them (1, 2).

This wide-spread surgical practice since the Mesolithic (3) is certified by the trepanation procedures discovered throughout the world, including in Europe and the Mediterranean Sea, North America, Africa and Australia, the most common practice being found in archaeological sites from Andes and Mesoamerica (4).

The first obvious signs of skull trepanation dates from 5 100 years B. C. ago and was found in 1996 in Alsace, France. Although the reason for which this intervention was performed is unknown, the bone scarring around the craniectomy is a sign of the fact that the patient survived the surgery (5, 6). The skull has two burr holes, one smaller, located at the level of the frontal bone, close to the coronal suture, and one larger, located posteriorly, with an extension at the level of both parietal bones. Moreover, the first neurosurgical trepanation of the skull, performed for psychosurgical purposes, was carried out in 1 500 B. C., "to let out a spirit imprisoned in the body" and "sooth pains and melancholy or release demons" (7).

The reason for which these trepanations were carried out is still somewhat unclear, as several causes can be speculated (5). Brothwell suggests four reasons for which trepanations were performed in the prehistoric era: as a surgical treatment for a head injury (especially for skull fractures), as a treatment for mental illness, headache and epilepsy, to promote longevity and to obtain roundels that were later used as amulets (8).

The anthropological studies have highlighted the fact that the frontal bone, followed by the parietal bone and the occipital bone were the most common locations for burr holes (9). This suggests that our ancestors anticipated that the human mental activity mainly occurred in the frontal lobes.

Brothwell also states in his studies that even though trepanation maneuvers were carried out in poor conditions in a time when the aseptic and antisepsis principles were not yet anticipated, almost half of the cases of trepanation found in human skull remains attest to a complete cure. In his work, Digging up bones. The excavation, treatment and study of human skeletal remains, Brothwell notes: "if the edges of the hole are rounded and the exposed diploic spaces of the spongy inner tables shows signs of closing or have closed" (8).

Hippocrates of Kos (460-355 B. C.), considered to be the father of rational medi cine, because he applied logic and observation in the medical practice, offered, in his treatise On injuries of the head, coherent information on the anatomy of the skull and classifications of skull fractures, proposing a methodical management of head trauma. Moreover, Hippocrates provided amazing technical details of the trepanation technique (10), being considered to be among the first who supported the use of this procedure only from pure medical reasons, not mystical or spiritual ones, thus separating medicine from theology and philosophy (11, 12).

Hippocrates's followers, however, sought to find a treatment for mental illnesses in trepanation, from antiquity until the early Middle Ages. Therefore, in the 1170s, the Italian surgeon Rogerius of Parma (1140-1195) used trepanation as a treatment for mental illnesses. In his work, Practica Chirurgiae, he wrote: "for mania or melancholy a cruciate incision is made in the top of the head and the cranium is penetrated, to permit the noxious material to exhale to the outside. The patient is held in chains and the wound is treated as above, under treatment of wounds" (13). It was only in late 19th century, once with the development of the European schools of neuroanatomy and neurology, the scientists started to look for logical explanations for the trepanation procedures. Thus, the most important observations about the clinicopathological correlations of neural destruction, with an impact on cognitive functions, such as language, were made by the physicians Paul Broca (1824-1880) and Carl Wernicke (1848-1905) (14, 15).

THE MOST BEAUTIFUL "EXPERIMENT OF NATURE"

The most famous "experiment of nature" was, without a doubt, Phineas Gage's dramatic and strange accident from 1848, aged 25, the foreman of a railway constructions team from the obscure country town of Cavendish, USA. After an explosion, a 109 cm long and 3 cm thick iron bar penetrated his orbit and brain, coming out of his skull, into the air. The consequences of this accident were downright surprising: from an intelligent patient and an upright citizen, the patient became an uninhibited rogue (16). His physician, John Martyn Harlow (1819-1907), referred to the destruction of "the equilibrium or balance, so to speak, between his intellectual faculty and animal propensities", but his friends were much more convincing when they said that "Gage was no longer Gage" (17). Moreover, Dr. Harlow correlated Gage's behavioural changes with the cerebral area in the frontal region, which was assumed to have been destroyed by the iron bar when it penetrated the skull. 150 years later, Damasio and his collaborators published a study on Gage's exhumed skull and proposed a trajectory of the injury through the left hemisphere, through the anterior half of the orbitofrontal cortex (Brodmann areas 11 and 12), through the anterior mesial frontal cortices (Brodmann areas 8 to 10, 32) and the most anterior region of the cingulate gyrus (Brodmann area 24). Damasio correlated these injuries with the symptoms of a lot of patients with a similar neuropathology (18).

THE BIRTH OF MODERN PSYCHOSURGERY

Modern psychosurgery was born once with the Swiss psychiatrist Gottlieb Burckhardt (1836-1907), who is considered to be the first modern psychosurgeon (19) because he attempted to practice a systematic psychosurgery. He operated on 6 patients with intractable psychiatric illness and aggressive behaviour, five of whom were suffering from "primare Verrucktheit", a clinical category equivalent to schizophrenia (20) in chronic patients hospitalized at the Swiss Prefargier Asylum, managed by Burckhardt. In a small room on the grounds of the asylum (21), Burckhardt bilaterally removed different parts of the frontal and temporal cerebral cortex of his patients, regions responsible for pathological behaviour in relation with the neuroanatomical and functional models of the time (22), surgical interventions which he then called topectomies.

The German Friedrich Goltz (1874), who demonstrated that the total removal of the neocortex in dogs made them more hyperactive and angry, while the ablation of the temporal cortex made them gentler and calmer than usual (23, 24, 25), was the one who influenced Burckhardt. The latter thought that such procedures would also have calming effects on his patients, stating that "none of the cases operated upon was of traumatic origins, the indications for the operation were therefore purely psychiatric" (9). Therefore, in 1890, Burckhardt started to perform surgeries on his patients. After removing the skull, using a scalpel, he excised the cerebral cortex (26). Of the 6 patients operated by Burckhardt, three showed improvements, being easier to manage; one died after a week due to seizures (24); one committed suicide; and for one patient, the surgery produced no results (26).

One of his patients, a painter aged 26, suffering from schizophrenia and auditory and visual hallucinations, who painted a nose and a mosquito in a corner of all his paintings, Burckhardt excised 4.6 g of cortical tissue from portions from Wernicke's area (the posterior half of the first and second temporal circonvolution from the left hemisphere) in a surgical procedure, performed on 5 June 1889, which lasted approximately 4 hours. One week after the surgery, mild aphasic symptoms occurred and the visual and auditory hallucinations persisted, which displeased Burckhardt, who decided to intervene again, this time on Broca's area (19, 20).

In a surgical procedure which lasted two hours and a half, he resected 2.5 grams of cortex, excising both pars opercularis and pars triangularis of the inferior frontal gyrus of the left hemisphere. This time, the surgery was successful, diminishing hallucinations without the occurrence of postoperative motor aphasia deficits (19). The patient's mother stated that the patient became quieter and better behaved (20). Although impressed by the possibilities made available by psychosurgery, Burckhardt stopped, because in 1890-1891, when he presented his results before the Academie francaise, he shocked the medical world who considered him to be irresponsible and reckless. They ridiculed and ignored him in the academic medical world (27). In 1891, Burckhardt wrote with a heavy heart: "Doctors are different by nature. One kind adheres to the old principle: first, do no harm (primum non nocere); the other one says: it is better to do something then do nothing (melius anceps remedium quam nullum). I certainly belong to the second category". (20, 28)

After Burckhardt, neuroresearchers continued to investigate frontal lobe resection. For this purpose, the Estonian neurosurgeon Ludovicus Puusepp (1875-1942) performed frontal lobotomies, but without much success (29), destroying the association fibres between the frontal and parietal cortex, in 3 maniac depressive patients (29), while the American neurosurgeon Wilder Penfield (1891-1976) described the relief of psychiatric symptoms in patients after the resection of lesions replacing the space at the level of the frontal lobe (30).

1935 was an important moment in the history of psychosurgery. At the Second World Congress of Neurology held in London, the American physiologist John F. Fulton (1899-1960) presented his experiment: following the resection of the frontal cortex in two chimpanzees, they became "devoid of emotional expression", and the resection of the anterior frontal association cortex succeeded in calming behavioural changes (31). Fulton and his collaborator Carlyle Jacobson brought the two chimpanzees at the Congress and demonstrated to the symposium that the animals were no longer able to evoke "experimental neuroses" and that they lacked all signs of anxiety and frustrational behaviour (22). Among the participants at the Congress there were two Portuguese neuro-researchers, Antonio Egas Moniz (1874-1955), a neurology professor at the University of Lisbon and his collaborator, the neurosurgeon Almeida Lima (1903-1985), as well as the American neurologist Walter Freeman (1895-1972), who have greatly influenced the practice of frontal lobotomies in psychosurgery (31, 32).

CONCLUSION

The neurosurgical treatment of mental illnesses imagined by mankind has a long and controversial history, which began since antiquity, and was built on fame and infamy. Throughout the centuries, neurologists, neurosurgeons and psychiatrists have attempted to find a treatment for mental illness in psychosurgery, which laid the foundation of modern psychosurgery involving structures such as amygdala, hippocampus, thalamic and hypothalamic nuclei, as well as the orbitofrontal and prefrontal cortex and cingulate gyrus. The most common modern psychosurgical procedures are limbic leucotomy, capsulotomy, cingulotomy and subcaudate tractotomy and involve a close collaboration between psychiatrists and neurosurgeons.

ACKNOWLEDGEMENTS AND DISCLOSURES

The authors state that they are no declared conflicts of interest regarding this paper.

REFERENCES

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Dana Mihaela TURLIUC-Department of Neurosurgery, "Grigore T. Popa" University of Medicine

Serban TURLIUC-Department of Psychiatry, "Grigore T. Popa" University of Medicine

Andrei Ionut CUCU-"Prof. Dr. N. Oblu" Clinical Emergency Hospital

Claudia Florida COSTEA-Department of Ophthalmology, "Grigore T. Popa" University of Medicine

Correspondence:

SERBAN TURLIUC

M. D., Ph. D., Lecturer Psychiatry, Senior Psychiatrist, "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, "Socola" Institute of Psychiatry Iasi, Romania No. 36 Sos. Bucium, zip code 700282, Iasi, Romania

E-mail: serban_turliuc@yahoo.com

Submission: March, 7th, 2016

Acceptance: April, 20th, 2016
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Author:Turliuc, Dana Mihaela; Turliuc, Serban; Cucu, Andrei Ionut; Costea, Claudia Florida
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Date:Jun 1, 2016
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