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PubMed1998

[Contribution of Gottlieb Burckhardt (1836-1907) to psychosurgery from the medical history and ethical viewpoint].

Psychosurgery is defined as the practice of destroying or removing healthy brain tissue in order to change behaviour. Although the neurologist Egas Moniz (1874-1955) is occasionally said to be the founder of psychosurgery, the first psychosurgical operations were performed by Gottlieb Burckhardt, a Swiss psychiatrist who practised in the late 19th century. In 1891 he reported the results of topectomies on six patients suffering from different psychiatric diseases. The aim of the present article is to illuminate the life of Burckhardt as well as his contribution to psychosurgery. Special attention is paid to the ethical aspects of his operative interventions. First of all, we have to make allowance for the fact that the therapeutic chances in 19th-century psychiatry were quite poor. Therefore, Burckhardts topectomies might have been seen as a new and hopeful way of therapy. But by analysing Burckhardt's case reports, it becomes clear that he did not intend to cure his patients but only to ameliorate their disturbing behaviour and their non-compliance. Burckhardt himself tried to justify the immense risk of his operations by referring to the necessity of progress in medicine. Although Burckhardt spoke of promising improvements, his positive appraisal can hardly be maintained. For this and other reasons, his contemporary colleagues mainly declined his methods and reports.

Ethics, Medical↗

PubMedDate not supplied

[Psychosurgery and the neurosurgical treatment of pain: a systematic review of the experience gained in these kinds of treatment].

INTRODUCTION: Psychosurgery and the neurochemical treatment of pain (NTP) are therapeutic options restricted to patients who show resistance to medical treatments. Surgical techniques have been perfected over the last few decades. AIMS: Our aim was to conduct a systematic review of the studies dealing with psychosurgery and NTP reported in the literature, based on the standards of quality used in evidence-based medicine. DEVELOPMENT: Following screening and selection, nine of the 178 papers found (MEDLINE, 1990-2002) were selected for the study: three referring to the treatment of neuropathic pain and six about the treatment of obsessive-compulsive disorder (OCD). The objectives were the therapeutic results in all cases, the study of the anatomical-functional bases in three of them and the description of side effects in five. After adapting the standards of quality used in evidence-based medicine (there are no standards for papers about surgery), one was classified in group B, six in group C and two as C-D. The three papers about the treatment of pain reported a significant improvement in the pain scales in 40-77% of patients. As regards the treatment of OCD, results showed an overall improvement of the scales in 20.4-70% of the patients with an improvement above 50%. The side effects are also described. CONCLUSIONS: Data published support the indication of psychosurgery and NTP for selected patients with neuropathic pain and OCD. The methodological limitations of the papers prevent us from drawing conclusions about the other diseases for which these techniques have been indicated.

Diagnosis, Differential↗

PubMed1988

Psychosurgery and personality--some legal considerations.

The practice of psychosurgery is subjected to different rules, sometimes written, often unwritten, in the different jurisdictions. No commonly accepted definition on what psychosurgery exactly is has been given by the national legislatures. Some legislatures have simply outlawed psychosurgery; some have no specific rules; others have provided a stable legal basis to it, while protecting the patient (informed consent; review committees; second opinions).

Belgium↗

PubMed1988

Ethics of psychosurgery.

The ethics of psychosurgery involve questions of moral philosophy and pragmatism in alleviating human suffering. The weighing of scientific data along with philosophical oughts and shoulds is required. The medical literature indicates definite efficacy for some kinds of limbic surgery, mainly cingulotomy and capsulotomy, in some kinds of conditions, namely major depression, pain and anxiety. The relative utility of these procedures given the severity of the illnesses and the safety of the procedures described is significant. Ethical and moral conflicts over altruism, autonomy and suffering require recognition before their due considerations (Kleinig 1985). The following recommendations emerge from these considerations: 1. No consideration of ethics in psychosurgery is complete without consideration of both the scientific data and moral conflicts. 2. The considerable efficacy and safety of cingulotomy and capsulotomy must be acknowledged. 3. Indications and contraindications do exist for selecting patients. Major psychiatric Axis I diagnoses of depression and anxiety are the indications. Personality disorders are not indications. 4. Peer review, unfettered consent and knowledge of the psychodynamics of severe illness are three ingredients necessary for wise decisions about performing limbic surgery. 5. The liberal advocation of autonomy without responsibility is an amoral, not liberating, point of view. 6. Politics should be denounced as the most serious ethical problem in medical decision making. Political intrusion into the scientific matters and the doctor-patient relationship has created ethical problems with psychosurgery and continues to do so today.

Caudate Nucleus↗

PubMed1995

[Partial status epilepticus developed 41 years after psychosurgery--an electroencephalographic and neuropathological study].

The authors report an 85-year-old man with schizophrenia, who had undergone bilateral frontal gyrectomy at the age of 44 and had a single series of convulsions 6 months after the psychosurgery. Forty-one years later, he had developed partial seizures with secondary generalized seizures, and died of partial status epilepticus. Ictal EEG showed generalized high-amplitude spikes or sharp waves spreading from the left frontal region. Interictal EEG showed slowing of background activity and high-amplitude paroxysmal discharges on the left frontal and central regions. Postmortem examination of the brain revealed tissue defects in the superior and middle frontal gyri caused by resection at the time of gyrectory and old cysts in the deep frontal white matter as late sequelae of the psychosurgery. There was fibrillary gliosis in the surrounding cerebral convolutions and the deep white matter. We considered that the glial scar in the frontal lobes, on the left side in particular, had developed the epileptogenic focus. The pathophysiological mechanism by which the intractable epileptic seizures appeared 41 years after psychosurgery is discussed.

Aged↗

PubMed1976

Psychosurgery: some current observations.

The term "psychosurgery" encompasses a wide variety of different neurosurgical procedures applied in the treatment of behavioral and psychiatric disorders. Arguments about the effectiveness and ethicality of psychosurgery are often based on studies using outdated procedures or inappropriate patient populations. The debate over psychosurgery is also obscured by the frequent confusion between its use in classical psychiatric syndromes and in such controversial areas as aggression or violent behavior associated with temporal lobe epilepsy. The author believes that such factors need to be clarified so that practitioners can choose a personal position based on sound medical fact.

Ethics, Medical↗

PubMed1998

[Gottlieb Burckhardt's (1836-1907) contribution to psychosurgery: medicohistorical and ethical aspects].

Psychosurgery is defined as the practice of destroying or removing healthy brain tissue in order to change behaviour. Although the neurologist Egas Moniz (1874-1955) is occasionally said to be the founder of psychosurgery, the first psychosurgical operations were performed by Gottlieb Burckhardt, a Swiss psychiatrist who practised in the late 19th century. In 1891 he reported the results of topectomies on six patients suffering from different psychiatric diseases. The aim of the present article is to illuminate the life of Burckhardt as well as his contribution to psychosurgery. Special attention is paid to the ethical aspects of his operative interventions. First of all, we have to make allowance for the fact that the therapeutic chances in 19th century psychiatry were quite poor. Therefore, Burckhardts topectomies might have been seen as a new and hopeful way of therapy. But by analysing Burckhardt's case reports, it becomes clear that he did not intend to cure his patients but only to ameliorate their disturbing behaviour and their non-compliance. Burckhardt himself tried to justify the immense risk of his operations by referring to the necessity of progress in medicine. Although Burckhardt spoke of promising improvements, his positive appraisal can hardly be maintained. For this and other reasons, his contemporary colleagues mainly declined his methods and reports.

Ethics, Medical↗

PubMed1978

Psychosurgery and the Porteus Maze Tests: review and reanalysis of data.

Because of current interest in assessing psychosurgery outcome, a reanalysis of Porteus maze test findings was done. The maze tests are generally considered to measure foresight and judgment. Review of the literature relating to the effects of practice on the test shows average gains of 1.25 years on the second application of the test and an additional gain of 0.70 years on the third application. Much of the early psychosurgery research did not take practice effects into account. Reanalysis of data shows that the magnitude of changes in maze performance depends on the site of surgery and length of time between surgery and testing. The more posterior the frontal lobe surgery, the shorter the postoperative interval, the greater the loss in maze test ability. Losses following relatively posterior frontal lobe surgery are probably permanent.

Frontal Lobe↗

PubMed1988

Regarding the experimental neurophysiological basis of psychosurgery.

A survey is given, on reports in the literature and personal experiences, on the neurophysiological basis of psychosurgery. Animal experiments as well as clinical-experimental observations in human beings are reviewed, following the usual present day targets: frontal lobe, cingulum, amygdala, thalamic and hypothalamic areas and anterior internal capsule. As a result, it has to be stated that there are no definite data resulting from animal experiments which could sustain the neurophysiological basis of psychosurgery. For psychiatric diseases animals are definitely not an adequate model. Therefore it is considered to be our neurosurgical duty to collect experimental data in human beings in a methodically proper manner and with respect to our ethical precepts.

Amygdala↗

PubMed1993

On the history of psychosurgery in Russia.

The history of psychosurgery in Russia can be divided into 3 periods: The first period starts at the turn of the century under the initiative of Bekhterev. His pupil and one of the fathers of Russian neurosurgery Puusepp performed leucotomy-like cuttings of frontal association fibers in manic-depressive cases and psychic equivalents of epileptics as early as 1906-1910. The second period includes the time from the late 1930ies till the late 1940ies. The classical leucotomy of Moniz and Lima, with some modifications, was used for treatment of schizophrenia and severe pain. In 1950 psychosurgery was prohibited by the special order of the Minister of Health of the USSR for ideological reasons. The third period starts in the early 1980ies with the acceptance of modern stereotactic techniques for treatment of intractable pain and obsessive-compulsive disorders.

History, 19th Century↗

PubMed1979

Psychosurgery on sex offenders and sexual "deviants" in West Germany.

About 70 men have undergone a stereotaxic hypothalamotomy in West Germany for sexual behaviors. In most cases the nucleus ventromedialis (Cajal) has been unilaterally destroyed. The question of whether this kind of psychosurgery shoudl be legally controlled is being discussed by both scientists and the public in West Germany. The justification for this psychosurgery is taken from a theoretical basis which is at least questionable and which stems from a biologically truncated and therefore limited perspective on human sexuality. An inspection of the published reports shows that the indication for surgery was based on questionable scientific and clinical grounds and practically excluded psychotherapeutic and sociotherapeutic aspects. In the authors' opinion stereotaxic hypothalamotomy can in no way be regarded as an unquestioned, applicable method of therapy. We consider it essential that this surgery be suspended at least as long as the possible therapeutic effectiveness and the possible adverse side effects remain unclear.

Germany, West↗

PubMed2001

Dr. Gottlieb Burckhardt--the pioneer of psychosurgery.

The first attempt at psychosurgery--intentional damage to the intact brain for the relief of mental illness--was undertaken in 1888 by the Swiss psychiatrist Gottlieb Burckhardt. Six chronic schizophrenic patients underwent localized cerebral cortical excisions. Most patients showed improvement and became easier to manage, although one died from the procedure and several had aphasia or seizures. Burckhardt, a learned neuropsychiatrist, presented his results in 1890 and in 1891 published his scientific rationale and detailed clinical outcome in a scholarly paper. Nevertheless his approach had shocked the medical community as reckless and irresponsible. Burckhardt was ridiculed, his academic endeavors ceased and his surgical endeavor largely ignored. Nevertheless he continued practice as a fine psychiatrist and mental hospital director. Burckhardt's career and interesting ideas on higher cerebral functions are reviewed and placed in perspective regarding the development of "modern" psychosurgery almost one-half century later.

History, 19th Century↗

PubMed1982

Psychosurgery.

Psychosurgery emerged in the late 1930s as a powerful therapeutic tool with great promise for psychiatry. Because of initial favorable case reports and studies, some influential support, and the need to aid thousands of returning World War II veterans with mental disabilities, the prefrontal lobotomy was widely implemented. It soon fell into disrepute through unfavorable reports of personality changes and neurologic sequelae, equivocal large-scale reports, and the introduction of major ataractic drugs and other treatment modalities. Psychosurgery has persisted in the form of restricted cerebral lesions, most stereotactically placed for relatively few mental illnesses. Evidence suggests that contemporary procedures are associated with minimal side effects and greater efficacy, but more extensive, better controlled studies are necessary.

Combat Disorders↗

PubMed1981

Electroencephalographic changes as prognostic indicators after psychosurgery.

Thirty-five patients were studied by EEG with recordings taken the day before, two weeks after, and six months after psychosurgery. Most showed a characteristic frontal slow activity of varying degrees after operation with varying enhancement of background activity. The amount and spread of the frontal slow waves two weeks after operation showed a significant positive correlation with the clinical outcome one year later, which suggests a relatively objective and very early indication of the subsequent clinical response to psychosurgery.

Adult↗

PubMed1978

The incidence of psychosurgery in the United States, 1971--1973.

As part of the work of the APA Task Force on Psychosurgery, the author surveyed 1,901 neurosurgeons on how many psychosurgical procedures they performed in 1971, 1972 and 1973. A total of 1.481 questionnaires were returned: 195 neurosurgeons indicated they had performed a total of 476 procedures for intractable pain and 1.039 procedures for psychiatric conditions. Excluding the procedures reported by 4 neurosurgeons who performed more than 20 psychosurgical operations in any one of the three years, the number of psychosurgical operations in 575 for the three years, which the author suggests should allay fears about the abuse of psychosurgery.

Humans↗

PubMed1994

Psychosurgery: stereotactic subcaudate tractomy. An indispensable treatment.

BACKGROUND: Stereotactic subcaudate tractotomy (SST) is the only type of psychosurgery performed at the Geoffrey Knight Unit, London, where nearly 1300 operations have been done since 1961. Statistically reliable data are not available to prove the effectiveness of SST. A detailed statement about contemporary psychosurgery is given. METHOD: Relevant publications from the Unit and via Medline are discussed. The outcome figures are reviewed. The outcome is assessed at the Unit in global and clinical terms, associated with results of self-completed questionnaires. RESULTS: SST allows 40-60% of patients to live normal or near-normal lives, perhaps with continuation of medication. A reduction in suicide rate to 1% post-operatively, from 15% in cases of uncontrolled affective disorders is seen. CONCLUSION: As a treatment of last resort, no controlled trial against a comparable treatment is possible. It appears reasonable to offer SST to patients with suicidal and deluded depression or with frequently swinging moods, not responding to other treatments.

Adult↗

PubMed1992

The present status of psychosurgery in Australia and New Zealand.

OBJECTIVES: To assess the extent and nature of psychosurgery currently being performed in Australia and New Zealand, and the present status of legislation regulating its practice. METHODS: Details of current legislation were obtained through inspection of statutes and direct communication with Departments of Health. All full and associate members of the Neurosurgical Society of Australasia were surveyed by postal questionnaire. Ninety-eight neurosurgeons were surveyed, of whom 72 (73%) replied. RESULTS: In the 1980s a mean of nine (SD, 5.9) operations were performed per year; about two were performed per year in the late 1980s. Ninety per cent of these operations were performed at one centre in Sydney. The most common indications were severe and medically intractable depression and obsessive-compulsive disorder. Surgery is now exclusively stereotactic and involves the creation of lesions in the orbitomedial frontal or cingulate tracts or a combination of the two. The nature and type of surgery are comparable to those in other centres in the Western world. Regulatory legislation is in place in most, but not all, States in Australia and in New Zealand. CONCLUSIONS: Further developments of other forms of psychiatric treatments may make psychosurgery, in its present form and at its present level of validation, redundant. If it is to have a resurgence, it would have to be based on a much sounder theoretical premise, and a stronger demonstration of efficacy and predictability of effect.

Adult↗

PubMed1991

Psychosurgery: a retrospective.

Of the 56 patients within the Yakovlev collection who had undergone psychosurgery 11 (20%) improved, 18 (32%) were either worse or without improvement, and 27 (48%) were without any clinical follow-up. Thus, in retrospect, psychosurgery was perhaps not as successful as once envisioned.

Adult↗