Archival ArticlePeer-Review Report: FrontiersSurgery of the Mind, Mood, and Conscious State: An Idea in Evolution
Introduction
Since the beginning of human existence, the desire to modify human behavior and consciousness through indirect or direct physical intervention has been a “holy grail.” Throughout history, these efforts have taken many different directions, with the first millennia characterized by largely shamanistic or ritualistic interventions or trepanations with little understanding of the underlying physiology or therapeutic effect. In the past century, an exponential increase in our awareness of the diversity and the prevalence of diseased states of the human mind combined with the increasing technical and technological sophistication of our interactions with the human cerebrum have created an unprecedented opportunity (7). The epidemiology of psychiatric illness and other diseases of the mind and conscious state is staggering—5 of the top 10 causes of disability worldwide are psychiatric and neurobehavioral disorders (96). It is estimated that the incidence of major depression alone in a single individual's lifetime is between 12%−18%, and with greater than 120 million patients, it represents the greatest cause of disability worldwide (5). The remainder of the top 10 includes alcoholism (fourth), bipolar disorder (sixth), schizophrenia (ninth), and obsessive-compulsive disorder (tenth) (96). In the case of major depression, as many as one third of patients become resistant to treatment (30).
As the enormous prevalence and social cost of psychiatric disease continues to gain recognition, with concomitant improvements in the efficacy and safety of surgical intervention, surgery of the mind and mood promises to become one of the most epidemiologically important fields of neurosurgery. Although “psychosurgery” has many varying connotations and definitions, particularly the narrow category of ablative lobotomies, which drew popular attention and criticism in the middle of the 20th century, in this article it is defined as the full spectrum of neurosurgical treatments for psychiatric illness, including all the various modalities of open, stereotactic, functional, and radiosurgical procedures.
The history of psychosurgery predates the start of recorded history itself. Numerous reports exist of prehistoric examples of trepanation. Although the therapeutic purpose of trepanation is open to speculation, it likely included the treatment of psychiatric illness. The most well-documented example is a skull found in the Neolithic burial site of Ensisheim in Alsace, France, which dates to roughly 5100 BC (Figure 1) (2). The skull had two separate areas of trepanation and evidence of subsequent healing, indicating that the lesions were performed intentionally while the individual was still alive, as opposed to an epiphenomenon such as infection or postmortem trauma, and that the individual survived for an extended period of time after the procedure. This example represents not only the earliest form of neurosurgery or psychosurgery but of a surgical procedure of any kind. There is also extensive archeological evidence of trepanation in pre-Columbian Mesoamerica, with the most numerous examples originating in Peru and Bolivia, where the procedure was practiced with considerable skill, as evidenced by the number of skulls with evidence of postoperative healing, as well as the associated archeological trove of tools developed for the purpose (Figure 2) (122). Although the majority of these were likely performed for trauma or depressed skull fractures associated with the bludgeoning-type weapons of the day, there is also evidence to suggest that the operation was conducted for other ailments as well, including the shamanistic exorcism of malicious spirits, a possible cultural proxy for mental illness, epilepsy, depressed consciousness, or even the restoration of life itself.
There is also mention of trepanation in the classical writings of Hippocrates and Galen, and evidence suggests it was practiced throughout the early Medieval period. After an apparent lull, trepanation returned to prominence in the Renaissance era, with many references and depictions of the procedure in contemporary medical texts and artwork of the time. One notable example is The Cure of Folly or The Extraction of the Stone of Madness, a painting by the 15th-century Dutch painter Hieronymus Bosch (Figure 3). Although many portions of the painting are pointedly allegorical, it nonetheless depicts the extraction of a “brain stone” as a cure for either stupidity or madness, depending on the interpretation of the term “folly” (111). The idea that madness could be caused by a physical stone in the brain was a common superstition at the time, although it is unclear to what extent trepanation was performed to that purpose. Although there is some more contemporary evidence of the use of trepanation in certain African tribes, with the advent of the later Renaissance understanding of physiology and naturalism, the use of trepanation as a form of metaphysical treatment of psychiatric illness passed from Western medical practice until its reincarnation in the 20th century (130).
Section snippets
The Origins of Functional Neuroanatomy
Although classical philosophers such as Aristotle and Descartes were some of the first to postulate that the brain was the center of conscious thought, the modern grandfather of neuroanatomy was arguably the German physician Franz Joseph Gall, the progenitor of phrenology (Table 1) (118). In 1819 he published his landmark work The Anatomy and Physiology of the Nervous System in General, and of the Brain in Particular, with Observations upon the Possibility of Ascertaining the Several
The Advent of Minimalism
Despite the affirmative findings of the Belmont Report, the social and legal backlash against psychosurgery nevertheless caused a precipitous decline in the practice of psychosurgery in the 1970s, and the practice of psychosurgery remains limited to a small scale at select centers internationally. Nonetheless, the practice of psychosurgery lingered and was aided by a number of technological and technical evolutions that brought about a quiet renaissance in the safety, efficacy, and
The Neuromodulatory Era of Psychosurgery
The aforementioned constellation of advances in the latter half of the 20th century set the stage for a conceptual breakthrough in the surgical treatment of psychiatric illness in the late 1990s with advent of the first nonablative, nondestructive treatment modality with the ultimate introduction of deep-brain stimulation (DBS) to the field (Table 4).
The concept of electrical stimulation of the human cerebrum is not a new one—in fact, it is not even a creation of the 20th century. The physician
The Future of Psychosurgery
The neurosurgical contribution to the treatment and management of psychiatric disease presents great promise but also significant challenges. The connotations associated with psychosurgery have significantly limited its practice, but the increased safety of medical practice and the social demand for more innovative solutions to medical and epidemiologic problems has created an environment in which the modern iteration of psychosurgery can find traction. The increasing societal and ethical
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.