Modern psychosurgery before Egas Moniz: a tribute to Gottlieb Burckhardt

TABLE 1

Burckhardt’s surgeries documented in his 1891 paper

Contemporary Research Influences

The neuroscience environment that prevailed in the late 1880s influenced Burckhardt’s decision to perform experimental topectomies in human patients. In 1870, Fritsch and Hitzig provided invaluable proof of the neurophysiological reality of functional specialization in brain using electrical stimulation, followed by ablation methods. They observed the entire cortical surface in dogs and found that stimulations in some areas elicited motor responses—extension, flexion and rotation of limbs—while others did not.¹¹ Burckhardt was also impressed by the work of Friedrich Goltz. Goltz found that total removal of the neocortex made dogs easily provoked to rage, while removal of the temporal cortex resulted in more calm and tame animals.^7,11 Burckhardt was also strongly influenced by the neuropathological studies of Jules Bernard Luys in the brains of patients with dementia, recorded in Traité des maladies mentales. He understood that the paracentral lobule, according to Luys, appeared to be a bridge from which hallucinatory excitations flew off to motor areas.¹¹

Burckhardt also referred to the autopsy studies of Broca and Wernicke with respect to localization of language functions and hallucinations. He decided that it did not matter whether the first activation of a verbal hallucination originated in cortical areas as expressed by Tamburini and Wernicke, or in subcortical areas, as expressed by Hagen or Meynert.¹¹ Burckhardt believed that patients with auditory hallucinations could be helped by the removal of a particular pathologically functioning area and made several interesting speculations about the possibility of the acoustic word–memory cortex, implicated in the “chain of processes” that cause auditory hallucinations. He seems to have drawn ideas from the work of French author Mairet, who demonstrated hypertrophic temporal gyri in patients with schizophrenia in 1883.¹⁴ Mairet had also proposed that the “megalomanic” type of dementia was located in the convex region of frontal and temporal lobes and that the “melancholic” form was found in the first temporal gyrus, the anterior third of the sphenoid gyrus and hippocampus.¹¹ Three central conceptual neurophysiological ideas influenced the views of Burckhardt: 1) all mental disorders have a physical basis; 2) associationism and connectionism were the predominant models for understanding nervous system functioning; that is, the nervous system was believed to include 3 systems: an input or afferent sensory system, a linking or connecting system for information processing, and an efferent motor or output system; 3) and each mental module (or faculty) was considered to be related to a specific brain site.²

This model was in accordance with Wernicke’s wiring diagram for language function and helped Burckhardt explain the symptom clusters related to specific anatomical sites after each surgery. It was according to this model that Burckhardt predicted that lesions in certain association areas might alter behavior in specific ways. He thought that affect was a cortical event that was transformed into motion, not through subcortical, but through the cortical regions—this was the reason that validated the use of topectomies in psychiatric diseases.^11,16 He believed that severing certain connections would alleviate symptoms without hampering the input or output neurons. He also thought that the operation would not only prevent the expression of symptoms, but also the patient’s experience of them.¹¹ He wrote:

If excitation and impulsive behavior are due to the fact that from the sensory surfaces excitations abnormal in quality, quantity and intensity do arise, and do act on the motor surfaces, then an improvement could be obtained by creating an obstacle between the two surfaces. The extirpation of the motor or sensory zone would expose it to the risk of grave functional disturbances and to technical difficulties. It would be more advantageous to practice the excision of a strip of cortex behind and on both sides of the motor zone creating thus a kind of ditch in the temporal lobe.²

Burckhardt at Prefargier Clinic

Shortly after Burckhardt’s arrival as director at Prefargier, a 3-room laboratory was constructed to enable him to pursue his research activities in the areas of anatomy and psychophysiology. His first work, presented on February 4, 1884 at Prefargier, was a study on the role of heredity in the surface configuration of brain.¹¹ His interest in clinical research started to blossom in 1888. Burckhardt wrote in the annual report:

The Committee, having funded me, and the installations and necessary preparations having been done, and the patient’s family having consented, we performed the first operation on December 29th. This is not the place to provide all the details. Let me simply state that, to my knowledge, Prefargier is the first institution where cranial trephination and the removal of small portions of cerebral cortex have been performed, not just to satisfy surgical indications, but rather for psychiatric purposes.

Starting on December 29, 1888, Burckhardt performed operations in 2 women and 4 men, with the first patient undergoing 4 procedures. Five of these patients suffered from “primare Verrucktheit,” a clinical category that should be considered as equivalent to schizophrenia. This clinical category was reintroduced by Sander (1868), and popularized as “originare paranoia” by Krafft Ebing, by which he meant a hereditary delusional/hallucinatory psychosis with an onset at puberty.¹ The patients included in Burckhardt’s case series had intractable mental illnesses and were deluded, aggressive, and having auditory hallucinations. He had little surgical experience, and the surgeries were all performed in a small room on the grounds of Prefargier.¹ The patients received bilateral localized topectomies (selective removal of the cerebral cortex), in the areas now known as the Wernicke and Broca centers, as well as in the temporal and parietal lobes. However, there is no detailed description of postoperative evaluation of aphasias or the extent of weakness of contralateral extremities. Of the 6 patients, 3 had partial improvement in symptoms and 1 died after status epilepticus developed.

Illustrative Cases

We have chosen 2 illustrative cases from Burckhardt’s surgical series, based on the previous descriptions made in the original German text (1891), as well as the accounts of Joanette et al.¹¹, Moutier (1908),² and Freeman and Watts.⁵ These cases reflect 2 cardinal neurophysiological aspects of Burckhardt’s approach to psychosurgery: 1) acting on a psychic center (the localizationist tradition) and 2) controlling the influence of a given psychic center on another center (the associationist tradition).¹¹

Berlin Congress and Aftermath

Burckhardt presented his operative findings and outcomes at the Berlin Medical Congress of 1889, attended by the greatest alienists of the time.²⁰ Those in attendance included academic luminaries like Victor Horsley (1857–1916), Velentin Magnan (1835–1916), and Emil Kraepelin (1856–1926). Horsley presented the results of his first 44 neurosurgical operations (10 deaths) at the same meeting.¹ Burckhardt’s paper, according to a report by Meuron,⁶ had made everyone feel ill at ease and encountered harsh comments from colleagues. However, his unconventional work was subsequently discussed in a number of countries. Worcester (1891) presented a summary to his American colleagues, emphasizing the side effects and brevity of the follow-up.^1,20 Kraepelin (1893) referred to Burckhardt’s interventions with disrespect: “he suggested that restless patients could be pacified by scratching away the cerebral cortex.”¹ Giuseppe Seppilli (1891) wrote for an Italian audience, stating that Burckhardt’s modular view did not “fit in well with the view held by most [experts] that the psychoses reflect a diffuse pathology of the cerebral cortex and [ran counter to] the conception of the psyche as a unitary entity.” Due to his theoretical weakness, Seppilli concluded, it would be most unlikely that anyone would follow Burckhardt’s ideas and procedures and concluded that “an absence of treatment was better than a bad treatment.”^2,18

After the Berlin meeting, Burckhardt went on to publish his case series in a masterful paper that is often quoted but rarely read. It is 88 pages long and includes 6 case histories, repeated mental state assessments, a complete review of clinical and experimental literature on brain localization, and a sound theoretical argument.¹ In Britain, William Ireland summarized Burckhardt’s views well:

Dr. Burckhardt has a firm faith in the view that the mind is made up of small faculties, holding their seats in distinct parts of the brain. Where excess or irregularity of function occurs, he seeks to check it by ablation of a portion of the irritated centers. He defends himself from the criticisms which are sure to be directed against his bold treatment by showing the desperate character of the prognosis of the patients upon whom the operations were performed...

Ireland also wondered “whether any English physician would have the hardihood to imitate Burckhardt.”¹⁰ Psychosurgery was not publicly attempted again until 1910, when Estonian neurosurgeon Lodovicus Puusepp severed the “association fibers” between the frontal and parietal cortex in 3 patients who were described as manic depressive or “epileptic equivalents.” ^2,17 Later successors, such as Moniz, Freeman, and Watts, performed several leukotomies or lobotomies, while others like Mettler followed the techniques of Burckhardt in using topectomy procedures for affected patients.^5,15,19 Controversies over the history and origins of modern psychosurgery continue today, but the impact of Burckhardt’s personal surgical series had clearly spurred the research in neurophysiology and psychosurgery that followed. Near the end of his 1891 paper, he makes the following comment:

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.^3,12

Conclusions

The transition to the modern era of psychosurgery starts with the series of topectomy operations performed by Gottlieb Burckhardt, the Swiss surgeon whose pioneering work paved the way for later surgeons, including Egas Moniz. His psychosurgical techniques posed a bold challenge and opposition to the fundamental practice of treating the mentally ill, leading to his being ostracized from the medical community. His work has remained obscure, but is nonetheless noteworthy for the neurosurgical community.