Dr. Robert G. Heath: a controversial figure in the history of deep brain stimulation.

The history of psychosurgery is filled with tales of researchers pushing the boundaries of science and ethics. These stories often create a dark historical framework for some of the most important medical and surgical advancements. Dr. Robert G. Heath, a board-certified neurologist, psychiatrist, and psychoanalyst, holds a debated position within this framework and is most notably remembered for his research on schizophrenia. Dr. Heath was one of the first physicians to implant electrodes in deep cortical structures as a psychosurgical intervention. He used electrical stimulation in an attempt to cure patients with schizophrenia and as a method of conversion therapy in a homosexual man. This research was highly controversial, even prior to the implementation of current ethics standards for clinical research and often goes unmentioned within the historical narrative of deep brain stimulation (DBS). While distinction between the modern practice of DBS and its controversial origins is necessary, it is important to examine Dr. Heath's work as it allows for reflection on current neurosurgical practices and questioning the ethical implication of these advancements.

The Pioneering and Unknown Stereotactic Approach of Roeder and Orthner from Göttingen. Part I. Surgical Technique for Tailoring Individualized Stereotactic Lesions.

During the 1950s through the 1970s, Hans Orthner and Fritz Roeder, two German neurologists from Göttingen, developed a sophisticated technique to perform functional stereotactic surgery with outstanding accuracy. They introduced direct air ventriculography performed in the same surgical session as the ablative stereotactic procedure. For individualized surgical targeting, Orthner prepared a stereotactic atlas (>60 brains) with an ingenious brain-slicing device, the Göttinger macrotome. Brains were grouped based on similarity of six different head and ventricle measurements. A brain cluster representing the best match for a patient was selected for stereotactic targeting. Stereotactic lesions were tailored in an individual manner and shaped by stringing together multiple small coagulations following intraoperative test stimulation. This was achieved from a single probe trajectory by using well-engineered string electrodes with calibrated curving and involved laborious calculations. Only high-frequency thermocoagulation was regarded as appropriate for lesioning. With this meticulous technique, the most advanced stereotactic procedures were performed, including bilateral pallidotomy that ultimately could be restricted to the ansa lenticularis and ventromedial hypothalamotomy, the most delicate stereotactic operation performed to date. Outside Göttingen, this technique has only been used by Prof. Dieter Müller in Hamburg, Germany. This elaborate stereotactic approach is widely unknown and deserves to be discussed in a historical context.

[Professor Hans Otto Lüders].

Professor Lüders has made significant contributions to Clinical Neurology and particularly to Epilepsy and Clinical Neurophysiology. Some of his most important contributions include the following: 1.He pioneered the use of chronically implanted, large plates of subdural electrodes in the presurgical evaluation of patient who were candidates for epilepsy surgery. These electrodes were used to record epileptic seizures and by electrical stimulation to establish the location of eloquent cortex. Lately he has also advocated the use in the USA of stereotactically implanted depth electrodes for presurgical evaluation of epilepsy patients who had deep seated epileptic foci which were impossible to assess with subdural electrodes. These techniques were imported from Europe. 2.Mapping studies with subdural electrodes led to the discovery of a number of cortical eloquent areas that had not been described before: a. The basal temporal language area located in the dominant fusiform gyrus. b. The "negative motor areas" located in the caudal region of the inferior frontal gyrus (bilaterally) and immediately in mesial frontal pre-SMA region (also bilaterally). He concluded that these "negative motor areas" most likely correspond to praxis regions. c. The dominant posterior fusiform gyrus which plays a crucial role in processing reading material. Stimulation of that area produces "alexia without agraphia". 3.He developed a new classification of epileptic seizures based exclusively on semiological ictal characteristics. With the development of the semiological seizure classification he also defined several new seizure types: a. Dialeptic seizures, b. Hypnopompic seizures, c. Hypomotor seizures. 4.Working with general epilepsy principles, he established the existence of 6 zones that characterize the epilepsies: the epileptogenic zone, the irritative zone, the seizure onset zone, the epileptogenic lesion, the symptomatogenic zone and functional deficit zone. 5.He described the ictal DC (direct current) shift seen at the beginning of focal seizures and its value for localization of the seizure onset zone.

Estimulação cardíaca artificial bifocal de segurança: relato de caso e revisão de literatura / Safety bifocal pacing: case report and literature review

Relatam-se dois casos de pacientes portadores de marcapasso definitivo bifocal direito de segurança, totalmente dependentes de estimulação cardíaca artificial. Durante o seguimento, em ambos ocorreu perda da estimulação por um dos cabos-eletrodos ventriculares. A estimulação foi mantida pelo segundo cabo-eletrodo e os pacientes não relataram sintomas. A estimulação cardíaca bifocal deve ser considerada em pacientes altamente dependentes da estimulação artificial ou ainda naqueles submetidos à estimulação cardíaca por via epicárdica...

We describe two cases of patients with right bifocal pacing, totally dependent on cardiac pacing. During follow-up, in both cases occurred exit block of one ventricular lead. The pacing was kept by the other lead and the patients reported no symptoms, showing the value of the bifocal pacing in those patients highly dependent on cardiac pacing or in patients undergoing epicardial pacing...

Cardiodesfibrilador implantável subcutâneo: um novo dispositivo para o tratamento da morte súbita / Subcutaneous implantable defibrillator: a new device for sudden death treatment

A morte súbita é um importante problema de saúde pública e o cardiodesfibrilador implantável (CDI) tem se mostrado mais efetivo que as drogas antiarrítmicas em seu tratamento. A despeito do grande benefício clínico dessa terapia, existem relatos de complicações relevantes relacionadas ao cabo-eletrodo transvenoso. Com o propósito de as minimizar, recentemente foi lançado nos mercados europeu, neozelandês e norte-americano um CDI com sistema totalmente subcutâneo (CDI-S) que dispensa a fluoroscopia. Os resultados iniciais de estudos clínicos publicados são promissores e mostram que o CDI-S converte com sucesso episódios de taquicardia ventricular (TV) e fibrilação ventricular (FV) induzidas ou espontâneas, com taxas de complicações ou de choques inapropriados semelhantes às do CDI convencional. Parece ser uma opção atraente para pacientes pediátricos com doença cardíaca congênita, pacientes com acesso venoso obstruído ou com alto risco de infecção, bem como para jovens com doença cardíaca elétrica, tais como miocardiopatia hipertrófica e síndromes de Brugada e do QT longo. Devido à impossibilidade de estimulação cardíaca permanente, não está indicado para os que necessitam de estimulação anti-bradicardia, terapia de ressincronização cardíaca (TRC) ou com história de taquicardia ventricular monomórfica repetitiva que se beneficiariam de estimulação anti-taquicardia (ATP). Estudos clínicos em andamento irão definir com maior precisão a segurança e a eficácia em longo prazo, o custo-efetividade e o perfil ideal dos pacientes que obterão os maiores benefícios dessa nova tecnologia...

Sudden death is an important public health problem; the implantable cardioverter defibrillator (ICD) has proven more effective than antiarrhythmic drugs in the treatment of sudden death. Despite the great clinical benefit of this therapy, there are reports of significant complications related to transvenous lead-electrode. In order to minimize these complications, recently was launched on the market in Europe, New Zealand and the United States a subcutaneous system (S-ICD) that even eliminates the need for fluoroscopy. The initial results of published clinical studies have been promising and show that ICD-S successfully converts the ventricular tachycardia episodes (VT)/ventricular fibrillation(VF), induced or spontaneous, with rates of complications or inappropriate shocks similar to conventional ICD. It seems to be an attractive option for pediatric patients with congenital heart disease that limits the implantation of transvenous leads, in cases of obstructed venous access, in patients at high risk of infection, as well as young people with electrical heart disease, such as hypertrophic cardiomyopathy, Brugada syndrome and long QT syndrome. Due to the impossibility of permanent cardiac pacing, the S-ICD is not indicated for patients that requiring anti-bradycardia pacing, or cardiac resynchronization therapy (CRT), or with a history of repetitive monomorphic ventricular tachycardia that would benefit from anti-tachycardia pacing (ATP). Ongoing clinical studies will better define its safety and long-term efficacy, cost effectiveness and better patient profile that this new technology will benefit...

The early history of the cochlear implant: a retrospective.

IMPORTANCE: Histories of cochlear implant (CI) technology have often been inaccurate owing to the confusion of terms and anatomical situations or to biased reporting. This retrospective, published shortly after the death of inventor William F. House-and more than 50 years after placement of the first CI-offers a precise account of the early experimental period. OBJECTIVE: To clarify the first steps in the development of the CI, ie, an electrical stimulating device partially inserted into the cochlea. EVIDENCE REVIEW: Literature review based on published data, oral history material, interviews, and written contact with protagonists. FINDINGS: The first CI was implanted by William House and John Doyle of Los Angeles, California, in 1961. In 1964, Blair Simmons and Robert White of Stanford University, Stanford, California, placed a 6-channel electrode through the promontory and vestibule directly into the modiolus. The next step in the development of the CI was its clinical trial on a cohort of patients. Robin Michelson, Robert Schindler, and Michael Merzenich at the University of California, San Francisco, conducted these experiments in 1970 and 1971. In 1973, the first international conference on the "electrical stimulation of the acoustic nerve as a treatment for profound sensorineural deafness in man" was organized in San Francisco. At the same time, Claude Henry Chouard in France and Graeme Clark in Australia began their research. The final step in the establishment of CI as a clinically feasible technology involved the independent evaluation of implant users. The first such evaluation-the result of a 1975 request from the National Institutes of Health-was published in 1977 by Robert Bilger and coworkers at the University of Pittsburgh, Pittsburgh, Pennsylvania. CONCLUSIONS AND RELEVANCE: Inspired by French experiments with electrode implantation at the VIII nerve, the initial practical development of the CI is nonetheless a Californian story, divided between the House group at Los Angeles and teams at Stanford University and UCSF.

Surgical therapy of neurogenic detrusor overactivity (hyperreflexia) in paraplegic patients by sacral deafferentation and implant driven micturition by sacral anterior root stimulation: methods, indications, results, complications, and future prospects.

Spinal cord injured patients with a suprasacral lesion usually develop a spastic bladder. The neurogenic detrusor overactivity (NDO) and the overactive external sphincter cause incontinence and threaten these patients with recurrent urinary tract infections (UTI), renal failure and autonomic dysreflexia. All of these severe disturbances may be well managed by sacral deafferentation (SDAF) and implantation of a sacral anterior root stimulator (SARS). Since September 1986 to December 2002, 464 paraplegic patients (220 females, 244 males) received a SDAF-SARS. The SDAF was done intradurally in almost all cases, which means that we used a single operation field to do a two-stages procedure (SDAF and SARS). The results include data on 440 patients with a mean follow-up of 8.6 years (18 months to 18 years) until December 2004. The complete deafferentation was successful in 95.2%. Of these patients, 420 paraplegics use the SARS for voiding, (frequency 4.7 per day) and 401 for defecation (frequency 4.7 per week). Continence was achieved in 364 patients (83%). UTIs decreased from 6.3 per year preoperatively to 1.2 per year postoperatively. Kidney function remained stable. Early complications were 6 CSF leaks and 5 implant infections. Late compli cations included receiver or cable failures and required surgical repair in 44 patients. A step-by-step program for trouble-shooting distinguishes implant failure from myogenic or neurogenic failure. SDAF is able to restore the reservoir function of urinary bladder and makes the patient achieve continence. Autonomic dysreflexia disappeared in most cases. By accurate adjustment of stimulation parameters, it is possible for the patient to have a low resistance micturition. The microsurgical technique requires intensive education. In addition, the therapist should be able to manage late complications.

History of cochlear implants and auditory brainstem implants.

Cochlear implants have evolved during the past 30 years from the single-electrode device introduced by Dr. William House, to the multi-electrode devices with complex digital signal processing that are in use now. This paper describes the history of the development of cochlear implants and auditory brainstem implants (ABIs). The designs of modern cochlear and auditory brainstem implants are described, and the different strategies of signal processing that are in use in these devices are discussed. The primary purpose of cochlear implants was to provide sound awareness in deaf individuals. Modern cochlear implants provide much more, including good speech comprehension, and even allow conversing on the telephone. ABIs that stimulate the cochlear nucleus were originally used only in patients with neurofibromatosis type 2 who had lost hearing due to removal of bilateral vestibular schwannoma. In such patients, ABIs provided sound awareness and some discrimination of speech. Recently, similar degrees of speech discrimination as achieved with cochlear implants have been obtained when ABIs were used in patients who had lost function of their auditory nerve on both sides for other reasons such as trauma and atresia of the internal auditory meatus.

Neuromodulation in voiding dysfunction: a historical overview of neurostimulation and its application.

This article presents a historical overview of neurostimulation and its application in voiding dysfunction.

Deep brain stimulation for movement disorders.

Movement disorders remain the primary indication for the use of intracranial neurostimulation techniques. This review will discuss the history of this technology as well as the mechanisms of action, current clinical indications, and future prospects for the treatment of movement disorders.

[Pacemaking in Cracow in years 1966-1980]. / Elektrostymulacja serca w Krakowie w latach 1966-1980.

Permanent pacemaking, a new and effective bradycardia--treatment method, has appeared in the sixties. In Cracow the first emergency temporary stimulation by means of transvenously inserted intracardiac electrode was performed in 1966. Permanent technique of artificial pacing was introduced soon after. The number of pacemaker implantations grew successfully, obtaining 750 of the end of the seventies when the Institute of Cardiology of Nicolaus Copernicus Medical Academy was established. Assortment of implantable devices also became wider, including such rare constructions like nuclear pacemakers and an inductive coupled pacemaker.

[The story of one invention--the paper about rehabilitation of deafness]. / Historia pewnego wynalazku--rzecz o rehabilitacji gluchot.

Author described his own patented idea, concerning magnetic induction in transfer signals to receptors of cochlea. This system made possible without touch transfer signals from microcomputer to electrodes implanted surgically to cochlea during rehabilitation of deafness by method cochlear implants.

The Tulane Electrical Brain Stimulation Program a historical case study in medical ethics.

In 1950 physicians at Tulane University School of Medicine began a program of research on the use of electrical brain stimulation that would span three decades and involve approximately 100 patients. Initially, electrical brain stimulation was used to treat of schizophrenia, but later it was applied to a variety of other conditions. Throughout its history the Tulane research was well publicized in both the professional and lay literature, and for almost twenty years, with rare exception, these accounts were laudatory. However, in the early 1970s this work began to draw sharp public criticism. Despite its public and controversial nature, the Tulane electrical brain stimulation program has received relatively little attention from historians. This review recounts the history of the Tulane program with particular emphasis on the ethical propriety of the work. Factors that shaped the historical context in which the Tulane experiments were conducted are discussed.