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Table of Contents    
LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 194-195

Stone of folly: Historical vignette revisited


Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital, Kolkata, India

Date of Submission14-Jan-2013
Date of Decision16-Jan-2013
Date of Acceptance28-Mar-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Prasad Krishnan
Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital, Kolkata
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111156

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How to cite this article:
Krishnan P, Bhattacharyya AK, Chowdhury SR, Kartikueyan R. Stone of folly: Historical vignette revisited. Neurol India 2013;61:194-5

How to cite this URL:
Krishnan P, Bhattacharyya AK, Chowdhury SR, Kartikueyan R. Stone of folly: Historical vignette revisited. Neurol India [serial online] 2013 [cited 2020 Nov 26];61:194-5. Available from: https://www.neurologyindia.com/text.asp?2013/61/2/194/111156


Sir,

Trephination of the skull and removal of an intracranial stone by a "sleight of hand" was a form of quackery practiced on mentally ill patients in the middle ages in Europe. We describe a patient with olfactory groove meningioma compressing the inferomedial frontal lobe and psychiatric symptoms that had startling similarity to a stone on preoperative imaging.

A 65-year-old lady had been complaining headache for several years duration. The only investigation retrievable was skull X-rays done 5 years ago which showed a right frontal calcified lesion [Figure 1]a and b. Over the last 1 year, she developed irrelevant speech, forgetfulness, and behavioral abnormalities (disinhibition, emotional lability, talkativeness) for which she had consulted several psychiatrists. She presented to us with mild left sided hemiparesis. Cranial computed tomography scan showed hyperdense right parasagittal 4.12 cm × 2.7 cm × 3.5 cm lesion abutting the falx and extending into the olfactory groove with mass effect and perilesional edema [Figure 2]. Reconstructed images resembled a stone in the floor of the anterior cranial fossa [Figure 3]. The patient underwent right frontal craniotomy and gross total excision of the lesion under general anesthesia. Intra operatively the mass was heavily calcified and had to be cut with scissors. Histopathology report was consistent with meningioma. Her behavioral abnormalities subsided and hemiparesis improved.
Figure 1: (a) Lateral X-ray skull showing calcified lesion in the anterior cranial fossa floor. (b) Antero-posterior X-ray skull showing medial basifrontal calcified lesion

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Figure 2: Computed tomography scan of brain showing right sided hyperdense parasagittal frontal lesion

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Figure 3: Volume reconstructed images of the computed tomography scan show lesion resembling a "stone"

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In the middle ages in Europe, itinerant quacks used to perform a variety of operations of which lithotomies (removal of urinary calculi) were very common. Less well-described is the entity of trephination and removal of intracranial "stones." [1] The surgery would be performed on the unfortunate victims of altered mentation [1],[2] and has been famously described by Heironymus Bosch in his painting "The Cure of Folly" also called "The Extraction of the Stone of Madness" [Figure 4].
Figure 4: Trephination in the middle ages to extract the "stone of folly" - painting by Heironymus Bosch (tagged as a public domain work of art)

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Focal neurological signs and features of raised intracranial tension may be absent in slowly growing brain tumors. Medial frontal lesions have been highlighted to cause "subtle, non focal abnormalities." [3] The possibility of an organic cause should be kept in mind in new onset psychiatric symptoms above the age of 40, particularly if non-responsive to standard medications and accompanied by headache, seizures, vomiting, papilledema or focal deficits. [3],[4] While 3% of patients admitted with psychiatric symptoms have been stated to have brain tumors, [3] conversely 21% of meningiomas have been described to present with purely psychiatric symptoms (mostly affective) in the absence of neurological findings. [5] Further there is no psychiatric symptom specific for the patients with brain tumors [4] and neither is the presentation laterality (right or left) specific. [5]

To conclude, though in their book "History of Madness," Foucault and Khalfa describe Bosch's doctor [the stone cutter] as being "far more insane than the patient he is attempting to cure with false knowledge," [6] in current medical practice, armed with the knowledge that slowly growing intracranial lesions can present primarily with disturbed behavior, the "folly" would actually be in delaying imaging to rule out any structural lesion.

 
  References Top

1.Gross CG. A hole in the head. Neuroscientist 1999;5:263-9.  Back to cited text no. 1
    
2.Grabman JM. The witch of Mallegem. Print by Pieter Breughel the Elder (ca. 1528-69): Pieter van der Heyden, engraver. J Hist Med Allied Sci 1975;30:385.  Back to cited text no. 2
    
3.Filley CM, Kleinschmidt-DeMasters BK. Neurobehavioral presentations of brain neoplasms. West J Med 1995;163:19-25.  Back to cited text no. 3
    
4.Ristić DI, Vesna P, Sanja P, Dejanović SD, Milovanović DR, Ravanić DB, et al. Brain tumors in patients primarly treated psychiatrically. Vojnosanit Pregl 2011;68:809-14.  Back to cited text no. 4
    
5.Gupta RK, Kumar R. Benign brain tumours and psychiatric morbidity: A 5-years retrospective data analysis. Aust N Z J Psychiatry 2004;38:316-9.  Back to cited text no. 5
    
6.Foucault M. History of Madness. Abingdon, Oxon (GB): Routledge; 2006.  Back to cited text no. 6
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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