Textbook of Contemporary Neurosurgery (2 Volumes) Vincent A Thamburaj
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History of Neurosurgery1

Vincent A Thamburaj
‘The farther backward you can look the farther forward you are likely to see’.
—Sir Winston Leonard Spencer Churchill
British politician (1874–1965)
Pharaoh Imhotep, considered as the earliest known physician, lived in the 14th century BC in Egypt.31 In addition, he was the world's first named architect who built the Egypt's first pyramid. His book ‘Edwin Smith Papyri’ (Fig. 1.2), dates back to 1500 BC and is considered to be the oldest book on surgery. Its surgical section deals with injuries to the spine and cranium, in addition to treatment of carbuncles, cutaneous tumors, hernia, hydrocele, etc. Even in his days, cautery was used for checking excessive bleeding during operations.5,69,36
Medicine can be regarded as the oldest of the Indian sciences, and has been proved to be the science in which Indians specialized first.44,82 Muthu (1913) places this period between 4000 and 900 BC.65 HH Wilson (1823) and JF Royle (1837) pioneered the study of Indian medical history.87
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Fig. 1.1: Trephined skull, from the neolithic period (with permission from Wellcome Library, London)
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Fig. 1.2: Edwin Smith Papyrus, oldest text on surgery (with permission from Wellcome Library, London)
Sir William Hunter stated, “Arabic medicine was founded on translation from Sanskrit treatises and in turn, European medicine down to the 7th century was based on the Latin version of Arabic translation of Hindu medicine”.33
Sushruta is considered as the “Father of Indian Surgery”. He lived, taught and practiced his art in the area that corresponds presently to the city of Varanasi (Kashi, Banaras) in northern part of India. The famous Indian Rhinoplasty is a modification of the ancient Rhinoplasty described by Sushruta in 600 BC.14 Even today, pedicled forehead flap is referred to as the Indian flap. Ackernecht2 has aptly observed that there is little doubt that plastic surgery in Europe which flourished in medieval Italy is a direct descendant of classical Indian surgery.22 Sushruta also recommended using leeches to keep wounds free of blood clots. This has only recently been rediscovered and is now used, especially in plastic surgery, to help reduce congestion in tissues, especially in wounds and in flaps used for reconstructing body parts. In “The source book of plastic surgery”, Frank McDowell26 aptly described Sushruta as follows; “Through all of Sushruta's flowery language, incantations and irrelevancies, there shines the unmistakable picture of a great surgeon. Undaunted by his failures, unimpressed by his successes, he sought the truth unceasingly and passed it on to those who followed. He attacked diseases and deformities definitively, with reasoned and logical methods. When the path did not exist, he made one”. Rhazes of Persia repeatedly quoted Sushruta as the foremost authority in the field of surgery.64 Eminent surgeon Whipple105 declares, “All in all, Sushruta must be considered the greatest surgeon of the premedieval period”.
The exact period of Sushruta is not clear, but most scholars put him in a period between 600 and 1000 BC.22,107,40 Johnston Saint suggests that Sushruta was a contemporary of Buddha (600 BC) because of the style of language used.43 The Bower manuscript, which was unearthed in 1890 and housed in the Oxford University library39 is probably the most authentic document of ancient India. It was studied carefully by Hoernle, who placed its origin to around 500 BC.40 The Sushruta's place in this manuscript justifies his period between 600 and 800 BC.
Sushruta considered surgery the first and foremost branch of medicine.64,83,94 He has described surgery under eight heads: Bhedana (incision), Chedana (excision), Lekhana (scarification), Vedhya (puncturing), Esana (probing), Ahrya (extraction), Vsraya (drainage or evacuation), and Sivya (suturing).41,100 His master literature ‘Sushruta Samhita’ (Fig. 1.3) was translated into Arabic as ‘Kitab-Shaw Shoon-a-Hindi’ and ‘Kitab-i-Susrud’.17 The first European translation of ‘Sushruta Samhita’ was published by Hessler in Latin and into German by Muller in the early 19th century.17 The first complete English translation was done by Kaviraj Kunja Lal Bhishagratna in three volumes in 1907 at Kolkata.93
The “Sushruta Samhita” describes more than 300 different surgical procedures and more than 120 surgical instruments (from forceps, specula, and scalpels to scissors, saws, needles, and trocars). In short, all the principles of surgery (the concepts of accuracy, precision, economy, hemostasis, and perfection) find an important place in Sushruta's writings.83,22,64 Sushruta considered the brain as the center for all special senses, and describes certain cranial nerves connected with specific sensory functions.48
  • Two nerves lower down at the back of ear which if cut, produce deafness
  • A pair of nerves inside the two nostrils which if cut, cause anosmia
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    Fig. 1.3: Text from Sushruta Samhita (with permission from Wellcome Library, London)
  • A pair of nerves below the end of the eyebrow which if cut causes blindness
  • Ten nerves maintain the functions of the body by carrying impulses of sound, touch, vision, taste, smell, respiration, sighing, yawning, hunger, laughing, speech, and crying.
The followers of Sushruta were called as Saushrutas. They were expected to study for at least 6 years. Before he started his training, students had to take a solemn oath, which can be compared to that of Hippocrates.41,100 They acquired anatomical knowledge by means of the sacrifice of animals, principally the horse, and men.46 Ancient Indians pioneered inhuman dissection as is mentioned in Sushruta Samhita.50 The dead, wrapped in grass and placed in a cage was allowed to decompose. After an interval of seven days, the thoroughly decomposed body was taken out and very slowly scrubbed with a whisk made of grass roots (of kusa). At the same time every part of the body beginning with the skin should be examined with the naked eye. Since, the Hindu anatomists were forbidden by tradition and religious beliefs to cut the body, they used ‘kusa’ grass to peel off the layers of the skin and study the interiors.42,21,18 Sushruta taught the surgical skills to his students on various experimental modules, for instance, incision on vegetables (like watermelon, gourd, cucumber, etc.), probing on worm eaten wood, preceding present day workshops by more than 2600 years.
Mental disorders were also an important subject of an-cient Indian medical writings. Najabuddin Unhammad (AD 1222), an Indian physician, depicted different types of disorders: schizophrenia (Sauda-a-Tabee); depression (Muree-Sauda); delusion of love (Ishk); organic mental disorder (Nisyan); paranoid state (Haziyan) and delirium (Malikholia-a-maraki). The treatments for these maladies included physiotherapy, drugs, hypnotism, and psy-chotherapy using talismans, charms and prayers. Some of the more unusual treatment methods described included terrorizing the patient with snakes, lions, elephants, or men dressed as bandits.74
Hippocrates (circa 460–377 BC), an ancient Greek physician and teacher, is largely known as the “Father of Medicine”. He separated medicine from divine forces, using observations and inductive reasoning instead of theology and philosophy to guide clinical practice.61,78,102 On injuries of the head, he has described fissured fractures, contusions without fracture, depressed fractures, “hedra” or dinted fractures, cranial lesions distant from the scalp wound (contrecoup fractures) and wounds above cranial sutures.3,72 There are four neurosurgical tools described by Hippocrates for the purpose of trephination. They are trepan and serrated trepan used for sawing of bone up to the meninges. The third one was a probe called “sound” used for determining the depth of the hole. The fourth one was a “raspatory” used for scraping the contused bone and fracture.95 On epilepsy, he states, “It is thus with regard to the disease called Sacred: it appears to me to be no more divine or more sacred than other diseases, but has a natural cause like other infections”.109
The Hippocratic Oath (Fig. 1.4) is widely believed to have been written by Hippocrates in the 4th century BC or by one of his students. Hippocrates is also credited as being the “Father of Spine Surgery”.60 On joints, Hippocrates has described methods for the management of spinal diseases, such as correction of curvatures of the spine and spinal injuries.1 For the treatment of spinal deformities, he developed the Hippocratic table, a support used to help correct the placement of vertebrae that moved backward; many consider it to be the prototypical ancestor of modern orthopedic tables.60
Following the death of Hippocrates and emergence of Alexander the Great, the human development shifted to Alexandria, where Alexandrian school flourished. Herophilus (circa 335–280 BC) born in Chakedon (now Istanbul, Turkey) and moved to Alexandrian school.
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Fig. 1.4: Part of Hippocratic oath (with permission from Wellcome Library, London)
He is credited with dissection on humans.38,62 He described the anatomical origin of nerves to the spinal cord and divided them into motor and sensory tracts, making an important differentiation between nerves and tendons. He also described ventricles and venous sinuses of the brain and in particular, the “confluence of the sinuses,” known also as the Torcular Herophili.31
Aulus Aurelius Cornelius Celsus (25 BC–AD 50) a medical encyclopedist, is credited with, ‘De Re Medicina’ (Fig. 1.5), is considered as one of the most important early medical documents since the days of Hippocrates.15,16 The book contains a vivid description of inflammation. He recognized injuries to the cervical spine fracture could lead to vomiting and difficulty in breathing and injury to the lower spine, on the other hand, could cause weakness or paralysis of the leg, as well as urinary retention or incon-tinence.
Galen (AD 129–200), born in Pergamon (now part of Turkey), was one of the earliest to recognize the powers of brain to carry the voluntary actions and sensory information through the spinal cord to the brain. His writings still represent more than 80% of all surviving medical writings of antiquity7 (Fig. 1.6). Among the anatomical experiments, he performed the transection of the spinal cord, which led him to describe loss of function below the level of the lesion.27,28 He was among the first physician to describe Pott disease of the spine, “Brown Sequard Syndrome”, “blow bottle” for breathing and lung exercises and introduced the words “kyphosis, lordosis, and scoliosis”.28 He advocated elevation of depressed skull fractures, fractures with hematomas and comminuted fractures.31
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Fig. 1.5: Page of text ‘De Re Medicina’ (with permission from Wellcome Library, London)
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Fig. 1.6: Title page ‘certaine workes of Galen, called methodus medendi’- translated by T Gale (with permission from Wellcome Library, London)
During Galen's period, many more instruments had been added to the physicians’ armamentarium such as guarded drill version of that instrument, dural protector, a flat piece of metal that was passed through fracture fissures under the bone and over the dura and served as another layer of protection.63,83 Galen also pioneered the study of hydrocephalus. He described the corpus callosum, ventricular system, fornix, tectum, pineal and pituitary glands, and the cranial nerves.32,84,91
Paul of Aegineta (AD 625–690) is a product of Alexandrian school. In his classic work, ‘Seven Books of Paulus of Aegineta’75 he had classified skull fractures into several categories: fissure, incision, expression, depression and arched fractures and a number of instruments that he designed for neurosurgical procedures. He was the earliest to do spinal decompressive laminectomy on a routine basis.
The Chinese regarded the human body as sacred and surgery was considered inferior compared to other branches of medicine. Little is known about ancient Chinese surgical procedures. Hua T'o is one of the rare names mentioned 7in connection with surgical therapy.31 Zhang Zhong Jing (AD 150–219) is considered the “Hippocrates of traditional Chinese medicine”.58,104 In his treatise he had described a variety of diseases in 397 sections, including headache, stiffness, anxiety, and fevers.58 During Mongolian rule and Genghis Khan's legacy, specialties in the medical community increased dramatically, developing complex, narrowly focused subdivisions.31
The Iranian neuroscience history can be traced to the 3rd century BC, when the first cranial surgery was performed in the Shahr-e-Sukhteh (Burnt City) in south-eastern Iran. Antiepileptic drug therapy plan in Medieval Iranian medicine is individualized, given different single and combined drug-therapy with a dosing schedule for each of those.34 Among the most famous physicians of ancient Persia were “Razi” (AD 864–930) popularly called as “Rhazes” by the people of West, and “Ebn Sina” (AD 980–1036), popularly called as “Avicenna” by the people of West. 66,89,92
Rhazes, is credited with the first description of smallpox and is regarded as one of the pioneers in neurosurgery, pediatrics, and ophthalmology.9,57 He was one of the first physician to introduce the concept of “concussion” and advocated surgery for penetrating injuries of the skull, even though outcome of the surgeries were almost always fatal. He introduced the use of animal gut as a material for sutures.
Avicenna explained many neuropsychiatric conditions, such as, hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo, and tremor.68 He was critical to the work of his predecessors Galen and Hippocrates. He wrote clinical chapters on sciatic nerve disease, facial paralysis, and traumatic lesions of the nervous system, tremors, epilepsy, and headaches, among other clinical conditions.9,92
Together with the work of Hippocrates and Galen, the “Al-Qanun fi al-Tibb”—Canon of Medicine-Law of Medicine (Fig. 1.7) became the standard of medical science in Europe for centuries.89 In his Canon medicine there are number of interesting neurological findings. Many of his medical texts were written in Persian or translated from Greek into Persian.10,55
Greek, Persian and Indian medical traditions were carried from East to West and back again through Persia51 in the medieval period and coincided with rise of medical teaching in Europe.88
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Fig. 1.7: Nervous system—Avicenna's Canon of Medicine (with permission from Wellcome Library, London)
Constantinus of Africa (1020–1087) translated Arabic manuscripts into Latin and introduced Arabic medicine to school of Salerno (now Naples, Italy) and hence to all of Europe.19 Roger of Salerno (approximately 1170) was the first writer on surgery in Italy. His work, “Practica chirurgiae”86 had a tremendous influence on the medieval period, offering several interesting surgical techniques such as reanastomosis of severed nerves and paid particular attention to the nerves’ alignment. He introduced an unusual technique of checking for a dural tear or a leakage of cerebrospinal fluid (CSF) in a patient with a skull fracture; while the patient held his breath (Valsalva maneuver).31 Theodoric of Borgognoni (1205–1298) was a pioneer in the use of aseptic technique. His surgical work, written in 1267, provides one of the best reviews of contemporary medieval surgery.98 He argued for meticulous surgical techniques. William of Saliceto (1210–1277), an Italian surgeon, wrote “Chirurgia”106 which was highly original and not based on previous writings. Lanfranchi of Milan (approximately 1280) often called the “Father of French Surgery” produced his “Cyrugia parva”, a work in which he perfected the use of the suture for repairs.52 Lanfranchi developed a method of esophageal intubation for surgery, a technique not commonly practiced until the 20th century.
Guido da Vigevano (1280–1349), was considered as pioneer of anatomy during medieval times.
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Fig. 1.8: Guido da vigevano–miniature anatomical table (with permission from Wellcome Library, London)
The systematic anatomical drawings in his textbook, although based on empirical and observational concepts, set a milestone for further development of anatomical science (Fig. 1.8).8,12 In his period, science and arts reached an apex. His drawings are the earliest portrayals of the cerebral convolutions in the history of neuroscience.108
Leonard of Bertapalia (1380–1460) of Venice offered a course of surgery in 1429 that included the dissection of an executed criminal. Leonard was interested in injuries of the head and devoted one-third of his book on surgery of the nervous system.53,54 He considered the brain and spine to be the most precious of organs, regarding them as the source of voluntary and involuntary functions.
With the emergence of British colonization in the “Renaissance” period (15th–17th centuries), further development in medicine continued. Ancient texts, typically written in Latin or ancient Greek, were improved upon and many of the errors of ancient concepts were corrected, especially in anatomy. Most of the personalities are from Europe. Some of the better known personalities are briefly mentioned here. The list is, by no means, complete.
Ambrose Paré (1510–1590) was keenly interested in developmental malformations, and described several conditions that would now be referred to a pediatric neurosurgeon.90 His patients included Henri II King of France, who died of a penetrating orbital wound, and he described a number of other craniofacial wounds sustained in war or in warlike sports. He provided an extensive discussion on the use of trephines, shavers, and scrapers. His influence extended throughout the literate world, including Japan.90
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Fig. 1.9: Drawing of brain, 16th century from ‘De humani corporis fabrica’ by Andreas Vesalius (with permission from Wellcome Library, London)
Andreas Vesalius (1514–1564) of Brussels was a surgeon and “Father of Modern Anatomy”.96 His most influential books on human anatomy ‘De humani corporis fabrica’ [On the workings of the human body (Fig. 1.9)] has excellent illustrations of skull, brain and dural coverings.111 He has made interesting contribution to hydrocephalus.
Thomas Willis (1621–1675) published “Cerebri Anatome” in 1664 providing the greatest insight to date into the structure and function of the circular arterial anastomosis, later known by his name.47 Although description of the circulation at the base of the brain is part of this text, the majority of the book is devoted to functional anatomic features of the brain.35
Until the 18th century, surgery remained mainly cranial rather than neurological. Intradural exploration was avoided. Another important factor was the paucity of knowledge of brain functions. Knowledge of neuroanatomy pioneered by Vesalius, of neurophysiology pioneered by 9Magendie, and of neuropathology pioneered by Morgagni had been accumulating, but could not be surgically utilized before the aseptic era. The functions of the spinal cord were earlier appreciated, and quite effective means of reduction of fracture-dislocations of the spine, even utilizing skeletal traction, were in vogue. Percival Pott (1714–1788), better known for “Pott's spine” and “Pott's puffy tumor” (pus under the pericranium), has described spinal gibbus and aggressive management for head injuries.77 Jean Cruveilhier (1791–1874), a pathologist at the University of Paris, had made original descriptions of spina bifida, spinal cord pathologies, cerebellopontine angle tumor, meningiomas among others.30
Introduction of anesthesia in the 1840s greatly facilitated surgery in general. In the 1860s Ignaz Philipp Semmelweis of Hungary brought asepsis to obstetrics and Joseph Lister of Glasgow, Scotland, initiated asepsis in surgery. Later, cerebral investigations by Franz Gall, Paul Broca, Pierre Flourens, David Ferrier, Carl Wernicke, John Hughlings Jackson and others ushered in the era of cerebral localization, in which cognitive processes were linked to particular parts of the brain.76
Sir William Macewen [1848–1924 (Fig. 1.10)], reportedly, performed the first successful intracranial surgery where the site of the lesion (a left frontal meningioma) was localized solely by the preoperative focal epileptic signs. On the basis of these signs Macewen thought that there was good evidence of an “irritation to the lower and middle portions of the ascending convolutions in the left frontal lobe”. He had an early association with Lister's aseptic technique. His monograph, “Pyogenic infective diseases of the brain and spinal cord” and its accompanying volume, “Atlas of head sections” was the most comprehensive study of pyogenic brain diseases.13 Another important contribution by Macewen to modern surgery was the technique of endotracheal anesthesia with the help of orotracheal intubation, which he described in 1880 and is still in use today.
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Fig. 1.10: Sir William Macewen (with permission from Wellcome Library, London)
Sir Victor Haden Horsley (1857–1916) followed Macewen's lead in clinical neurological surgery. He introduced bees wax for bleeding bone.103 He developed surgery for craniostenosis and decompressive craniectomies. His early experimental work on cortical localization was done with the young physiologist, Sharpey-Schafer. With Clarke, he developed the “Horsley-Clarke” stereotactic frame which was the beginning of stereotactic neurosurgery.
Fedor Krause (1857–1937), with Wilhelm Wagner, Ernst von Bergmann and Otfrid Foerster was one of the pioneers of Neurosurgery in Germany.11 He introduced Horsley's procedures concerning surgery for epilepsy in Germany. He is also known for his work in plastic and reconstructive surgery, as well as his operations of the frontal lobe. He developed several operative techniques concerning tumors of the brain and nervous system, and with Hermann Oppenheim (1858–1919) he successfully removed a pineal tumor.
Ludvig Martynovich Puusepp [1875–1942 (Fig. 1.11)] is considered as “Cushing of the East” and rarely mentioned in the western literature.
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Fig. 1.11: Ludvig Puusepp; Cushing of the East (from http://hdl.handle.net/10062/4747)
He joined Vladimir Bechterew, the notable and influential physiological neurologist of Russia as a surgical member in his team. In April 1910, he was appointed as Professor and Head of the department of Neurosurgery in St Petersburg, the first independent department of Neurosurgery in the world.4,45 In November 1920, he joined the University of Tartu in Estonia (East Germany). Within the same year he was granted the citizenship of the Republic of Estonia and became the Chair of the Nervous diseases and Neurosurgery.
Ludvig Puusepp was a pioneer and was always well ahead of his time. He published a number of papers and monumental volumes covering almost every conceivable subject in this surgical specialty; the list includes, “Influence of X-ray beams on cortical areas in dogs” and “About the cerebral center regulating penile erection and ejaculation”.56 In 1917, he published his first major textbook “Fundamentals of surgical neuropathology—peripheral nervous system”.4,56 In 1929, he published the world's first neurosurgical journal “Folia Neuro-chirurgica”.67
Bekhterev published Puusepp's “Foundations of learning on brain functions” which comprised text of seven volumes.4 Most noticeable were, Treatment of neuralgia by alcohol injection, Influence of tobacco on cerebral blood circulation, Surgical management of infantile internal hydrocephalus, Surgical management of spastic paralyses, Surgical treatment of mental disease.4,56 Puusepp coined the term “Arachnoiditis ossificans”79 Enterogenous cyst of the central nervous system (CNS) was first reported by Pussep in 1934.80 Abduction of the little toe on stimulating the posterior external part of the sole of the foot indicative of lesions of the extrapyramidal and pyramidal tracts was named as, Puusepp's reflex.85
Puusepp was not only a skillful surgeon and a writer, but also an inexhaustible innovator. He expeditiously implemented each innovation at his clinic in the field of neuroradiology. His work performance includes a method for the diagnosis of syringomyelia and the elaboration of a special surgery for treatment of the same. His trial to measure brain pressure by means of a manometer, especially designed for that purpose, is noteworthy. Similar technology was put to use as a routine method only 30 years later.4,45 Puusepp sectioned the cortex between the frontal and parietal lobes in three patients who were described as manic, depressive or epileptic equivalents.23 He suggested that the temporo-subtemporal decompression introduced by Cushing to alleviate intracranial pressure (ICP) in glioma should be performed in two steps. In 1913, he published this two-staged method and called it “physiological enucleation”.56
In North America around this time, development of Neurosurgery was rather slow, but soon picked up. William W Keen (1837–1932) gained worldwide attention, for his several innovative procedures including drainage of the cerebral ventricles and several successful removals of large brain tumors.6 In 1892, Keen with James White wrote the first American surgery text based on Listerian principles and introduced innovative approach to aseptic surgery.
William Stewart Halsted (1852–1922) is known as “Father of Surgical Subspecialities”. He pioneered the modern surgical fundamental principles of absolute control of bleeding, accurate anatomical dissection, complete sterility, exact approximation of tissue in wound closures without excessive tightness, and gentle handling of tissues. A surgical glove was his innovation.110
Harvey William Cushing [1869–1939 (Fig. 1.12)] graduated in medicine in 1895.37 In 1894, as an intern he devised the first anesthetic chart, the ether chart, in collaboration with Ernest Amory Codman. They again collaborated and were the first to introduce the use of X-rays in surgical practice. He fostered neuroradiology and radiotherapy throughout his life.57 In 1896, at the age of 27, he joined as an assistant to William Stewart Halstead at the Johns Hopkins Hospital. Later he worked with European giants, such as Theodore Kocher, Hugo Kronecker and Victor Horsley for nearly one and half years.37 He brought the newly developed Riva-Rocci manometer from Italy and stressed its importance to measure blood pressure.57
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Fig. 1.12: Harvey Cushing (with permission from Wellcome Library, London)
By 1899, he restricted his professional activities exclusively to clinical neurosurgery and related neuroendocrine research and so placed neurosurgery on a firm footing as an appropriate specialty. Despite the fact that Cushing had not performed a successful intracranial operation by 1904, he was asked to contribute for the new five-volume edition of “Surgery”, edited by WW Keen. This monograph rapidly became the single most important text in neurosurgery and provided the basis for the field until “The Brain” by Walter Dandy supplanted it.57 In 1905, he published a paper on “The Special Field of Neurological Surgery”. In February 1910, he successfully removed a tumor from the right parietal hemisphere of General Leonard Wood, one of the most influential figures of his time.20,37,57
In March 1909, Cushing carried out his first operation for acromegaly. In the same year “The hypophysis cerebri: Clinical aspects of hypopituitarism and hyperpituitarism”, was published. This was one of the greatest contributions in medicine and led to the foundation of a new medical discipline, Endocrinology. In 1912, Cushing published the book “The Pituitary Body and Its Disorders”.101
Cushing was associate Professor of Surgery at Johns Hopkins from 1903–1912. He was responsible for establishing the Hunterian Laboratory at Johns Hopkins in 1905. In 1910, he was appointed as Mosley Professor of Surgery and chairman of the department at Harvard Medical School. From 1913–1932 he remained Surgeon-in-Chief at the Peter Bent Brigham Hospital.20,36 He established the Laboratory of Surgical research at Harvard.20,37
In 1917, he suffered from an attack of polyneuritis, which plagued him for the rest of his life.37 But he continued his mission with Dr William Bovie and in 1927, he established the application of electrical coagulation to neurosurgery. His neurosurgical skills reduced the mortality rate at brain surgery from 90% to approximately 8%. He was instrumental in the formation of American ‘Society of Neurological Surgeons’ in 1920.
At this time, chiefly owing to Cushing's influence, America was leading the world in Neurosurgery. Throughout his career, Cushing was gathering round him young colleagues in the related fields of neurophysiology, neuro-ophthalmology and neuropathology. His sense of mission led him to take on a series of carefully selected young men including Walter Dandy and Percival Bailey in addition to foreign trainees. Jefferson of Manchester, McConnell of Dublin, Cairns of the London Hospital, Norman Dott of Edinburgh, McKenzie of Toronto, Wilder Penfield of Montreal, Balado of Buenos Aires, Olivecrona of Stockholm, Paul Martin of Brussells, de Vet of Netherlands, Torkildsen of Oslo, and Clovis Vincent of Paris were some of his trainees who contributed vastly in the development of neurosurgery in their countries. Cushing died on October 7, 1939 at the age of 70 of myocardial infection. Autopsy showed a posterior coronary occlusion, complete occlusion of the femoral artery on both sides and an incidental 1 cm colloid cyst of the third ventricle.37
Walter Edward Dandy (1886–1946) along with Cushing and Halstead is considered as one of the three marshals of American Neurosurgery. Dandy is credited with numerous discoveries and innovations, including the description of the circulation of CSF in the brain, surgical treatment of hydrocephalus, the invention of air ventriculography and pneumoencephalography, and the description of brain endoscopy, the establishment of the first intensive care unit (ICU) and the first clipping of an intracranial aneurysm, which marked the birth of cerebrovascular neurosurgery.25
Percival Bailey (1892–1973), with Cushing, published a book “Tumors of the glioma group” a contribution in the field of neurology by him. Bailey applied his knowledge of neuroanatomy and neuropathology to define the microscopic nature of gliomas, their relation to the normal glial cells of the developing and adult nervous system, the clinical correlation of these tumors and the prediction of their prognosis based on their microscopic appearance.24 Among Bailey's distinguished pupils were Earl Walker, William Sweet, and Chisato Araki of Kyoto and Kenji Tanaka and Kentara Shimizu of Tokyo, who were to return to Japan and foster neurosurgery in Japan.
Herbert Olivecrona (1891–1980) was greatly interested in neurosurgical education in medical schools and the training programs.59 He acknowledged the use electrocautery unit and suction for the control of intraoperative hemorrhage and the cleaning of the operative field.70 He recognized the potential for functional and psychiatric neurosurgery.
During this period, surgeons from Asia and Africa had their neurosurgical training in Europe and North America and established neurosurgical units in their respective countries. Jacob Chandy (1910–2007) a Penfield trainee started India's first Neurosurgical unit at Christian Medical College (CMC) and Hospital, Vellore, Tamil Nadu in South India in 1949.71 In the earlier years, Dr Baldev Singh, a 12neurologist was closely associated with him. At the end of the same year B Ramamurthi (1922–2003), on his return from the UK, opened the neurosurgical department at Government General Hospital, Madras (now named Chennai).71 Ram G Ginde started the specialized department of neurosurgery at Seth GS Medical College and King Edward Memorial Hospital, Mumbai in 1951.29 With the initiative of four wise men, B Ramamurthi, Jacob Chandy, Baldev Singh and ST Narasimhan, the Neurological Society of India was inaugurated in 1951 at Hyderabad along with the annual meeting of the Association of Physicians of India.72
In India, the first residency training program was started in 1954 at Christian Medical College, Vellore. The first recognized university course for MS and later for MCh began in the year 1958 and KV Mathai was the first person to receive this degree in India.72 Soon, similar program followed at Madras Medical college, Madras (presently, Chennai) and later in other centers. The Institute of Neurology was later established here in 1965.
B Ramamurthi (Fig. 1.13) is credited with development of neurosurgery in various parts of India and remained the “Face of Indian Neurosurgery” to the rest of world.49 His numerous publications touch upon every aspect of CNS tuberculosis, from diagnosis to pathogenesis and therapy. He provided some of the earliest descriptions of lesions like the intramedullary spinal tuberculomas, optochiasmal arachnoiditis, tubercular spinal arachnoiditis.97 He along with his colleagues succeeded in making the Madras Institute of Neurology—an international leader in the field of stereotaxy and attracted trainees from all over the world. Besides using it for patients with movement disorders, its scope was extended to use it for the management of epilepsy, pain relief, cerebral palsy and drug addiction and some psychiatric disorders.97 He was also the force behind the establishment of the National Brain Research Centre (NBRC), New Delhi.
During early 20th century, improved understanding of neuropathology and physiology, advances and Dandy's contribution in diagnostics made neurosurgery a “safe” specialty, both for the patients and the surgeons. An ingenious valved shunt system by Nulsen and Spitz in 1952 has brought hydrocephalus under surgical control.6 The stereotaxic apparatus of Horsley and Clark has been revived and simplified for specific clinical purposes. Encouraged by colleagues such as Donaghy and Krayenbuhl, Gazi Yasargil created innovative instrumentation, such as the floating microscope, the self-retaining adjustable retractor, microsurgical instruments and ergonomic aneurysm clips and appliers. His genius in developing microsurgical techniques for use in cerebrovascular neurosurgery has transformed the outcome of patients with conditions that were previously inoperable.99
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Fig. 1.13: B Ramamurthi—The face of Indian neurosurgery
It must be said “the romance” with medical neurologists has begun to wane, and technical innovations appear to replace the art of neurology since the last decades of the 20th century, Advances in neuroradiology with computerized tomography (CT) and magnetic resonance imaging (MRI) have made myelograms, ventriculograms, and pneumoencephalograms history. Innovative radiotherapy, radiosurgery and aggressive chemotherapy have emerged. Ever improving interventional radiology and introduction of neuroendoscopy have greatly reduced the surgical morbidity. Invasion by computers and robotics have taken neurosurgery to a different level. Subspecialities within neurosurgery are the order of the day. They are discussed in respective sections.
  1. Abu al-Qasim Khalaf ibn Abbas al-Zahrawi. On Surgery and Instruments (translated by Spink MS, Lewis GL). University of California Press;  Berkeley, CA:  1973. pp. 812–9.
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