Ramamurthi and Tandon’s Textbook of Neurosurgery (3 Volumes) Prakash Narain Tandon, Ravi Ramamurthi
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1History
Thimmappa Hegde
2

Evolution of Neurosurgical Techniques1

Thimmappa Hegde,
Sarat Chandra P
 
INTRODUCTION
 
Medical Practice in Ancient India
The history of medical science in ancient India takes us back to antiquity. Recorded history of medical science is as old as the “Vedas”. It is based on the practical experience and careful methods pursued by the sages in the olden days. The ancient writings of the Hindus, which give us an idea of the culture and traditions at that time, were classified as “Srutis” and “Smritis”. Smritis are the scriptures, written by the sages, who have recorded the eternal truths as revealed by the Brahma, “The Creator”. The Srutis stand as primary in point of authority, being taught through generations by word of mouth only and learnt by rote. The real systems of medicine which developed indigenously in India included “Ayurveda” and “Siddha”. These are all pervasive health sciences and are not for medical purposes only. Ayurveda is considered as an essential part of the “Vedas”. The primary aim of Ayurveda is to enable a person to maintain normal health by prescribing diet, medicine and a regimen of life. Ayurveda is a science of life and teaches mankind how to lead a healthy life and live long happily. Daily methods of good living known as “Dinacharya” are particularly emphasised. It also deals with physical and mental diseases and their cure. “Dhanavantri”, “Charaka”, “Atreya” and “Sushruta” have been considered the great masters in this science. The Siddha system of medicine is said to have originated in the days of Mohenjodaro, even thousands of years before the Vedic period, possibly between 3000 and 5000 BC. The word “Siddha” means the one who has attained perfection. According to the mythological sources, the origin of Siddha medicine is attributed to Lord Shiva, who gave the first discourse on this subject to Nandi Thevar, the celestial physician. These would indeed be valuable additions to our modern pharmacopoeia. Both Ayurveda and Siddha are similar and are based on the theory of “Tridosha”. The third system of medicine—The Unani or the Greco-Arabian system—was introduced when Mohammedans came from Arabia and Persia. This includes blood as the fourth humour. The Siddha systems contain many valuable therapeutic agents, which should be studied scientifically. These three systems are taught and widely practiced in India and command much influence even today. The modern system of medicine was introduced in India by the Portugese and developed further by the British from the 16th and 17th century onwards.7
 
Medical Education in Ancient India
The educational system of ancient India was based on a personal relationship between the pupil and the teacher. The idea of organisation in education and its application to the methods of collectivism were emphasised by Buddhism. There were many Universities or “Viharas” in Ancient India that were famous, among which were Nalanda, Takshila and Kashi. The ruins of the ancient University of Nalanda are situated at Baragaon in Bihar. The best account of this university has been provided by two Chinese pilgrims, Yuon Chwang and I Tsing (5th to 6th century AD). Nalanda was known to be the largest residential university that India ever had and was a great centre for learning. Education was free, made possible by liberal grants by royal and private philanthropy. It had a large population of 8,500 pupils and 1,500 teachers. It was in such an academic atmosphere that Ayurveda was taught. The Takshila University was also a great centre of medical education, the remains of which can still be found in Rawalpindi, Pakistan. The course of training extended over a period of 7 years, at the end of which the student had a thorough severe test of his knowledge before he went into practice. The Banaras University (Kashi) flourished from 7th century BC to 12th century AD. The most outstanding feature of this university was its school of surgery.7
 
Medical Ethics in Ancient India
In admitting students to the study of medicine, as much importance was attached to moral fitness as to the intellectual and physical fitness of the pupils, for it was considered axiomatic that moral excellence was the basis of all true education. The object of education was not merely to prepare the student to earn a livelihood but also to infuse into him a strong desire to lead a good and virtuous life altogether. It was stressed that the study of medicine was solely for the purpose of showing compassion to all beings and not for selfish purposes. Various oaths have been described in “Charaka Samhita” and “Sushruta Samhita” to inculcate such habits amiably. For instance, one of such oaths in Charaka Samhita states “Thou shalt behave and act without arrogance and with 4care and attention and with undistracted mind, humility, constant reflection and with ungrudging obedience.”7 Please note that this preceded the Hippocratic Oath by several centuries.
 
NEUROSURGICAL TECHNIQUES IN ANTIQUITY
 
Neurosurgery in Ancient India
Surgery had advanced a great deal in ancient India, the various wars being chiefly responsible as wounds and other injuries inflicted on the battlefield had to be treated effectively and expeditiously. The Indian people, generally speaking, possessed a progressive and enterprising mind and this along with their extensive knowledge of pharmacopoeia consisting of herbal, mineral and other drugs, helped a great deal in this process. The greatest name in the surgery of ancient India was that of Sushruta who probably flourished around 1000 BC that was in the pre-Buddhist period. This is supported by the fact that the “Atharva Veda”, which is pre-1000 BC, agreed with Sushruta's system of describing the bones of the human body. The Mahabharata, the great Indian Epic, also refers to Sushruta as one of Vishwamitra's sons. At that time, surgery was taught at Banaras (Kashi) and medicine by Punarvasan Atreya at University of Takshila (Taxila). It was in Banaras where Indian surgery reached its highest point. “Sushruta Samhita” was written here by Sushruta, who for the first time brought together the existing knowledge of surgery.7 Sushruta (Fig. 1), unlike his Greek contemporaries who were morbidly reluctant to perform human dissections, has vividly described the cranial nerves, including the optic and vestibulocochlear nerves in cadavers. He also described various surgical procedures like excising, probing, puncturing, suturing and evacuating fluids. His method of management of spinal injuries in itself reflects his great knowledge on the subject. For instance, on treatment of dislocation of the neck and downwards, the surgeon was instructed to grasp the head at the nape of the neck along with the angle of the jaw and lift it up. On the whole, however, he believed that the treatment of fractures of the spine was hopeless.4,60
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Fig. 1: Sushruta—The practice and teaching of medicine by Sushruta from an Indian print of the 18th century AD
Charaka was another master of ancient Indian medicine. He was said to be the incarnation of Shesha, the serpent God with thousand heads, who is supposed to be the repository of all sciences, especially medicine. He was the son of Visudha, a learned sage, and is said to have been born at Banaras around 320 BC. His book Charaka Samhita is still used as the standard book on Ayurvedic medicine. Buddhist tradition makes him a contemporary of the great Indo-Scythian King Kanishka, to whose court he was attached in the capacity of a physician. He described various ailments like hemicranial headache, facial paralysis, spasm of the throat, and diseases of the mouth, nose and eyes. Management of all these was based usually on correcting the humors of the body.7
Atreya, Dhanvantri, Agnivesa and Vagbhata are a few other names of famous physicians of antiquity. Jivaka, the personal physician of Gautama Buddha, is reported to have removed intracranial masses using trephine holes. In the 10th century AD, two physicians were asked to attend King Bhoja of Dhar. All medical therapy for his severe headache had failed. The physicians advised surgery. A drug called “Sammohini” rendered the King unconscious. The head was then trephined and a pearly tumour was removed from the brain. He made a complete recovery.7
 
Trephining in Neolithic Period
In 1875, two historians of great repute, Prunières and Brocard, discovered that trephining of the skull was frequently carried out in the Neolithic period, many millennia before our historic period (Figs 2A and B). Trephining was then probably performed to remove foreign bodies, as well as splinters of fractured skull, and also perhaps for mystic reasons, e.g. to release evil spirits from the skull, which were thought to unbalance the humors in the body and ultimately lead to diseases. Graveyards from the Paracas and Parachamac regions in Peru provide ample evidence that pre-Incan surgeons were performing trephination in great numbers as early as in 3000 BC. Neolithic Celtic remains have revealed the presence of round or oval skull pieces, presumably removed by trephination. Trephination was also performed in England as discovered in a skull excavated at Crichel Down in 1938.71
Such trephined skulls were found in all parts of the world demonstrating the similarity of medicine of ancient civilisations. New growth of the bone about the edges of the trephines proved that these procedures were often followed by survival. The patient was usually, perhaps always, dulled or made unconscious with soporific potions.
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Figs 2A and B: Skull trephine as performed during Neolithic period (Anthropologic Institute of Florence)
Trephining is still practiced among some primitive races for instance, the Kabyles of Northern Africa, the hill tribes of Dagestan and in many parts of Melanesia. All these operations owe their origin more from a demonical or magical concept rather than rational therapy.4,47
 
The Edwin Smith Surgical Papyrus
The Edwin Smith surgical papyrus, dating from the 17th century BC, is one of the oldest of all known medical papyri (Figs 3A and B). Edwin Smith was an Egyptologist who bought this ancient manuscript roll at Luxor, Egypt, in 1862, from unknown sources. Though he understood the importance of this manuscript, it was not until 1930 that James H Breasted, then Director of the University of Chicago Oriental Institute, translated the treatise and established its importance. More interestingly, this ancient composite manuscript, as discovered by Breasted, was a copy made by an Egyptian scribe from a still earlier document based on the contributions probably of several earlier authors dating to perhaps as early as 3000–2500 BC.8
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Figs 3A and B: Edwin Smith papyrus—case 47 and 48 taken from Edwin Smith papyrus along with hieroglyphic interpretation shown on the right side (Plate XVII from Breasted)
The papyrus, apart from being the oldest one of its kind in existence, has many more unique features. It contains actual cases and not recipes. The treatment of cases is rational and mostly surgical. Each case had been given one of the three different verdicts: (a) favourable, (b) uncertain, and (c) unfavourable. It is of special interest to neurosurgeons because it contains the first descriptions of the cranial sutures, the meninges, the external surface of the brain, the cerebrospinal fluid and intracranial pulsations. Also of great interest are the different modes of treatment described for various types of head injuries. The frustration in treating spinal injuries was recognised even then.8
 
Hippocrates and Neurosurgery (460–377 BC)
Hippocrates is considered the father of Western medicine and his writings have influenced the practice of medicine for more than 20 centuries. Littre, who is an authority on the work of Hippocrates and his students, had collected more than 53 subjects in 72 books.1,4 Surprisingly, most of the Hippocratic workers seem ignorant of structural anatomy and most of their writings prove to be confusing, if not wrong. The observations of Hippocrates on head injuries and their treatment are recorded in the work “On injuries of the head”. The clinical acumen of Hippocrates is well demonstrated by his descriptions of aphasia, unconsciousness, pupillary inequality and ophthalmoplegia. He was aware of the fact that a blow on one side of the head could lead to convulsions and paralysis of the limbs on the opposite side. It is very interesting to note the meticulous instructions he gave for surgery of head injuries. His instructions for the use of the trephine were the most precise. “……… The opening should not be made over the cranial sutures, for the dura being adherent, was likely to be damaged”, “… the trephine should repeatedly be removed from the skull and cooled with water during the procedure and the incision examined to be sure that the dura mater was not reached”.57
Celsus (30 BC) further described the treatment of head injuries and pointed out the occurrence of contrecoup fractures and advised trephining for fractures.4 Galen (130–201 AD) was a disciple of Hippocrates and went far beyond his master. Unlike his master, who had great humility and would often say, “I don't know”, Galen had an explanation for almost everything.4
Galen's descriptions for trephination were similar to that of Hippocrates, e.g. “…………. the trephine should be rotated slowly and carefully, with frequent inspections so as not to breach the dura mater……….”. He emphasised upon the description of the 5 types of skull fractures listed by Hippocrates. He described dressings in great detail, including a dressing of wool with oil of roses, with a warning not to put pressure on the dura. Other Greeks who further added to knowledge, during this period were, Aretaeus the Cappadocian (150 AD), Oribasius (325–403 AD) and Heliodorrus.1,4,57,60
6
 
Neurosurgical Techniques in the Medieval Period (500–1500 AD)
During this period, not much was added to the techniques of management of skull fractures than what was already known. However, significant contributions were made during the later part. Paul of Aegina (625–690 AD) advocated exploration and extraction of broken pieces of bone in spinal fractures. Roger of Saleron (1170 AD) described in detail the surgical management of skull fractures. Lanfrane compiled his textbook of surgery in 1296 and was the first surgeon who advocated suturing of divided peripheral nerves. Guy de Chauliac (1300–1360 AD), who has been called “the father of modern surgery”, described repair of peripheral nerve injuries, and classified head injuries according to their management very much similar to present day management. Jacopo Berengano da Carpa (1470–1530 AD) described cranial fractures in detail and advised early surgical intervention.4,17
 
Neurosurgical Techniques in the Renaissance (1500–1700 AD)
Two key figures deserve mention during this period. Ambroise Pare of the French army (1510–1590 AD) described elevation of depressed fractures and debridement of wounds in detail (Figs 4A and B). He described the use of traction for spinal injuries and like his predecessors realised the futility of treatment of cord injuries. He, however, advised removal of splinters of broken vertebra impinging on the cord as a last resort. Fabricus Hildain (1560–1634) perhaps gave the earliest description of laminectomy.4,17
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Figs 4A and B: (A) Ambroise Pare was unquestionably one the greatest surgeons of the Renaissance. He was born in 1510 at Bourghersent in Meyenne and acquired his initial surgical skills from a barber shop. He knew no Latin and thus wrote in French to the considerable opposition of the Professors of Sorbonne, who could not conceive of a member of the college not knowing Latin. He was surgeon to Henry II, Francis II and Charles IX who also protected him during the massacre of St Bartholomew. He has been described as a man of genius, an infatiguable worker and being honest to the highest degree. He introduced various radical changes in surgical procedures like giving up the method of hot iron cautery used by Arabians, marked improvement of amputation surgery, surgery for hare lip, etc. (B) Here shown on the right are some of the instruments being used by him
 
Neurosurgical Techniques in the Pre-Listerian Period (1700–1846 AD)
Neurosurgery was still limited to head injuries till the beginning of the pre-Horsley era in view of the lack of knowledge of antisepsis in the Western world and of anaesthesia. There were, however, a few surgeons who cannot be ignored. Jean Louis Petit (1674–1750 AD) advised trephining in all cases of scalp wounds with fractures. SF Morand in 179210 was the first to operate successfully upon a temporal abscess. Sir Percival Pott (1713–1788 AD) used a trephine for treatment of brain abscesses. Gurthrie (1785–1856 AD) realised the importance of epidural haematoma and advocated its urgent management.4,17
 
Neurosurgical Techniques in the Pre-Horsley Period (1846–1890 AD)
Dramatic developments started to take place in this era. Various discoveries laid down a strong foundation for the development of contemporary neurosurgical techniques. The era of painless surgery was ushered in with the discovery of chloroform and ether (1846–1848 AD). The antiseptic principles described by Lister in 1867 reduced the infection rate significantly and gave a boost to the surgeons to proceed beyond the dura mater (Fig. 5). Almost simultaneously, clinical localisation was improved markedly by neurologists like Fritsch, Hitzig, Ferrier, Gowers and Hughlings Jackson.34
In 1884, Sir Rickmann Godlee operated upon a brain tumour for the first time solely on the basis of clinical localisation by Hughes Bennet.30 The patient unfortunately died a month later due to meningitis. This, however, did not discourage the other surgeons and only increased their determination to cross the last frontier. Sir William Macewen carried out his first surgery on a brain abscess in 1881.31 He published his monograph on “Pyogenic Infective Diseases of the Brain and Spinal Cord” in 1893, where he reported 94 cases of “infective intracranial lesions”. Of the 19 cases of cerebral and cerebellar abscesses in total, 18 had total recovery, a record that remains unparalleled even today.10 In 1887, Van Bergmann, an outstanding German surgeon published a monograph on cerebral surgery containing case histories, diagnosis and operative management of over 189 patients most of them with brain abscesses.4,10,59 PC Knapp and EH Bradford in 1889 finally summarised the situation in an article that documented 23 cases of brain tumours, which were operated upon based on purely clinical localisation.4,10,60
7
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Fig. 5: Joseph Lister (1827–1912 AD) was born at Upton in the county of Essex and is considered as one of the greatest figures in the history of surgery. He is best known for his antiseptic principles, including introduction of carbolic acid spray in the operating room, the results of which were published in the Lancet in 1867. He was the first physician to sit in the House of Lords. Part of the Glasgow ward where he carried out his work and most of his publications are still preserved at Welcome Historical Medical Museum in London
 
DEVELOPMENT OF CONTEMPORARY NEUROSURGICAL TECHNIQUES
Before proceeding on this fascinating journey, it would be useful to look at the development in other branches of medicine, which have made this journey possible.
In 1851, Hermann von Helmholtz invented the ophthalmoscope (Figs 6A to C). To quote from his work on visualising the retina “… I had the great joy of being the first who saw before him a living human retina”.84
 
The Development of Techniques for CSF Access and Analysis
The puncture of the subarachnoid space for a therapeutic purpose was made for the first time in 1885 by Corning when he injected cocaine for anaesthesia. Six years later, Quincke described lumbar puncture for relief of raised intracranial pressure.22
The first edition of Keen's “An American Textbook of Surgery” described the use of ventricular puncture using the landmarks outlined in 1890. However, the usefulness of ventricular puncture was fully realised in 1918 when Walter Dandy described pneumoencephalography and ventriculography for the purpose of localisation of cerebral masses.
 
Development of Neuroradiology
Roentgen discovered X-rays in 1896 and within a year, its use in medicine was well established. This constituted the main tool for diagnosis based on bony erosion, sutural diastases and pineal shift and calcification.35,70
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Figs 6A to C: Helmholtz's ophthalmoscope—Photographic reproduction of the original illustration of ophthalmoscope published in German in 1851, and later translated into English by Shastid TH in a monogram titled “The Description of an Ophthalmoscope—Being an English translation of von Helmholtz's—Beschreiburg lines Augenspiegels” in 1916
Diagnostic radiology took a great leap forwards in 1918 with the introduction of pneumoventriculography and pneumoencephalography by Dandy. This discovery came about when Dandy noticed air under the diaphragm in the X-ray film of a patient with intestinal perforation.13
In 1921, myelography was introduced when Jean Sicard, a French clinician, and his pupil, Jacques Forestier, injected analgesics into the spine of a patient suffering from low back pain and subsequently found that the oil they used as a carrier for the analgesic, lipiodol, was radiopaque.72
The invention of myelography encouraged the outstanding Portuguese neurologist, Egas Moniz, to develop “Arterial Encephalography”.48
Neuroimaging attained its pinnacle with the invention of the CT scan and MRI. In 1967, Godfrey Hounsfield of EMI Laboratories working on the interpretation of data derived from X-ray transmission hit upon the idea of simplifying data by sectioning the object into a series of “slices” for a complete diagnostic picture.33
The MRI scan was based on the Nobel Prize winning work of Block and Purcell in the 1940s, which was applied to medical imaging in the 1970s.59
More recently, functional imaging, like positron emission tomography (PET), functional MRI and SPECT, has been introduced. It may be noted that though the principle of PET was suggested as early as in 1951 by Wrenn and his colleagues, it was introduced in clinical 8practice in 1970. All these inventions collectively gave a tremendous boost to the development of neurosurgical diagnosis and techniques, which also evolved more or less simultaneously.75,8587
 
Patient Positioning
Victor Horsley was the first to stress the need for proper cranial immobilisation. Harvey Cushing (Fig. 7) was the first surgeon to devise a horse shoe shaped head rest which kept the patient's eyes, nose and mouth free and provided access for administration of anaesthetics. He also introduced the practice of shaving just prior to surgery.60
De Martel, in 1913, introduced the sitting position. He constructed a special chair in which the patient's head could firmly be fixed. The hazards of the sitting position were later described by Bailey.4,60 Frank Henderson Mayfield (Fig. 8) introduced the three pinhead clamp, which made patient positioning safer and easier.76 Victor Horsley was the first surgeon to use the operator worn headlight to illuminate the operating field.60
 
Surgical Gloves
As late as 1900, operations were performed with bare hands, asepsis being achieved by continuously dipping the hands in a bucket of carbolic acid. Halsted (Figs 9A and B) was the first surgeon to introduce the use of gloves during operations. There is a romantic edge to the story of its origin. Halsted's scrub nurse was allergic to carbolic acid and he devised the gloves primarily for her. She later on became his wife.4
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Fig. 7: Harvey Cushing (1869–1939) was perhaps the greatest neurosurgeon of all times. Results in neurosurgery before him were dismal. As found out by Cushing at Johns Hopkins, ten years before 1901, antemortem diagnoses were made in only 32 cases of 36,000 admitted. Of these, only two cases were operated with fatal results. From this stage, Cushing introduced most painstakingly, various methods like maintenance of ether chart, absolute haemostasis, gentle use of cotton pledgets, use of silver clips and electrocautery for haemostasis and above all slow and gentle handling of tissues, which he inherited from Halsted, all of which reduced the mortality significantly. His operative mortality during the last years of his practice was only 8.7% for a total of 635 surgeries. He was also the author of a series of brilliant monographs: The pituitary body (1912), Tumours of nervus acousticus (1917), A classification of the tumours of the Glioma group (1926, with Percival Bailey) and so on down to Meningiomas (1938). His “Life of Sir William Osler” (1925) obtained the Pulitzer Prize, which was a classic in medical biography and a best seller
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Fig. 8: Frank H Mayfield was born in 1908 in South Carolina and underwent his medical graduation from The College of Virginia. He was fortunate to have had the guidance of the eminent surgeons of that time, Drs Cushing, Dandy and Coleman. Apart from designing the three pin head clamp to which his name is attached, he is also known for this pioneering work in lumbar disc surgery, development of aneurysm clips and many surgical instruments. He was the first recipient of The Harvey Cushing Medal in 1977 by the American Association of Neurological Surgeons
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Figs 9A and B: (A) WS Halsted (1852–1922) was the first professor of surgery at Johns Hopkins. He was a quiet but effective force in transforming surgery from a series of dramatic events into a less conspicuous, painstaking and scientific study of disease. In addition to introduction of surgical gloves, use of silk ligatures and of infiltration anaesthesia with cocaine, he also devised numerous operative procedures and technical improvements often based on previous experiments on animals. (B) Photograph of Halsted in the so called “All star operation theatre” being assisted by Cushing and Finney (opposite), Bloodgood (at his right), Young (at the instruments) and Follis (leaving the theatre). Note the use of gloves and caps but no masks. The technique of handling tissues gently and slowly formed the basis on which Cushing developed neurosurgical techniques to set a standard for the future generations of neurosurgeons
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Craniotomy
Earlier, the skull was opened with a trephine and the opening was enlarged with a mallet and chisel to the extent required. It was traumatic to the brain and often produced unacceptable deformities.4,5
In 1889, Wilhelm Wagner introduced the osteoplastic craniotomy, which allowed access to large areas of the brain without a disfiguring cranial defect. This was introduced after several years of painstaking studies on cadavers. Taison, in 1894, suggested that the bone be divided from within outwards using a chainsaw between burr holes. Almost simultaneously, Leonardo Gigli described an ingenious yet simple instrument for sawing the bone, which was initially intended to perform symphysiotomy in obstetrical surgery (Fig. 10).
D'Vilbiss, in 1896, designed a bone cutting forceps for making linear cuts in the bone from within outwards. De Martel, in 1908, introduced the metal guide for introducing the Gigli saw between burr holes. He also introduced a power-driven perforator with an automatic disengaging gear, which stopped the motor as soon as the perforator penetrated the skull. Poirier, in 1891, advocated that the dural flaps should be cut with the base towards the midline to reduce bleeding from dural emissary veins.4,5,11,84
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Fig. 10: The Gigli saw was devised by Leonardo Gigli in 1898. He devised a grooved probe, which he named as a “whalebone” to introduce the wire between burr holes
 
Suction and Irrigation
Cushing was the first surgeon to utilise a hand bulb syringe attached to a rubber catheter to cleanse the tracts of brain wounds in the First World War.11 Power suction was introduced many years later by Herbert Olivecrona.60
 
Brain Retractors
The malleable self-retaining retractor fixed to the edge of the cranial defect was introduced by De Martel.11 Yasargil later introduced the currently popular Leyla retractor. He named the retractor after his daughter when he saw her playing with a doll, which maintained its new position whichever way it was twisted. Many modifications and improvisations were made later by various innovative neurosurgeons like Suzuki, Rhoton, etc.11,60
 
HAEMOSTASIS
One of the most important reasons why early surgeons were discouraged from performing neurosurgery was bleeding and the difficulty of controlling it. Cushing himself, after having witnessed Victor Horsley, perform one of the surgeries, seriously contemplated against continuing this profession.3,24,42
 
Scalp Haemostasis
Brown, in 1909, introduced the practice of infiltrating the scalp with a mixture of local anaesthetic and diluted adrenaline solution. Cushing advocated the use of firm digital pressure along the edges of the proposed incision and the technique of everting the galea with artery clamps—a practice followed even today.3,11,42
Victor Horsley, in 1892, invented bone wax, which was initially made of bee's wax and had haemostatic qualities by virtue of its tamponade effect on bone bleeding.3,42 Later, absorbable gelatin sponge (Gelfoam) was also found to be useful in controlling bleeding from the bone.
 
Cerebral Haemostasis
Various ingenious methods were devised in the past including packing with cotton, wool, oil of olive and caustics. Presently, three basic methods are used.
 
Thermal Methods
Galen popularised the use of hot irons for cautery as a primary method of haemostasis. Pare abandoned this method around 1500 years later. Thermal cautery was reintroduced by Cushing and Bovie in 1928 in the form of electrocautery (Fig. 11). Greenwood introduced the bipolar forceps in 1930 and this was further modified by Malis. More recently, a variety of lasers which were initially introduced by Maimman in 1960 have been used for haemostasis.3,42,60,84
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Fig. 11: Photograph of original hand-made model of the pistol-grip with pencil attached and a cluster of terminal electrodes of various types. This was initially devised by Bovie in 1927 and later modified by Cushing in the form of only a pencil to improve the precision
 
Mechanical and Chemical Methods
Since the time of Hippocrates, the use of caustics, like copper sulphate, was in vogue but these fell out of favour as they caused indiscriminate destruction. Horsley, and later Cushing, introduced the use of crushed muscle. Correll and Wise first introduced Gelfoam (absorbable gelatin sponge) in 1945. Yackel and Kenyon of Eastman Kodak Laboratories first produced oxidised cellulose (Oxycel) and oxidised regenerated cellulose (Surgicel) in 1942, but these came into clinical use much later. The use of microfibrillar collagen (Avitin) as a haemostatic agent was first demonstrated by MR Hait in 1969.3,42,85
 
OPERATING MICROSCOPE IN NEUROSURGERY
The operating microscope was used by otologists to perform middle ear surgery as early as 1921. For the use of the microscope in neurosurgery, it required many adaptations in the form of improved illumination, manoeuvrability and magnification. Hans Littmann of Carl Zeiss Company was one of the pioneers in developing such a suitable model. Since then many more models have been introduced. Almost simultaneously micro instruments have been developed by neurosurgeons, including Yasargil, Rhoton, Maroon, Hardy, Suzuki and many others.85
 
DEVELOPMENT OF NEUROSURGICAL TECHNIQUES IN SURGERY FOR BRAIN TUMOURS
 
Gliomas
Bailey and Cushing were among the first to classify gliomas according to their histological features. Cushing and Eisenhardt started the practice of examining the biopsy specimen during surgery. Early efforts by Horsley in 1893 and Cushing in 1909 consisted of external decompression with or without partial removal and this soon proved to be unrewarding.12,33 Dandy, in 1921, advocated radical internal decompression.14 Cushing (Fig. 7) later greatly improved the operating techniques in glioma surgery. His methods of achieving haemostasis with cotton pledgets, reducing brain swelling by increasing head elevation and painstaking closure of the dura, greatly contributed to reduce the morbidity and mortality in such patients. He also stressed the importance of excision of the mural nodule to achieve a permanent cure for cystic gliomas. The use of intravenous hypertonic solutions was introduced by Sachs and Bailey to reduce intracranial pressure before the dural opening.11,24,80
 
Meningiomas
William Macewen probably performed the first surgery for meningioma in 1879. However, Franceso Durante performed the first successful surgery for an intracranial tumour in 1885 when he removed an olfactory groove meningioma.2 The principle of replacing the diseased bone after autoclaving was first introduced by Naffziger.2
 
Pineal Tumours
Krause (1926) was the first surgeon to explore this ominous territory. He described his supracerebellar infratentorial approach in three patients and surprisingly all patients did well.37 Van Wagenan, in 1931, described a transventricular approach, which never gained wide acceptance.78 Walter Dandy used the parafalcine supratentorial interhemispheric approach, which was the culmination of extensive studies on experimental animals. He used either the sitting or lateral position to allow the hemisphere to fall by gravity. However, in the absence of steroids, operating microscope and advanced anaesthesia, the surgical mortality was quite high.16 James L Poppen, in 1966, described his classical paraoccipital supratentorial approach (Fig. 12).21,58 The introduction of the operating microscope greatly improved the quality of outcome.
 
Acoustic Tumours
Sir Charles Ballance was the first to successfully remove an acoustic neuroma in 1894. He used a suboccipital craniectomy and removed the tumour with a finger. The patient surprisingly survived.6 Cushing subsequently developed the technique of subtotal internal decompression, which reduced the operative mortality significantly. Based on his experience and that of previous authors, Cushing felt that total excision should not be attempted.11 Dandy, in 1925, developed the technique of internal decompression followed by total excision. He also described the importance of unroofing the internal acoustic meatus for complete excision. His techniques laid down the principles for contemporary acoustic surgery [Figs 13(A and B) and 14].15 Givre and Olivecrona, in 1949, developed the technique for preservation of the facial nerve.26 Rand and Kurze, in 1968, described preservation of both facial and cochlear nerves.61
11
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Fig. 12: James L Poppen was born in 1903 at Drenthe, Michigan. He embarked on his neurological career in 1933 at the Lahey Clinic after having completed his 2 years surgical residency at the Illinois Research and Educational Hospital. Apart from having described numerous surgical techniques and also publishing his well-known “Atlas of Neurosurgical Technique”, he was highly regarded by his colleagues and residents for his unique and exceptional operative skill. He was very much appreciated for his mark of character that he had always treated the most minor operation or procedure with just as much care and dignity. One of his favourite quotes was “The same challenge exists to complete a lumbar puncture accurately and painlessly as to clip an intracranial aneurysm”
The use of the middle cranial fossa approach for acoustic tumours was described by William F House in 1961.
The translabyrinthine approach for cerebellopontine angle tumours was first suggested by Panse in 1904 and then subsequently first performed by Quix in 1911 and later by Schmieglow. However, it lost its popularity after Cushing discouraged this procedure in 1921. With improvement in instrumentation and magnification, it was reintroduced by House and Hitselberger in 1960.33
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Figs 13A and B: (A) Photograph of the article by Dandy published in Surgery, Gynaecology and Obstetrics in 1925, advocating total excision of acoustic tumours. Prior to this, most of the surgeons were following Cushing's method of intratumoural decompression, as total excision was associated with high morbidity and mortality. (B) Photograph of the patient who underwent total excision of tumour by Dandy. Note the improvement of facial palsy in the photograph on the right following a spinofacial anastomosis
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Fig. 14: Walter Dandy
 
Pituitary Tumours
Harvey Cushing was the first to coin the terms hypopituitarism and hyperpituitarism. He mentioned these in his monograph on the subject in 1912. In 1932, he wrote an exhaustive review on basophilic adenomas.11
 
Trans-sphenoidal Surgery
The first successful removal through the transsphenoidal route was performed by Schloffer in 1907. Hirsch from Vienna pioneered an inferolateral endonasal approach in 1909. Harvey Cushing modified this surgery and standardised an oronasal rhinoseptal transsphenoidal approach. He used this approach for the next 20 years.80 Norman M Dott (Fig. 15) used the same approach, which he learned from Cushing throughout his career.
Guiot from Paris learned this method, from Dott, and popularised it in Europe in the 1960s.27 Per-operative fluoroscopy in transsphenoidal surgery was introduced by Guiot. In 1962, Jules Hardy, after having learned this procedure from Guiot, re-introduced it in North America.
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Fig. 15: Norman M Dott was born in Edinburgh in 1897 and graduated from The University of Edinburgh. He came under the influence of Harvey Cushing in 1923, when he had the opportunity to work under him at Boston under the Rockfeller Travelling Fellowship. It is interesting to note that in the initial years, he began practicing neurosurgery privately as this speciality was not recognised at Edinburgh Hospital. Among his many contributions include performing the first angiogram in the United Kingdom using Thorotrast to demonstrate a saccular aneurysm, he also worked on cerebrospinal fluid and its circulation, study of brain displacements, cerebral ischaemia, spinal cord compression, the treatment of facial paralysis by extrapetrous nerve graft and use of hypothermia during surgery. He also invented many instruments and designed operating tables and theatres
He further improved the technique by introducing per-operative fluoroscopy, the operating microscope and micro-instrumentation. He was also the first to recognise small intrapituitary lesions, which he later named as microadenomas.27,82
 
Transcranial Surgery
The subfrontal approach to pituitary tumours was devised by Krause and subsequently modified by Frazier in 1913.23 Cushing, in later years, favoured this approach. Bronson S Ray popularised a midline subfrontal approach. The consequences of heavy retraction led Ray and Patterson to devise the pterional approach.67,68 The subtemporal approach, initially suggested by Horsley, is used today though not frequently.85 A large number of skull base approaches are based on this subtemporal approach.
 
Spinal Cord Tumours
Credit goes to Victor Horsley for having excised an intradural extramedullary tumour in 1887 at the young age of 30 years. The surgery was performed on the basis of clinical localisation by William Gowers.17 Elsberg in his masterpiece monograph “Tumours of Spinal Cord: The Symptoms of Initiations and Compression of the Spinal Cord and Nerve Roots: Pathology, Symptomatology, Diagnosis and Treatment”, emphasised on the importance of careful neurological examination and the use of spinal manometric study to establish the presence and location of intraspinal blocks. He also described a case of central cervical disc herniation usually misnamed as a “chondroma”. In subsequent publications, he described in detail the clinical localisation of spinal cord and extradural tumours.1820 The first operative description of these tumours was accompanied by a beautiful colour illustration in Fedor Krause's masterpiece, “Surgery of the Brain and Spinal Cord”. Krause referred to the mass as an “enchondroma” also a misnomer.36 Although Cushing is given the credit for the first successful removal of an intramedullary ependymoma, the technique of intramedullary spinal cord surgery along with the management of other spinal tumours was described in detail by Charles Elsberg.19 Rasmussen, in 1940, described the pathological features of intramedullary tumours along with surgical considerations in great detail.65
 
CEREBROVASCULAR SURGERY
Hutchison was the first physician to diagnose a saccular, non-traumatic intracranial aneurysm clinically in 1875. This was confirmed at autopsy 11 years later.80 The development of cerebrovascular surgery would not have been possible but for the various developments which took place, including haemostatic clips by Cushing, angiography by Egas Moniz, and the use of the operating microscope.
Norman Dott performed the first planned surgery for an aneurysm in 1933. He used a muscle patch and achieved a good long-term outcome.
Walter Dandy, in 1937, clipped an aneurysm for the first time using a metal clip and shrivelled the sac with electrocautery. He also reported, in 1939, treatment of an intracavernous aneurysm by ligating the internal carotid artery in the neck, as well as intracranially, thus trapping it. However, carotid insufficiency and hemiplegia were soon noted to be the major complications of carotid ligation. Matas emphasised the importance of testing the efficiency of collateral circulation. Surgery for aneurysms developed by leaps and bounds, thanks to innovative neurosurgeons. Yasargil of Zurich, Drake of London, Ontario and Norlen of Goteborg are prominent amongst them.49,80
The first successful surgery for intracranial AVM was performed by Olivecrona in 1932 (Fig. 16). Results improved with the use of magnification and increased illumination provided by the operating microscope, making surgery more refined and accurate. Haemostasis improved with the introduction of bipolar forceps.80
In 1960, Julius Jacobson, a vascular surgeon, produced a very important paper “Microsurgery in anastomosis of small vessels”. In 1967, guided by the inspiration of Prof. Donaghy, MG Yasargil of Zurich performed the first extracranial to intracranial bypass. Pool, in 1966, reported on the use of the microscope for the first time in aneurysm surgery.
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Fig. 16: Herbert Olivecrona (1891–1980) was one of the eminent students of Cushing. He was the chief founder of Swedish Neurosurgery and trained many outstanding neurosurgeons, to name a few; Wilhelm Tonnis, Sjoquist Lundberg, Lars Leksell and Edward Bucsh. Apart from doing pioneering work in vascular surgery, he developed numerous neurosurgical techniques. He was the first to excise an acoustic schwanomma, preserving the eighth nerve. Sjoquist developed medial tractotomy for trigeminal neuralgia under his guidance
Rand had, however, used the microscope for aneurysm surgery in 1964 but had reported it only in 1967.69,80
 
SURGERY FOR EPILEPSY
Victor Horsley was the first surgeon who demonstrated that excision of a lesion responsible for focal epilepsy could lead to cure. Foerster and Penfield did creditable work in defining the structural basis of traumatic epilepsy and, in 1930, published their results with radical operations. Gibbs, Davis and Lennox, in 1935, established for the first time the correlation of clinical epileptic seizures with EEG studies. Electrocorticography was first performed in humans by Foerster in 1935 and Penfield and Jasper in 1941. Penfield was one of the chief pioneers for the development of epilepsy surgery (Fig. 17). He outlined the motor and sensory homunculus using stimulation studies in awake patients and described in detail the various types of seizure phenomenon. However, the most intriguing observation, both laudatory to reviewers and to Penfield himself, was the production of “psychical hallucinations” in the form of vivid recollections of past events on stimulation of certain areas of the temporal cortex, which threw light on the symptomatology and pathophysiology of temporal lobe seizures. He was responsible for establishing the value of cortical excision in the treatment of medically refractory focal epilepsy, especially that due to temporal lobe lesions. Falconer developed the technique of en bloc temporal lobectomy along with excision of the uncus, the hippocampus and amygdala.32,5055,6264,66 In the early 1970s, B Ramamurthi introduced the concept of making lesions in the medial temporal epileptogenic areas, stereotactically.40 Rasmussen introduced a series of modifications of the surgical technique to reduce the morbidity and mortality and improve the outcome of epileptic surgery.
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Fig. 17: Wilder Graves Penfield born in 1897 at Spokane, Washington, was a man of many facets, and an excellent academic record. He graduated from Johns Hopkins Medical School in 1918. He was selected as the head of the Department of Neurology and Neurosurgery in 1928 at the McGill University at Montreal on the formation of its Neurological Centre. Apart from his numerous contributions and his pioneering work on epilepsy and brain mapping, he was the author of the novel “No Other Gods”, a fictionalised version of Abraham's search for a monotheistic religion
 
SURGERY FOR MOVEMENT DISORDERS
Parkinson's observation of a patient in whom tremor disappeared following a stroke on the same side provided the idea of surgically interrupting the motor system at various levels. Victor Horsley, at the beginning of the 20th century, resected the pre-central gyrus of a boy with hemiathetosis and achieved dramatic results. Paul Bucy (Fig. 18) and his colleagues, in 1930, acquired considerable experience in unilateral subpial resection of areas 4 and 6 of the cortex in patients with various types of dyskinesias. Earl Walker was the first to suggest pedunculotomy as a mode of treatment for Parkinson's disease. In 1952, Irving Cooper, while performing a pedunculotomy, accidentally damaged the anterior choroidal artery. The surgery was terminated, but surprisingly, the patient had an excellent result. Following this, clipping of the anterior choroidal artery became an accepted form of treatment for some time, but the results were variable, as the anterior choroidal artery had a variable distribution, and it was realised that lesions in the basal ganglia may be more useful. This experience encouraged Cooper to develop chemopallidotomy.60,80
In 1948, Spiegel and Wycis modified Horsley's animal stereotactic apparatus and made a great advance in providing a suitable and stable stereotactic technique applicable to humans. Thus, stereotactic thalamotomy as a mode of treatment was laid on firm grounds for functional neurosurgery.25
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Fig. 18: Paul C Bucy was born in 1904 at Hubbard, Iowa. He earned his MD and MS degrees in Neuropathology from State University of Iowa and later in 1928 joined Bailey's newly created neurosurgical staff at University of Chicago. He became in charge of Neurological Surgery at the same institute in 1939. Among his various contributions include writing of the classic volumes, “Intracranial tumours of Infancy and Childhood” and “The Precentral Motor Cortex and Neurology”. He described the Kluver-Bucy syndrome in monkeys
The globus pallidus was the stereotactic target of choice for the treatment of Parkinsonian tremors in the early 1950s.38 In 1954, Hassler and Reichert reported dramatic mitigation of Parkinsonian tremor after a lesion was made in the ventrolateral thalamus.28 In 1949, Leksell described his stereotactic apparatus. He also developed stereotactic radiosurgery with the gamma knife.41
More recently, transplantation of neural tissues within the brain was described as a mode of treatment for Parkinson's disease though the concept was an old one.43,77 Mammalian neural transplant was attempted by Thomson as early as 1890. Le Gros Clark successfully transplanted embryonic neocortical tissue in the cerebral ventricle of a six-week-old rabbit.39 Since then, there has been an explosion of research in this field all over the world, and successful transplants into practically every region of the central nervous system have been reported both in lower mammals and primates. In India, the Department of Science and Technology73,74 established a National Neural Transplantation Unit at the All India Institute of Medical Sciences in 1986 under Tandon and Gopinath. Bjorklund et al.9 and Perlow et al.56 first suggested neural transplantation for Parkinson's disease. Suspensions of chromaffin cells of the patient's own adrenal medulla were stereotactically implanted into the caudate nucleus. The transitory improvement, though it established the validity of the approach, dictated a review of strategy. Madarazo et al. from Mexico carried out open surgery where they implanted the adrenal medulla into a cavity made in the caudate nucleus and demonstrated excellent results.46 Only a few others could duplicate the same results. After a critical review of adrenal medullary transplants in humans, Lindvall et al. concluded that there was not enough evidence to justify the claims made earlier.44,45 For all practical purposes, this procedure has been given up now, owing to the unpredictable nature and unacceptable surgical risks. More recently, foetal substantia nigra transplants in the striatum have been shown to relieve at least partly the manifestations of Parkinson's diseases.79,83 The latest trend is a trial of implantation of stem cells into the brain for various neural disorders. This is still experimental.
 
SURGERY FOR INTRACTABLE PAIN
Section of the posterior spinal roots was first performed by Bennet in 1888 for relief of pain. Foerster subsequently performed the same surgery for relief of tabetic pain. Cushing transected the spinal cord in a patient suffering from intractable pain due to metastatic malignancy.29 Martin performed the first cordotomy in 1911. Van Wagenen and Earl Walker performed the first frontal lobotomy for relief of intractable pain.80,85
 
SURGERY FOR TRIGEMINAL NEURALGIA
Since 1880s, the standard operative approach for trigeminal neuralgia was retrogasserian neurotomy. In fact for many years, Victor Horsley used to perform the surgery at the patient's residence itself. In 1891, Frank Hartley devised an extradural temporal approach to the Gasserian ganglion. About 6 months later, Fedor Krause, unaware of Hartley's surgery, performed the same operation. Cushing modified both the techniques and reduced the mortality considerably. In 1901, Charles Frazier performed a rhizotomy using the Hartley-Krause approach. This was subsequently modified so that only differential sectioning of the sensory root was done sparing the motor root. Walter Dandy used the suboccipital approach for rhizotomy which, however, did not become very popular. Dandy, however, made a very interesting observation of the nerve being frequently compressed by a blood vessel. In 1937, Sjoquist introduced trigeminal tractotomy for relief of facial pain. In 1930, Kircshner developed the technique of percutaneous electrocoagulation of the Gasserian ganglion. Various other authors have modified and perfected this approach. Gardner, in 1959, reported treatment of neuralgia by separating the compressing blood vessel over the nerve. Jannetta subsequently developed and popularised the technique of microvascular decompression.80,85
 
PSYCHOSURGERY
The idea of psychosurgery first came to Egas Moniz in 1935 while attending the Second World Congress of Neurology. He had come there to present his pioneering work on angiography when he heard from John Fulton and his associates the effects of brain lesions on animals. On his advice, his young neurosurgical colleague, Almeida Lima, began performing frontal lobotomies. Very soon psychosurgery became an accepted mode of therapy. This work earned Moniz the Nobel Prize in 1949.25,80,85
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Fig. 19: Clarke and Horsley's stereotaxic apparatus—This was being used on Rhesus monkeys. Accuracy was not very good as the direction of the probe depended on the calvarial measurements, rather than in relation to the ventricles. The apparatus (only part of which is shown here) was bulky and cumbersome
 
STEREOTACTIC SURGERY
The concept for development of stereotaxy was born in 1908 when Horsley and Clarke (Fig. 19) designed a frame for laboratory experiments that would direct a probe to a pre-determined location in the animal's brain with the help of a previously designed brain atlas.
Even earlier to this Zernov, a Russian neurosurgeon built a guidance frame to aspirate intracranial abscesses, which he called as an encephalometer. However, stereotaxy came of age only with the pioneering work of Spiegel and Wycis who designed an apparatus, which measured distances in relation to the ventricular anatomy rather than to the calvarium. This markedly improved the accuracy. Based on the same principle, a large number of frames were created, to name a few those designed by Leksell, Riechert, Talairach, Bertrand and Narabayashi.25 In India, Arjun Sehgal developed his own machine.
With the introduction of CT and MRI, the technique of stereotactic surgery was modified avoiding invasive investigations. With CT and MRI compatible machines, the localisation of a point in space was directed by coordinates given by computer applications. Stereotactic surgery has further advanced with the introduction of stereotactic radiosurgery and frameless stereotaxy.25
 
ENDOSCOPIC NEUROSURGERY
The concept of neuroendoscopy is not new. L'Espinasse, a virologist from Chicago, in 1910, used a small rigid cystoscope to cauterise the choroid plexus for the treatment of congenital hydrocephalus. This encouraged Walter Dandy in 1918 to develop a technique to treat communicating hydrocephalus by extirpating the choroid plexus using cystoscopes. The results were disastrous but he predicted with great foresight that this would evolve into a useful diagnostic and therapeutic tool with improvement of imaging techniques. Fay and Grant in 1923, using a small cystoscope, photographed the ventricle and choroid plexus for the first time. They also attempted to create a fistula through the corpus callosum to permit the escape of ventricular fluid into the subarachnoid space. The first successful endoscopic third ventriculostomy was reported in 1923 by Jason Mixter. Over the next few years, Putnam and Scarff reported better results with endoscopic plexus coagulation although this procedure had been abandoned earlier as a primary treatment for hydrocephalus. Renewed interest in neuroendoscopy developed with improvement of illumination, magnification and computer software along with the development of a flexible fiberoptic apparatus.85
 
DEVELOPMENT OF HIGH SPEED DRILLS
The use of drills in medical practice in fact dates back to 100 AD when Romans used a finger-operated drill to treat painful teeth. In the 18th century, a French dentist developed a drill turned by a bow, similar to the bow of a violin. A foot-powered drill for dental procedures was developed by George Greenwood in 1790. About 70 years later, George Harrington developed the first motor-driven drill for dental work, which was operated by a windup spring. George Green, a dentist in Kalamazoo, developed the first electrical dental drill and later developed an air-powered drill operated by foot bellows. In neurosurgery, Victor Horsley and William MacEwen were the first to experiment with various drills with mixed success. De Martel, in 1925, designed a cumbersome but effective drill. Jordan and Day later developed an electric drill, which operated up to 50,000 rpm. A water turbine drill, which eliminated the use of belts and gears of earlier electrical devices was devised by Nelson in 1953 at the National Bureau of Standards, this reached up to speeds of 61,000 rpm. Air-driven turbines were built independently by Iseman in 1941 and Borden in 1950. This led to the development of even higher drill speeds. Barber developed the “turbobit” in 1962 and the Robert Hall drill was introduced in 1963. After many modifications of the “turbobit”, a vane-type motor was introduced in 1967 by the Midas Rex Company, which remains the standard against which all other high-powered pneumatic drills are measured.81,85
Neurosurgery is a rapidly evolving speciality today. Many people have contributed various developments painstakingly over many years. Its development is still very much in the steeper part of the learning curve and we are fortunate to have been born to witness this era of change. Let us experience, enjoy and contribute towards this change.
 
ACKNOWLEDGEMENT
The authors wish to acknowledge BA's Computers, Bangalore, for preparing the manuscript.
REFERENCES
  1. Adams F. The Genuine Works of Hippocrates. Vols. 1 and 2. Wood;  New York:  1886. p. 300.

  1. 16 Al-Rodhan NR, Laws ER Jr. Meningioma: a historical study of the tumor and its surgical management. Neurosurgery. 1990;26:832–47.
  1. Arand AG, Sawaya R. Intraoperative chemical hemostasis in neurosurgery. Neurosurgery. 1986;18:223–33.
  1. Arturo C. A History of Medicine. In: Krumbhaar EB (Ed). Routledge and Kegan Paul Ltd;  London:  1947.
  1. Bakay L. An Early History Craniotomy, from Antiquity to Napoleonic Era. Charles C Thomas;  Springfield, IL:  1985.
  1. Ballance CA. Some Points in the Surgery of the Brain and Its Membranes. MacMillan;  London:  1907. p. 206.
  1. Bhatia LS. A History of Medicine with Special Reference to the Orient. Office of Medical Council of India;  New Delhi:  1997.
  1. Breasted JH. The Edwin Smith Surgical Papyrus. vol. 1 and 2. University of Chicago Press;  Chicago:  1930.
  1. Bjorkund A, Stenvi U. Reconstruction of nigrostriatal dopamine pathways of intracerebral nigral transplants. Brain Res. 1979;177:555–60.
  1. Canale DJ. William Macewen and the treatment of abscesses: revisited after one hundred years. J Neurosurg. 1996;84:133–42.
  1. Cushing H. Surgery of the head. In: Keen WW (Ed). Surgery: its Principles and Practice. Sanders;  1908. pp. 17–276.
  1. Cushing H. Intracranial Tumors. Charles C Thomas;  Springfield, IL:  1932.
  1. Dandy WE. Ventriculography following the injection of air into the cerebral ventricle. Ann Surg. 1918;68:5–11.
  1. Dandy WE. Treatment of brain tumors. JAMA. 1921;77:1853.
  1. Dandy WE. An operation for the total removal of cerebellopontine tumors (acoustic). Surg Gynecol Obstet. 1925;41:129–48.
  1. Dandy WE. Operative experience in case of pineal tumor. Arch Surg. 1936;33:19–46.
  1. Elsberg CA. Extradural spinal tumors—primary, secondary, metastatic. Surg Gynec Obstet. 1928;46:1–20.
  1. Elsberg CA. Surgical diseases of the spinal cord, membranes and nerve roots. Symptoms, diagnosis and treatment. Lewis;  1940.
  1. Elsberg CA, Beer E. The operability of intramedullary tumors of the spinal cord. Remarks on extrusion of intraspinal tumors. Am J Med Sci. 1911;142:636–47.
  1. Elsberg CA, Dyke CG. Diagnosis and localisation of tumors of the spinal cord. In: Waters CA, Kaplan II (Eds). Year Book of Radiology; 1935. p. 301.
  1. Fager CA, James LP. A bibliographical outline. Clinical Neurosurgery. Williams and Wilkins;  Baltimore:  1964.
  1. Fishman RA. Cerebrospinal fluid in the disease of nervous system. Mosby Saunders;  Philadelphia:  1992.
  1. Frazier CH. An approach to the hypophysis through the anterior cranial fossa. Ann Surg. 1913;57:145–50.
  1. Fulton JF, Harvey C. A Biography. Charles C Thomas;  Springfield, IL:  1946.
  1. Gildenberg PL. The history of stereotactic neurosurgery. Neurosurg Clin North Am. 1980;1:765–80.
  1. Harris P, Norman MD. A biographical sketch. Clinical Neurosurgery. Williams and Wilkins;  Baltimore:  1969.
  1. Givre A, Olivecrona H. Surgical experiences with acoustic tumors. J Neurosurg. 1949;6:396–407.
  1. Hassler R, Riecherd J. Implikationin and lokalisation nechode der gezieltein. Hirnoperationein Ner Venartzt. 1954;25:441–7.
  1. Horsley V. Discussion on the treatment of cerebral tumors. Br Med J. 1893;2:1365–7.
  1. Horwitz NH. Library: historical perspective. Neurosurg. 1997;40:1315–9.
  1. Hortwitz NH. Library: historical perspective. Neurosurg. 1997;41:314–8.
  1. Houndsfield GN. Computerized transverse axial scanning (tomography) (I) Description of system. Br J Radiol. 1973;46:1016–22.
  1. Hitselberger WE, House WF. Surgical approaches to acoustic tumors. Arch Otolaryngol. 1966;84:286–91.
  1. Jackson IJ, Wilder GP. A brief biographical sketch. Clinical Neurosurgery. Williams and Wilkins;  Baltimore:  1957.
  1. Keen WW, Sweet WM. A case of gunshot wound of the brain in which roentgen rays showed the presence of eight fragments of the bullet: localisation by Sweet's method made operation inadvisable. Am J Med Sci. 1903;126:1–10.
  1. Krause F. Surgery of the Brain and Spinal Cord. Rebman Company;  New York:  1912. pp. 1041–7.
  1. Krause F. Operative frieleging der vierhugel, nebst beobachtungen uber hirndruck und dekompression. Zontralbl Chir. 1926;53:2812–9.
  1. Laitinen LV, Bergenhein AT, Hariz MI. Leksell's posteroventral pallidotomy in the treatment of Parkinson's disease. J Neurosurg. 1992;76:53–61.
  1. Le Gros Clark WE. Neural differentiation in implanted fetal cortical tissue. J Neurol Psychiat (London). 1940;3:263–84.
  1. Leksell L. The stereotaxic method and radioscopy of the brain. Acta Chir Scand. 1951;10:316.
  1. Leksell L, Leksell D, Schwebel J. Stereotaxis and nuclear magnetic resource. J Neurol Neurosurg Psychiat. 1985;48:14–8.
  1. Light RV. Hemostasis in neurosurgery. J Neurosurg. 1945;2:414–34.
  1. Lindvall O, Brundin P, Widner H, et al. Graft's of fetal dopamine neurons survive and improve motor function in Parkinson's disease. Science. 1990;247:574–7.
  1. Lindvall O, Dunnet SB, Brendin P, et al. Parkinson's disease. In: Rose FC, John L (Eds). Clinical and Experimental Advances; 1987. p. 189.
  1. Lindvall O, Widner H, Rehncrona S, et al. Transplantation of fetal dopamine neurons in Parkinson's disease: 1 year clinical neuro physiological observations in two patients with putaminal implants. Ann Neurol. 1992;31:155–65.
  1. Madarazo I, Drucker-Colin R, Diaz V, et al. Open microsurgical autografts of adrenal medulla to the right caudate nucleus in two patients with intractable Parkinson's disease. Eng J Med. 1987;316:831–4.
  1. Margetts EL. Trepanation of the skull by medicine men of primitive cultures, with particular reference to present day native East African practice. In: Brothwell D, Sandison AT, Charles C Thomas (Eds). Disease in Antiquity: a Survey of the Diseases, Injuries and Surgery of Early Populations. Springfield, IL; 1967. pp. 673–701.
  1. Moniz E. Langiographie cerebrale: Ses applications et resultants en anatomie physiologie et clinique. Massan;  Paris:  1934.
  1. Peerless SJ, Charles GD. A biographical sketch. Clinical Neurosurgery. Williams and Wilkins;  1979.
  1. Penfield W. Thoughts on the function of the temporal cortex. Clinical Neurosurg. 1957;4:21.
  1. Penfield W, Erickson TC. Epilepsy and Cerebral Localization. Charles C Thomas;  Springfield, IL:  1941.

  1. 17 Penfield W, Flamigan H. Surgical therapy of temporal lobe seizures. Arch Neurol Psychiatry. 1950;64:491–500.
  1. Penfield W, Paine U. Results of surgical therapy of epileptic seizures. Canad Med Ass J. 1955;73:515–30.
  1. Penfield W, Perot P. The brain records of auditory and visual experience: a final summary and discussion. Brain. 1963;86:595–6.
  1. Penfield W, Jasper H. Epilepsy and the Functional Anatomy of the Human Brain. Little Brown and Co.;  Baltimore:  1954. p. 507.
  1. Perlow MJ, Freed WJ, Hoffer BJ, et al. Brain grafts reduce motor abnormalities produced by destruction of nigrostriatal dopamine system. Science. 1979;204:643–7.
  1. Phillips ED. The brain and nervous phenomenon in the Hippocratic writings. Irish J Med Sci. 1957;381:377–90.
  1. Poppen JL. The right occipital approach to a pinealoma. J Neurosurg. 1996;25:706–10.
  1. Purcell EM, Torrey HC, Pound RF. Resonance absorption by nuclear magnetic movements in a sold. Physiol Rev. 1946;69:37–8.
  1. Ramani PS, Hedge T, Sharma A, et al. A Brief History of Neurosurgery, Lavanya Prints Pvt. Ltd.;  1994. p. 62.
  1. Rand RW, Kurze T. Preservation of vestibular, cochlear and facial nerves during microsurgical removal of acoustic tumor: report of two cases. J Neurosurg. 1968;28:155–61.
  1. Rasmussen T. Cerebral hemispherectomy: indications, methods and results. In: Schmidek HH, Sweet W (Eds). Operative Neurosurgical Techniques. Grune and Straton;  New York:  1987. p. 1235.
  1. Rasmussen T. Surgery of frontal lobe epilepsy. In: Purpura DP, Penry JK, Walter RD (Eds). Advances in Neurology. Neurosurgical Management of Epilepsies. Raven Press;  New York:  1975. pp. 197–205.
  1. Rasmussen T. Surgical therapy of frontal lobe epilepsy. Epilepsia. 1963;4:181–98.
  1. Rassmussen TB, Kernohan JW, Adson AW. Pathologic classification with surgical consideration of intraspinal tumor. Ann Surg. 1940;111:513–30.
  1. Rasmussen T, Jasper H. Temporal lobe epilepsy, indications for operation and surgical technique. In: Baldwin M, Bailey P (Eds). Temporal Lobe Epilepsy. Charles C Thomas;  1958.
  1. Ray BS. Intracranial hypophysectomy. J Neurosurg. 1968;28:180–6.
  1. Ray BS, Patterson RH Jr. Surgical treatment of pituitary adenomas. J Neurosurg. 1962;19:1–8.
  1. Rob C. Occlusive disease of the extracranial cerebral arteries: a review of the past 25 years. J Cardiovasc Surg. 1978;19:487–98.
  1. Roentgen WC. Ueber eine neve art von strahlen. Stizungsber Phys Med Ges Wurzbg. 1985;137:132–41.
  1. Sanan A, Haines SJ. Repairing holes in the head: a history of cranioplasty. Neurosurg. 1997;40:588–603.
  1. Sicard JA, Forestier J. Method generale d’ exploration radigique par l'huile iodee (lipiodol). Bull Mem Soc Med Hop Paris. 1922;46:463–9.
  1. Tandon PN. Neural transplantation: promises and problems. Proc Ind Nat Sci Acad. 1992;385:1.
  1. Tandon PN, Gopinath G. Clinical use of neural transplant: the unresolved problems. In: Marwah J, Teitelbaun H, Prasad KN (Eds). Neural Transplantation, CNS Neuronal Injury and Regeneration. CRC Press;  Florida:  1994. p. 1.
  1. Ter-Pogossian MM, Phelps ME, Hoffman EJ, et al. A positron emission transaxial tomography for nuclear imaging (PET). Radiology. 1975;114:89–98.
  1. Tew JM. Biography of Frank Henderson Mayfield. Clinical Neurosurgery. Williams and Wilkins;  1980.
  1. Thomas WC. Successful brain grafting. NY Med J. 1890;51:701–2.
  1. Van Wagenen WP. A surgical approach for the removal of certain pineal tumors: Report of a case. Surg Gynecol Obstet. 1931;53:216–20.
  1. Vingerhoets FJG, Snow BJ, Calne DB. Positran emission tomography imaging of brain transplants for Parkinsonism. In: Marwah J, Teitelbaum H, Prasad KN (Eds). Florida: CRC Press. Neural Transplantation CNS Neuronal Injury and Regeneration; 1994. p. 183.
  1. Walker EA. A History of Neurological Surgery. Williams and Wilkins;  Baltimore:  1982.
  1. Weber G, Hugo A Krayenbuhl. A biographical sketch. Clinical Neurosurgery. The Williams and Wilkins Company;  Baltimore:  1967.
  1. Wellbourn RB. The evolution of transsphenoidal pituitary microsurgery. Surgery. 1986;100:1185–9.
  1. Widner H. Immature neural tissue grafts in Parkinson's disease. Acta Neurol Scand. 1993;87:43.
  1. Wilkins RH. Neurosurgical classics New York. American Association of Neurological Surgeons.  Park Ridge IL:  1992. pp. 16–27.
  1. Association of Neurological Surgeons, 1992.
  1. Wilkins RH, Rengachary SS (Eds). Neurosurgery, 2nd edition. McGraw Hill;  New York:  1996.
  1. Wrenn ER Jr, Good ML, Handler P. The use of positron emitting radioisotopes for the localization of brain tumors. Science. 1951;113:525–7.