Faculty Bibliography

The specialty of surgical neurology developed out of general surgery in the second half of the 19th century. It was aided by the development of general anesthetics, the advent of aseptic methods, and the emerging theory of cortical localization of function. This chapter examines the history of "modern" brain surgery, the leaders in this pursuit, and the landmarks that changed when and how these surgeries were conducted. It is stressed that the surgeries conducted by Broca, Macewen, Godlee, Horsley and others not only saved lives and ultimately created a new field, but also contributed to the basic sciences, fostering an improved understanding of the functional organization of the brain.

TRIGEMINAL NEURALGIA IS a well known clinical entity characterized by agonizing, paroxysmal, and lancinating facial pain, often triggered by movements of the mouth or eating. Historical reviews of facial pain have attempted to describe this severe pain over the past 2.5 millennia. The ancient Greek physicians Hippocrates, Aretaeus, and Galen, described kephalalgias, but their accounts were vague and did not clearly correspond with what we now term trigeminal neuralgia. The first adequate description of trigeminal neuralgia was given in 1671, followed by a fuller description by physician John Locke in 1677. Andre described the convulsive-like condition in 1756, and named it tic douloureux; in 1773, Fothergill described it as "a painful affection of the face;" and in 1779, John Hunter more clearly characterized the entity as a form of "nervous disorder" with reference to pain of the teeth, gums, or tongue where the disease "does not reside." One hundred fifty years later, the neurological surgeon Walter Dandy equated neurovascular compression of the trigeminal nerve with trigeminal neuralgia.

The authors review the brainstem auditory evoked potential (BAEP), and present studies on 40 healthy subjects. In addition to the conventional click evoked BAEP, three modified BAEP examinations were performed. The modified BAEP tests include a 1,000 Hz tone-burst BAEP, and more rapid rate binaural click and 1,000 Hz tone-burst BAEPs-each of the last two studies performed at four diminishing moderate intensities. In addition to the usual parameters, the authors examined the Wave V to Vn interpeak latency, and stimulus intensity versus Wave V latency and amplitude functions in the rapid rate binaural studies. Studies were also repeated on healthy subjects in a dependant head position in an attempt to increase intracranial pressure. Discussion centers on the BAEP, its current utility in medicine, unique neurophysiology, and literature support that the above modifications could increase the practicality of the test in patients at risk with intracranial lesions and perhaps improve the feasibility for real-time continuous or frequent monitoring in the future.

Sir Victor Horsley'S many contributions to neurological surgery include experimental and clinical studies of gunshot wounds (GSW) of the head. Horsley's publications from 1894 to 1897 and 1914 to 1915 on GSWs were reviewed. Horsley described GSWs in animal and clay models, illustrating characteristics of the primary missile tract and secondary cavitation. A transcranial GSW model in 67 dogs related intracranial damage to the projectile's velocity and sectional area, producing a marked sudden increase in intracranial pressure that presumably "tunneled" to the medullary respiratory and cardiac centers. If the resultant sudden apnea was treated with artificial respiration and prompt surgical decompression, the animal often survived. In these animal experiments, Horsley clearly described increased intracranial pressure, hypertension, and bradycardia-later recognized as the Cushing response or triad. With the onset of World War I, Horsley again reviewed the ballistics of military weaponry, emphasizing projectile spin and velocity as the main wounding mechanisms. He was outspoken against the "wicked tradition" of neglecting cranial GSWs and personally treated cases with aggressive respiratory support and prompt decompression of devitalized tissue. Horsley's contributions to the experimental and clinical aspects of GSWs to the head are consistent with his other important contributions to neurosurgery and have largely stood the test of time.

Craniopagus twins (CPT) are an uncommon, highly fascinating accident of nature. The clinical pathology of this complex entity is reviewed and placed in perspective. A logical classification aids understanding of the anomaly, and is essential to gauge outcome from separation attempts. 'Partial forms' lack significant shared dural venous sinuses (SDVS) and 'Total forms' with SDVS also exhibit more severe compressional brain distortion. Our classification consists of Partial Angular (PA), Partial Vertical (PV), Total Angular (TA) and Total Vertical (TV, formerly O'Connell Types I-III). Total vertical has a continuous cranium, and inter-twin axial facial rotation <40 degrees (Type I), 140-180 degrees (Type II) or intermediate (Type III). The term 'Angular' denotes an inter-twin longitudinal angle below 140 degrees , regardless of axial rotation. Our review categorized 64 well-delineated CPT, including 41 operative separation attempts in small children since initial success in 1952. Just over one-half were TV, almost one-third TA, and partial forms accounted for the remaining one-sixth. About 30% of CPT had shared or fused brain tissue, and a similar percentage of TA twins shared a posterior fossa. Partial forms had significantly higher birth weights, were separated at an earlier age (6 versus 11 months) and had lower mortality and better outcome compared with Total forms. A multi-staged surgical separation for Total CPT had a significantly better mortality than single-staged separation. Discussion emphasizes embryological, anatomical and clinical aspects of the malformation, with emphasis upon obstacles to a successful outcome.

The prominent New York City neurologist Foster Kennedy (1884-1952) trained at London's Queen Square from 1906 to 1910. He was exposed to a number of eminent neurologists including, Sir Victor Horsley and other surgeons. A previously published but little known group of Kennedy's personal letters written during his neurological training is reviewed in light of their historic neurosurgical context. These often entertaining although at times unflattering letters capture the elation and frustration of neurosurgical experience during that important developmental period. Descriptions of the personalities involved give rare insight to this era. The Foster Kennedy syndrome--homolateral optic atrophy and contralateral papilledema with an inferior frontal tumor--was characterized under the stimulating support of Gowers and Horsley.

Sir Victor Horsley is well recognized as the father of neurological surgery, publishing many articles within this discipline and on other neurologically related topics. Furthermore, he published many important articles in other areas of science and medicine, as well as on social issues (e.g., women's suffrage). Accordingly, we compiled, for the first time, a complete listing of his writings. We briefly describe here some of the characteristics of his bibliography, which is available on the Journal's web site.

IN 1910, RENOWNED neurosurgeon Sir Victor Horsley published a description of the signs and symptoms associated with a condition he referred to as a "neglected malady." We invite readers to identify the condition, on the basis of Horsley's description.