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Neurosurg Focus 18 (4):E3, 2005 Effect of hemostasis and electrosurgery on the development and evolution of brain tumor surgery in the late 19th and early 20th centuries JOHN R. VENDER, M.D., JASON MILLER, B.S., ANDY REKITO, M.S., AND DENNIS E. MCDONNELL, M.D. Department of Neurosurgery, Medical College of Georgia, Augusta, Georgia; and The Department of Neurosurgery, Gunderson Lutheran Medical Center, Lacrosse, Wisconsin Hemostatic options available to the surgeon in the late 19th and early 20th centuries were limited. The surgical lig- ature was limited in value to the neurological surgeon because of the unique structural composition of brain tissue as well as the approaches and operating angles used in this type of surgery. In this manuscript the authors review the options available and the evolution of surgical hemostatic techniques and electrosurgery in the late 19th and early 20th centuries and the impact of these methods on the surgical management of tumors of the brain and its coverings. KEY WORDS • brain tumor • hemostasis • electrosurgery • history of neurosurgery The confidence gradually acquired from masterfulness in mass, often resulting in excessive blood loss. With the ad- controlling hemorrhage gives to the surgeon the calm which is vent of the electrosurgery unit, tumors could now be de- so essential for clear thinking and orderly procedure at the bulked internally and the capsule delivered into the cavity. operating table. These techniques were already in use for the removal of Halsted schwannomas of the vestibulocochlear nerve. These expe- riences could now be applied to the more vascular lesions. OVERVIEW Originally, access to the intracranial space was obtained through a trephine. Given the limited imaging and locali- Challenges in Brain Tumor Resection zation capabilities of the era, this relatively small exposure The neurological surgeon of the late 1800s and early (usually Յ 3 cm in diameter) required almost perfect 1900s was faced with many challenges in the surgical placement of the opening. Also, many of the tumors that management of brain tumors. The limited ability to lo- were diagnosed at the time had reached significant size. calize these lesions, along with the limited understanding Therefore, both because of the tumor size and the sur- of tumor histological features and biological behavior ren- geon’s limited localizing ability, enlargement of the cranial dered surgical decision making difficult. Initially, surg- exposure would enhance the effectiveness of the tumor eries were targeted only toward lesions with external evi- surgery. The disadvantage of large exposures included a dence of either scalp or skull deformity or tumors resulting longer operating time and increased opening of tissues, in easily localized neurological signs. When surgery was both of which resulted in an increase in blood loss. With attempted, the greatest single hurdle facing the practition- improved hemostasis, larger cranial exposures were per- er was the inability to control bleeding. Many of the estab- formed and progressively more complex surgeries were lished surgical practices of the era were ineffective in deal- attempted.22 ing with the unique tissues and structures of the brain and One of the most, if not the most, critical additions to the its blood vessels. Also, the nature of the neurosurgical neurosurgeon’s armamentarium was the adoption of elec- approach, with its narrow and deep exposures, made use trosurgery as a tool for hemostasis, cutting and dissection of the ligature nearly impossible for even the most capable of tissue, and debulking of tumors. Sachs,21 in his manu- surgeon. Initially only surgeries on calvarial or extraaxial script reviewing electrosurgery published in 1931, de- lesions were attempted; operations involving penetration scribed three “epoch making contributions to the evolution of the brain’s surface were considered too dangerous. With of neurosurgical hemostasis: the first, Horsley’s bone wax, increasing experience, intraaxial lesions were attempted; the second, Cushing’s silver clip, and the third, the intro- however, inability to control hemorrhaging required a fast, duction of electrosurgery.” In this article we review the he- crude surgical technique. Surgeons were often forced to mostatic technologies and technological advances of the “shell out” tumors, usually with a digital or spoon tech- era, with an emphasis on the role of electrosurgery. We also nique, rather than cut into them in an effort to reduce their discuss the impact of improved hemostatic and dissection Neurosurg. Focus / Volume 18 / April, 2005 1 Unauthenticated | Downloaded 10/02/21 08:01 PM UTC J. R. Vender, et al. techniques on advances in the new field of intracranial intent. Ultimately, spring-loaded clamps were used for neuro-oncological surgery. compression of the scalp edges. Mayer first described in- jecting adrenaline along the incision line. Frazier described surgical exposure and direct compression of the carotid ar- HEMOSTASIS tery in the neck in extreme cases. Writing about hemostasis in 1928, Cushing and Bovie9 Intracranial vessels could be controlled by direct pres- stated the following: sure, although this was a time-consuming process depen- Since the methods of getting in and of getting out of the cra- dent on blood pressure and clotting function. Under ideal nial chamber have become more or less standardized, it is of- circumstances clotting will occur in 5 to 8 minutes. Ne- tentimes easier to expose a tumor than to know just what to do vertheless, blood pressure fluctuations, further manipula- with it when brought to view. The appropriate treatment will tion of the tissue, and removal of the compressive materi- depend of course, on many factors which will often put the skill al frequently resulted in rebleeding. Wounds frequently and judgment of the surgeon to a severe test; but the ideal is ex- required packing with hot sponges or gauze. This packing tirpation of the lesion in one session, and in accomplishing this could remain in place for several days with the scalp no technical element is more important than to control the loosely closed, followed by the patient’s return to the op- bleeding. erating room for removal of the packing. With or without packing in their wounds, many patients were in shock Hemostasis and Brain Tumor Surgery after surgery. New or recurrent bleeding was not uncom- Numerous hemostatic options existed for the surgeon mon with improvements in blood pressure. Compression at the turn of the 20th century. Unfortunately, the most di- of the brain also led to devitalized tissue, necrosis, and in- rect, widely accepted hemostatic technique, vessel liga- creased neurological injury and infection risk.18,22 ture, was often not practical in neurosurgery. Although Bone Wax. Bleeding from the diploë created a different improvements in instrument design helped with the scalp type of problem because the bone edges were not com- and larger brain blood vessel bleeding, most techniques pressible and packing was not always reliable. Horsley be- only indirectly affected blood clotting. Excellent research gan to work with bone wax in 1885. He first reported this on the vascular effects of heat and cold irrigation and the use of bone wax based on a technique described by Ma- use of living tissue grafts was described in this era. Also, gendie in the British Medical Journal in 1892. Although by the early part of the 20th century, the clotting cascade successful in dogs in an experimental setting, an antisep- was understood and attempts to purify thrombin were un- tic version needed to be developed for human use. With derway.18 Cautery, a technique that had been in disfavor, the aid of Mr. P. W. Squire, an antiseptic compound con- was reemerging thanks to the development of new techno- sisting of beeswax, almond oil, and salicylic acid was de- logy and a better understanding of the effects of electrical veloped and successfully used.15,18 current on tissue in the early 1800s. This new field of sur- Styptics. These materials, which have the ability to con- gical diathermy would dramatically change not only the tract organic tissue and subsequently reduce hemorrhage, methods for hemostasis, tissue dissection, and tumor re- never achieved widespread popularity as hemostatic section, but also the types of tumor surgeries attempted. agents. These compounds are mentioned as far back as Some of the early specialists in brain tumor surgery de- Galen, who described rules for implanting alum, copper tailed techniques for control of bleeding on the brain sur- sulfate button, or ferric chloride granules against the ves- face. As recounted in Walker’s book The Genesis of Neu- 22 sels of an amputated stump. The styptic is intended to be roscience, Horsley described spraying a sublimate or localized at the point of bleeding and its caustic action in- saline solution heated to between 110 and 115˚F, followed volves both the vessel and the neighboring tissue. The by the application of gentle pressure with a sponge. God- downside to this mechanism of action is the formation of lee described using galvanic cautery and Roberts applied an eschar, which covers the bleeding vessel. This precipi- a hot needle directly to the bleeding vessel. tation of proteins is not equivalent in specificity and relia- bility to the crystallization of fibrinogen into fibrin. Other than for use in extreme circumstances, this method was Specific Hemostatic Concepts not widely accepted. Nevertheless, in later years, Cushing Position, Pressure, and Patience. As reported in Walker,22 was reported always to have at hand a basin of Zenker the use of gravity to assist with reducing blood loss was solution, consisting of a corrosive sublimate, potassium widespread. In addition to elevation of the head, when pos- bichromate, sodium sulfate, and water. This was used for sible, patients were positioned seated or even standing. Nu- the destruction of neoplastic remnants after tumor resec- merous techniques evolved for compression of the scalp tion and also for application to bleeding spots that failed edges, including rubber bands, tubing, steel rings, plates to respond to other techniques.18 placed into the wound, and suture.

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