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Stereotactic Neurosurgery in the United Kingdom: the Hundred Years from Horsley to Hariz

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Stereotactic Neurosurgery in the United Kingdom: the Hundred Years from Horsley to Hariz LEGACY STEREOTACTIC NEUROSURGERY IN THE UNITED KINGDOM: THE HUNDRED YEARS FROM HORSLEY TO HARIZ Erlick A.C. Pereira, M.A. THE HISTORY OF stereotactic neurosurgery in the United Kingdom of Great Britain Oxford Functional Neurosurgery, and Northern Ireland is reviewed. Horsley and Clarke’s primate stereotaxy at the turn Nuffield Department of Surgery, of the 20th century and events surrounding it are described, including Mussen’s devel- University of Oxford, and Department of Neurological Surgery, opment of a human version of the apparatus. Stereotactic surgery after the Second The John Radcliffe Hospital, World War is reviewed, with an emphasis on the pioneering work of Gillingham, Oxford, England Hitchcock, Knight, and Watkins and the contributions from Bennett, Gleave, Hughes, Johnson, McKissock, McCaul, and Dutton after the influences of Dott, Cairns, and Alexander L. Green, M.D. Jefferson. Forster’s introduction of gamma knife radiosurgery is summarized, as is the Oxford Functional Neurosurgery, Nuffield Department of Surgery, application of computed tomography by Hounsfield and Ambrose. Contemporary University of Oxford, and contributions to the present day from Bartlett, Richardson, Miles, Thomas, Gill, Aziz, Department of Neurological Surgery, Hariz, and others are summarized. The current status of British stereotactic neuro- The John Radcliffe Hospital, Oxford, England surgery is discussed. KEY WORDS: Atlas, Computed tomography, Functional neurosurgery, History, Radiosurgery, Stereotactic Dipankar Nandi, Ph.D. frame, Stereotactic neurosurgery Imperial College London, and Charing Cross Hospital, Neurosurgery 63:594–607, 2008 DOI: 10.1227/01.NEU.0000316854.29571.40 www.neurosurgery-online.com London, England Tipu Z. Aziz, M.D., D.M.Sc. Pigmaei gigantum humeris impositi Sir Victor Alexander Haden Horsley (1857– Oxford Functional Neurosurgery, plusquam ipsi gigantes vident 1916) (Fig. 1A) studied medicine in University Nuffield Department of Surgery, [If I have seen further it is by standing College London before training surgically University of Oxford, and on the shoulders of giants] there. He was the first neurophysiologist who Department of Neurological Surgery, The John Radcliffe Hospital, Oxford; —Sir Isaac Newton (136) was also a neurosurgeon, pioneering a Great and Imperial College London British tradition of such hybrid scholars that and Charing Cross Hospital, n debates over the paternity of the disci- were particularly prevalent in the stereotactic London, England pline of neurosurgery, Sir Victor Horsley community (137). His uniquely deft approach frequently vies with Harvey Cushing and to neurosurgery, derived from experiments on Reprint requests: I more than 100 primates, made a reputation Erlick A.C. Pereira, M.A., notable others, including the Englishman Sir Oxford Functional Neurosurgery, Rickman Godlee and the Scot Sir William such that when tenure became available at the Nuffield Department of Surgery, MacEwen (19, 87, 89, 95, 120, 137, 167). Yet, it National Hospital for the Paralyzed and University of Oxford, and is a truth universally acknowledged, even Epileptic in Queen Square in 1886, “the Staff Department of Neurological Surgery, west of the Atlantic, that stereotaxis (as he intended to have Horsley and nobody else” The West Wing, The John Radcliffe Hospital, named it back then) was invented in London (140, p 27). Oxford, OX3 9DU England. by the Englishman. Although Dittmar, in Like Sir Isaac Newton two centuries before Email: [email protected] Germany, had used a guided probe to tran- him, Robert Henry Clarke (1850–1926) (Fig. 1B) sect the rodent medulla in 1873 (33) and the read mathematics at Cambridge University. He Received, January 27, 2008. Russian Zernov had described an encephalo- then undertook medicine at St. George’s Accepted, March 26, 2008. meter enabling brain surface localization in Hospital in London before surgical training in 1889 (181), neither technique enabled target- Glasgow. He returned to London to work with ing with respect to a fixed three-dimensional Horsley in the late 1880s (30). Throughout the Cartesian coordinate system. following decades, Horsley became intellectu- ally consumed by the experimental challenges of cerebral localization of motor function, fol- ABBREVIATIONS: CT, computed tomography; EMI, Electric and Musical Industries lowing the seminal work of Hughlings Jackson and others. 594 | VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 www.neurosurgery-online.com STEREOTACTIC NEUROSURGERY IN THE UNITED KINGDOM AB FIGURE 1. A, Sir Victor Alexander Haden Horsley; B, Robert Henry Clarke. (Courtesy of the Wellcome Library, London.) FIGURE 2. Clarke and Horsley’s 1905 primate stereotactic apparatus, showing also Clarke’s 1920 equatorial modification (top left). (Courtesy After Clarke developed aspiration pneumonia after aspirin of the Wellcome Library, London.) inhalation in the early 1890s, he traveled to Egypt to conva- lesce. While there, legend has it that while gazing up at the stars and contemplating his place in them, he conceived an Clarke’s original instrument was last applied by F.J.F. apparatus through which probing intracranial instruments Barrington, a London urologist who used it to study the effect could be inserted; the apparatus could be clamped to an ani- of brain lesions upon feline micturition (12). Barrington died mal’s head by laterally placed skull pins, bars attached to plugs suddenly in 1956. Among the contents of his laboratory, “in inserted into the external auditory meatus, and further bars true British fashion, was a biscuit tin” (120a, p 33). It contained resting upon the nose and orbital margins, which would fix the a number of pieces first thought to be the original apparatus device to a Cartesian coordinate system. He presented his idea but later found to be only parts. After many inquiries, a techni- to Horsley on his return to England soon afterward (155). A cian in the Royal Veterinary College where Barrington had once decade later, in 1905, they commissioned James Swift, a worked produced a mahogany box containing the original machinist at Palmer & Company in London, to construct the model, and it was returned to University College London in first machine from brass, “Clarke’s stereoscopic instrument 1970. It now resides in the Science Museum in London, having employed for excitation and electrolysis,” comprising frame, been promoted from closed storage to prominent display by carrier, and needle holder and costing £300 (Fig. 2) (159). the senior author (TZA) in 2000 (Fig. 3). Two further apparatus Results from experimental use of the first instrument for target- designs were made for Clarke by machinists Goodwin and ing electrolytic lesions in the deep cerebellar nuclei of rhesus Velacott, also of Palmer & Company in London, and exported macaques were published in 1906 (26). In 1908, Horsley and to the United States for animal research soon after the First Clarke described the apparatus and its use in greater depth, World War; one of them was sent to Johns Hopkins with the coining the term “stereotaxic” from the Greek words stereos proviso that the Baltimore institution would publish Clarke’s (meaning “solid”) and taxis (meaning “arrangement”) (82). “By stereotactic atlas (39). this means any cubic millimetre in the brain can easily be iden- Translation of Horsley-Clarke stereotaxy to humans was con- tified, recorded, and referred to” (26, p 1799). sidered not only by Clarke, but also by one of Horsley’s stu- Although Clarke suggested that the apparatus might be use- dents, the Canadian Aubrey Mussen. Mussen purchased one of ful in humans, neither he nor Horsley pursued the idea, and the original Horsley-Clarke contraptions secondhand for £100 they acrimoniously ceased collaboration shortly afterward. while working at the National Hospital in London from 1905 to Nevertheless, the apparatus, including its proposed use in 1906, returning to McGill University with it and subsequently humans, was patented by Clarke in 1914, and he devoted much publishing results from studies of the hypoglossal nuclei that time to improving it. A rectilinear modification enabling needle Horsley traversed with his deep cerebellar lesions (130). inclination at different angles in an equatorial frame enabling Mussen designed further stereotactic instruments with Clarke, 360 degrees of movement was described by 1920 (Fig. 2) (23). including a “cyclotome,” a probe used to make disk-shaped Three others used the original apparatus in London for exper- incisions along its axis, and a “spherotome,” used to cut spher- imental work: first, the visiting American surgeon Ernest Sachs, ical volumes, to which the leukotome of António Egas Moniz who studied the optic thalamus (154), and then the neurologist bears much resemblance (23). S.A. Kinnier Wilson, who studied the basal ganglia of 25 mon- Having returned to London in 1914, Mussen designed and keys using the “Clarke-Horsley machine” (179). had commissioned a modification of the Horsley-Clarke appa- NEUROSURGERY VOLUME 63 | NUMBER 3 | SEPTEMBER 2008 | 595 PEREIRA ET AL. Sachs and Mussen used Clarke’s second and third frames, respectively, for animal experiments in North America through- out the 1920s, (131, 156), as did others during the following decade. However, the key challenges in translating experimen- tal animal stereotaxy into a clinical tool were twofold. First, there was great variability between human cranial landmarks and cerebral structures and, second, humans could not be killed like animals to enable confirmatory
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