Opening the Closed Box
a brief note on brain surgery
by Edison McDaniels, MD
Recently I encountered a discussion about which period has had the greater impact on modern brain surgery: the seventy-five years just passed, or the hundred years before that? An academic argument to be sure, but interesting nonetheless.
They say chance favors the prepared mind. They might just as well have said technological advancement demands a proper foundation. Imagine for a moment a world in which Harvey Cushing had been able to look into the skull as easily as we can today. Forget for a moment how the foundations of building a CT scanner were not present in 1920 — no mathematical algorithms, no high speed computers, no computers at all. Would Cushing have been able to use CT?
He might have been able to localize lesions better, no doubt of that. But how to get at them? In the absence of adequate hemostasis, without modern day lighting to illuminate the basilar cisterns or the third ventricle, with no significant means of magnifying what he found — every brain surgeon knows visualization is key — CT would have remained an interesting curiosity to him. About as useful as visiting the deepest trench in the ocean is today: we can go there, but we can’t stay long and we can’t do much but look on with fascination.
This forraught view of technology works the other way round as well. When Dandy injected air in the head and first developed pneumoencephalography, it was state of the art. A true advance. But what do we do with pneumoencephalography today? Pretty much nothing. This all but barbaric practice has been relegated to the pages of neurosurgical history.
But why? Because it was too dangerous? No. Because we no longer need to peer into the innards of the skull? No (we do that everyday). It’s because we can peer into the skull with better tools. Higher resolution. Dandy developed pneumoencephalography in answer to a seemingly simple question: How do we look into a closed box?
That question, some forty years later, lead to the development of CT, and later still, MRI. It’s not a question we need to ask today. But in Dandy’s world, it was the preeminent question — the holy grail if you will. How do you localize a mass — a tumor — inside the head? One way was to do a neurologic exam.
The other way was to look into the closed box. Literally.
Egas Moniz asked the question as well, in 1927. His answer, inject something into the circulation, lead to one of the greatest advances in all of medicine, angiography. Moniz, of course, went on to win the Nobel Prize in Medicine in 1949, though not for angiography but his other great (eh, not so great?) contribution to medicine: prefrontal lobotomy.
We all know how that came out.
So is Moniz a giant of the first one hundred years? Or a stunning failure of the last seventy-five?
The growth of knowledge in any field is a continuum in which the leaders of today walk in the footsteps of yesterday’s giants. Like a game of shadows, the developement of modern day brain surgery largely parallels the development of modern day neuroimaging. Replacing CSF with air had its time and place, but there is no doubt its very success over forty years spurred continued research in many areas. Answering those questions, improving the resolution of our view if you will, lead to still more questions — more followers standing first in the footsteps and later on the shoulders of giants. The pace of discovery and improvement has quickened, but the giants of yesteryear are no less giants and the leaders of today are no less innovative.
Chance favors the prepared mind and technology demands a proper foundation. Thanks to those who came before us, we have that proper foundation and our minds are better prepared than ever before.
All of which is just another way of saying the innovators of today ask better questions. Hopefully, they get better answers.
About The Author
Edison McDaniels is a practicing surgeon & wordsmith, who writes short stories, novellas, and novels when he’s not incising skin. Read more about him at www.surgeonwriter.com and look for his fine & intense works of fiction at the Amazon Kindle store.
His latest novel, Not One Among Them Whole, is available for the Kindle and as a trade paperback from Northampton House Press.
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