Biomedical subjects
Publications and source records attributed to T F Dagi.
Over the last 100 years, stereotactic surgery has evolved from a laboratory method to a vibrant neurosurgical specialty. Its evolution exemplifies the process of technology immigration in neurosurgery. It also illustrates the issues that must be confronted as new technologies move into the clinical arena and are adopted.
Angiography failed to capture the enthusiasm of the neurosurgical community between the time of its introduction in 1927 and the late 1940s. It should have. This article reviews the facts that influenced the acceptance of angiography as a major neurodiagnostic technique.
The contributions of Arthur Elvidge (1899-1985), Wilder Penfield's first neurosurgical recruit, to the development of neurosurgery have been relatively neglected, although his work in brain tumors extended the previous work of Percival Bailey and Harvey Cushing. He published rigorous correlations of clinical and histological information and formulated a revised, modern nosology for neuroepithelial tumors, including a modern histological definition of glioblastoma multiforme. Well ahead of his time, he believed that glioblastoma was not strictly localized and was the first to comment that the tumor frequently showed "satellitosis." He was the first neurosurgeon in North America to use angiography as a radiographic aid in the diagnosis of cerebrovascular disease. Having studied with Egas Moniz, he was the first to detail the use of angiographic examinations specifically for demonstrating cerebrovascular disorders, believing that it would make possible routine surgery of the intracranial blood vessels. Seeking to visualize all phases of angiography, he was the impetus behind the design of one of the first semi-automatic film changers. Elvidge and Egas Moniz made the first observations on thrombosis of the carotid vessels independently of each other. Elvidge elucidated the significance of embolic stroke and commented on the ischemic sequelae of subarachnoid hemorrhage. Besides his contributions to neurosurgery, he codiscovered the mode of transmission of poliomyelitis. Elvidge's soft-spoken manner, his dry wit and candor, mastery of the understatement, love of exotic travel, and consummate dedication to neurosurgery made him a favorite of patients, neurosurgery residents, nurses, and other hospital staff. His accomplishments and example as teacher and physician have become part of neurosurgery's growing legacy.
Although facilities at many civilian centers far exceed those historically available to military neurosurgeons in the field, the principles derived from combat injuries continue to apply. It is hoped that there may be differences in salvageability at the margin owing to the availability of more sophisticated imaging and critical care monitoring techniques, neuroanesthesia, and the advent of possible pharmacologic neural salvage agents.
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There are three important principles to be derived from this case. First, it is essential not to confound the technical problem of assessing pain and suffering with the ethical issue of judgments about pain and suffering. Second, in most cases, the apparent limitations of traditional ethical theory in critical care decisions are precisely that: apparent limitations only. The alternatives, especially intuitionism, are far more troublesome. Finally, the claim of health-care workers to be professionals places legitimate constraints on the extent to which they may be permitted to have their needs and wants influence the ethical dialectic. The achievement and maintenance of "comfortable, compatible relationships" cannot be legitimately construed as a major objective of biomedical ethics--although one would hope it will become a cherished, if serendipitous, byproduct. In short, paraphrasing (and reversing) Archibald MacLeish on poetry: Ethics should not be/but mean.
The traditional surgical management of complex craniofacial injuries is performed in three stages: immediate craniotomy, orbitofacial repair in 7 to 10 days, and cranioplasty delayed 6 to 12 months because of the perceived risks of infection and prolonged anesthesia in the head-injured patient. Cosmetic considerations have always played a secondary role; however, there are reports that suggest that bone fragments and grafts can be safely placed even in contaminated wounds. In addition, advances in neuroanesthetic technique allow for prolonged administration of anesthesia without untoward effects on the patient. The purpose of this prospective study was to determine if early single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality. In this study, 13 patients (9 men, 4 women) ranging in age from 3 to 53 years, with Glascow Coma Scale scores of 10 to 15, all had a combined single-stage repair of their complex craniofacial injuries within 24 hours of their trauma. After initial assessment and resuscitation, all patients were evaluated with computerized tomography of the face and head before surgery. Bicoronal skin flaps were used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, and calvarial reconstruction. Dural grafts were necessary in 12 of 13 patients (92%), and supplementary bone grafting was required in 9 of 13 patients (69%), of which 3 of the 9 (33%) had iliac bone grafts, where split calvarial grafts were used in the other 6 of 9 (67%). No artificial cranioplasty material was used.(ABSTRACT TRUNCATED AT 250 WORDS)
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Upbeating nystagmus has been described in lesions of the posterior fossa. We report a case of upbeating nystagmus accompanying a focal hemorrhagic lesion of the left brachium conjunctivum, the anterior vermis, and the anterior superior left cerebellar hemisphere. The nystagmus was suppressed by a contralateral head tilt. We postulate that in this instance, acquired central nystagmus was inhibited by the otolith-ocular reflex.
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Spondylotic degeneration can give rise to concurrent stenosis of the lumbar and cervical portions of the spinal canal in tandem. Symptomatic tandem spinal stenosis (TSS) is characterized by the triad of intermittent neurogenic claudication, progressive gait disturbance, and findings of mixed myelopathy and polyradiculopathy in both the upper and lower extremities. Nineteen patients with clinically symptomatic and myelographically proven disease were studied retrospectively. Surgical intervention was directed at decompression of the stenotic lesions in both the cervical and lumbar regions. The most symptomatic level was usually treated first. After a mean follow-up period of 22 months, an excellent outcome was obtained in five patients (26%), four improved (21%), five deteriorated despite initial improvement (26%), and one was unchanged. Three patients could not be traced for follow-up review, and there was one postoperative death. Postoperative improvement correlated inversely with symptom duration. Sphincter disturbance, radiculopathy, myelography, cerebrospinal fluid analysis, and electrophysiological data were not prognostically significant. The presentation of TSS mimics amyotrophic lateral sclerosis and other forms of motor-neuron disease. In contrast to these conditions, however, TSS is amenable to treatment. Operative sequence and technique could not be related to outcome. Functional recovery in TSS depends on early diagnosis and timely surgical intervention.
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