[Skeletons in the cupboard--treatment of Arne Torkildsen]

Arne Torkildsen (1899-1968) developed Torkildsen's operation, the first successful shunt operation treating increased intraventricular pressure in the brain. He defended his doctoral thesis "Ventriculo-cisternostomy" in the University of Copenhagen in 1950, a thesis that had been rejected by the University of Oslo in his home country Norway. He was not found qualified for the post of associate professor in neurosurgery in spite of being recommended by two international adjudicating committees on four occasions. Torkildsen was accused of having misled the university by omitting one third of the operated patients from his thesis. No-one actually called him a cheat, but tales of cheating and infighting between colleagues aspiring to the same academic posts leave a confusing picture. This paper sums up the story and the possible motives different actors might have had for trying to promote or stop Torkildsen's academic career.

Third ventriculostomy for internal hydrocephalus complicated by unrecognized subdural hygroma and hematoma: a case report of a patient treated by Dr. Walter Dandy

The authors review the case of a patient treated by Dr. Walter Dandy. When the patient was a young child he underwent two right transtemporal third ventriculostomies during which he sustained an unrecognized contralateral subdural hygroma and a chronic subdural hematoma with a mild infantile hemiparesis. He was able to complete high school, albeit at a slower pace than usual. As an adult he held several limited employment positions, lived at home for several decades, and was later cared for at a nursing home for a short time. The patient died when he was 66 years of age.

History of ventriculostomy

Ventriculoscopy and neuroendoscopy had their beginnings in the early part of the twentieth century, when neurosurgeons were motivated by a desire to control hydrocephalus. The development of endoscopy was initially hampered by significant complications. When extracranial shunting became commonplace, endoscopy was essentially discarded by neurosurgeons. It was because of the continuing problems with shunting that a renewed interest in neuroendoscopy developed. Specific indications for various procedures have now been developed, and increasing success is being realized by the use of endoscopic procedures.

[Arne Thorkildsen and Thorkildsen's surgery]

Arne Torkildsen (1899-1968) studied neurosurgery for one year at Queen Square and for four years (1930-34) with Wilder Penfield in Montreal. He returned to Oslo, Norway, in 1935 and took up responsibility for the neurosurgical section of the Department of Neurology of the National Hospital of Norway. In 1939, he introduced a new technique for operative treatment of hydrocephalus (ventriculocisternostomy, Torkildsen's shunt). His technique was the first successful procedure for shunting of cerebrospinal fluid and soon became internationally known and accepted as the standard operation for obstruction of the aqueduct or posterior third ventricle. In 1950, he defended his doctoral thesis at the University of Copenhagen, describing the technique and the results of the operation. He was professor of neurosurgery at the University of Cairo, Egypt 1951-1954.

The scientific history of hydrocephalus and its treatment

Hydrocephalus cases were regularly described by Hippocrates, Galen, and early and medieval Arabian physicians, who believed that this disease was caused by an extracerebral accumulation of water. Operative procedures used in ancient times are neither proven by skull findings today nor clearly reported in the literature. Evacuation of superficial intracranial fluid in hydrocephalic children was first described in detail in the tenth century by Abulkassim Al Zahrawi. In 1744, LeCat published findings on a ventricular puncture. Effective therapy required aseptic surgery as well as pathophysiological knowledge--both unavailable before the late nineteenth century. In 1881, a few years after the landmark study of Key and Retzius, Wernicke inaugurated sterile ventricular puncture and external CSF drainage. These were followed in 1891 by serial lumbar punctures (Quincke) and, in 1893, by the first permanent ventriculo-subarachnoid-subgaleal shunt (Mikulicz), which was simultaneously a ventriculostomy and a drainage into an extrathecal low pressure compartment. Between 1898 and 1925, lumboperitoneal, and ventriculoperitoneal, -venous, -pleural, and -ureteral shunts were invented, but these had a high failure rate due to insufficient implant materials in most cases. Ventriculostomy without implants (Anton 1908), with implants, and plexus coagulation initially had a very high operative mortality and were seldom successful in the long term, but gradually improved over the next decades. In 1949, Nulsen and Spitz implanted a shunt successfully into the caval vein with a ball valve. Between 1955 and 1960, four independent groups invented distal slit, proximal slit, and diaphragm valves almost simultaneously. Around 1960, the combined invention of artificial valves and silicone led to a worldwide therapeutic breakthrough. After the first generation of simple differential pressure valves, which are unable to drain physiologically in all body positions, a second generation of adjustable, autoregulating, antisiphon, and gravitational valves was developed, but their use is limited due to economical restrictions and still unsolved technical problems. At the moment, at least 127 different designs are available, with historical models and prototypes bringing the number to 190 valves, but most of these are only clones. In the 1990s, there has been a renaissance of endoscopic ventriculostomy, which is widely accepted as the method of first choice in adult patients with aquired or late-onset, occlusive hydrocephalus; in other cases the preference remains controversial. Both new methods, the second generation of valves as well as ventriculostomy, show massive deficits in evaluation. There is only one randomized study and no long-term evaluation.

[75 years after Dandy, Fay and Mixter--looking back on the history of neuroendoscopy]

The first neuroendoscopic operation was done in the year 1910 by the urologically practicing doctor Victor Darwin Lespinasse (1878-1946). Lespinasse never published this procedure. He only reported the case in front of a local surgical society. Several years later (1922/23) the first endoscopic operations in the brain were published by three neurological surgeons within one year (Dandy, Fay and Mixter). This 75 year anniversary is the background for the following historical overview.

The history of ventriculoscopy: where do we go from here?

With the availability of better endoscopes, improved lighting and increased instrumentation, the use of ventriculoscopy and ventriculostomy in the management of hydrocephalus is becoming increasingly more common. Neurosurgeons recognized the potential for endoscopic surgery early in this century, but were frustrated in many of their attempts at treatment due to the poor quality of the instruments available. Nevertheless, much progress has been made, and the stage was set for better results with modern instrument design. This paper reviews the history of endoscopes in neurosurgery and ponders the direction these instruments will take us in the near future.

[History and significance of suboccipital puncture]

In 1919 Wegeforth, Ayer and Essick described the direct puncture of cisterna cerebello-medullaris. Without knowledge and independent of this Karl Eskuchen recommended in 1923 to tap the cistern after touching the squama occipitalis before. His proceeding found general resonance. It is less dangerous and practicable without much experience. Originally there were numerous diagnostical, therapeutical and scientific indications for the suboccipital puncture. Most of them are out of date. Still, it is the only practicable alternative when the lumbal puncture was with no purpose.