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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 249-255

Stereotaxy in relation to world wars: A review on evolution of stereotactic frames


1 Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Neurosurgery, MGM Medical College, Indore, Madhya Pradesh, India
3 Department of Neurosurgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
4 College of Nursing, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
5 College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission19-Jan-2022
Date of Decision27-Jul-2022
Date of Acceptance26-Oct-2022
Date of Web Publication07-Dec-2022

Correspondence Address:
Dr. Jitender Chaturvedi
Department of Neurosurgery, All India Institute of Medical Sciences, Block-A, Level-6, Medical College Building, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_5_22

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How to cite this article:
Chaturvedi J, Singh PR, Sharma AK, Mudgal SK, Sharma SK. Stereotaxy in relation to world wars: A review on evolution of stereotactic frames. J Med Evid 2022;3:249-55

How to cite this URL:
Chaturvedi J, Singh PR, Sharma AK, Mudgal SK, Sharma SK. Stereotaxy in relation to world wars: A review on evolution of stereotactic frames. J Med Evid [serial online] 2022 [cited 2023 Feb 1];3:249-55. Available from: http://www.journaljme.org/text.asp?2022/3/3/249/362951




  Introduction Top


Hippocrates said that 'War is the only proper school for a surgeon'. During the war time, medicine evolved to support the conflict. Wars thus catalysed medical innovations that were more war-oriented than serving civilians in peace. The effects of these wars were brutal, for the world lost around 40 million lives in World War I and another 80 million in World War II.[1] Nonetheless, our professional ancestors had to propel medicine forward while enduring a simultaneous global economic and political breakdown that occurred during the two catastrophes.

Until the start of the 20th century, neurosurgery was still in its infancy and was not recognised as a distinct speciality by the medical fraternity until World War I.[2] Stereotaxy, a sub-speciality of neurosurgery, is presently used in various indications. The examples include movement disorders, epilepsy, vascular malformations, delivery of radiation, determination of surgical targets and resection in conditions such as malignancies and pain syndromes.[3] For a technique as widespread and precise as stereotaxy, its origins have been rather modest and are closely linked to the two world wars, making for a fascinating read. This article aims to shine a beam of light into the historical tunnel of stereotactic neurosurgery and examine how the two world wars halted its development for a decade, but contributed to the cognizance of neurosurgery as a speciality and concomitantly aided the remarkable progress of stereotactic neurosurgery globally afterwards. We also review the historical facts and circumstances surrounding the introduction of stereotaxy into India.


  Pre-World War I: Era of Cortical Localization Preceding Stereotaxy Top


In the early 19th century, the German neuroanatomist and physiologist Franz Joseph Gall (1758–1828) popularised the concept of 'cranioscopy' (later termed as phrenology), which described the external skull landmarks for the functional localisation of brain regions. Unfortunately, it was dismissed owing to the religious beliefs existed at that time. However, it opened doors for modern neuroscience.[2],[4] After Gall's concept of phrenology, Pierre Paul Broca (1824–1880) further elaborated the concept of cranial localisation. He invented various calibration instruments such as the craniograph and sternograph, which augmented the concept of localisation. The cerebral localisation of intelligence and sensory perception was studied by the techniques of ablation and stimulation by the French physician Marie Jean Pierre Flourens (1794–1867), who termed this concept, 'action propre'.[5] Theodor Kocher, another proponent of localiser, invented his apparatus, a Craniometer, to localise various cortical regions in the spatial relationship to bony landmarks of the cranium as shown in [Figure 1].
Figure 1: Prototype of Theodore Kocher's Craniometer. The relationship of the skull sutures to the frame to localize underlying brain structures is appreciated. Source: Kocher T: Textbook of Operative Surgery. London, Adam and Charles Black, 1911[11]

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These initial experiments were the cornerstone for the development of modern stereotaxy development in its current form, as they revolutionised our understanding of the human Brain functions.


  Pioneers of Stereotaxy Top


Carl Dittmar (1844–1920); Leipzig, Germany

Carl Dittmar wrote an article in 1873 in 'Berichteüber die Verhandlungen der Königlich-Sächsischen Gesellschaft der Wissenschaftenzu Leipzig, mathematisch-physischeklasse' titled, 'Über die Lage des sogenanntenGefaesszentrums in der Medulla oblongata', which translates to, 'On the location of the so-called vasomotor centre in the medulla oblongata' while working in Ludwig's physiology laboratory at Leipzig, Germany. In this article, he elaborated his fixation of a 'guiding device' on to the rabbit's snout, akin to the supportive arm in modern-day stereotaxy, and steady introduction of a surgical knife to a specific location of the rabbit's brain (the vasomotor centre in the medulla oblongata). Therefore, for the first time in history, a guiding device was used for spatial localisation of a specific area of the animal's brain.[2],[6],[7] Since Dittmar's guiding device was not based on the Cartesian system, it cannot be termed as the first stereotactic device. Definitely, it was the first baby step taken towards the development of stereotactic frames.

Gaston contremoulins; France

As an art graduate who joined the department of physiology as a microphotography laboratory technician, Contremoulins was highly adept at innovating and refining new medical technologies. In 1897, a Persian surgeon, Charles Remy, proposed an idea to localise foreign objects in the brain by X-ray radiography. Contremoulins developed an efficient intracranial bullet finder mainly based on multiple radiographs in different planes for spatial reconstruction of the object.[8] He apprehended the concept of stereotaxy and is credited with the conceptualisation of reference frames, fudicial markers, adjustable pointers and phantom devices to localise objects during intracranial surgery. He also devised the largely successful 'compass method'.[9] This discovery granted him instant fame, and his device was popularised by the scores of physicians. At the beginning of World War I, it was extensively used to extract intracranial bullets. Its advantage was the short duration of its operation (merely around 5 min), that helped save several lives without any anaesthesia or antibiotics. A forgotten hero in the history of stereotaxy, his lack of a formal medical education makes his contributions even more remarkable and cannot be ignored.

Zernov (1843–1917) and Rossolimo (1860–1928); Moscow, Russia

D. N. Zernov, Professor of anatomy at the Moscow State University, invented an apparatus called an 'encephalometer'. It was used in humans nearly 20 years before the initiation of animal studies of the Horsley-Clarke apparatus. It was thus the first and closest to the modern stereotactic frame in its principle. Zernov demonstrated it at a meeting at the Moscow State University in March 1889 and the third Congress of Naturalists and Doctors in 1890, and later published a booklet in Russian and French describing its underlying principle.[10] The apparatus was made of aluminium fixed with five stays on the skull and had three parts: (1) the main ring in the horizontal plane along the nasion to inion which was fixed on the patient's head, (2) the equator which was perpendicular to the main ring and was divided into degrees, with 0° corresponding to the sagittal suture and (3) a meridian in the sagittal plane which was moved along the hemisphere of the equator. The meridian was set at a certain number of degrees using couplings tied to the meridian arch. The concerned area was identified, the coordinates were transferred to the map, and finally, the projection of the region was obtained. N. V Altukhov, a student of Zernov, contributed by developing encephalometric maps for different age groups and mapped the brain sulci and basal ganglia. Both Zernov and Altukhov collaborated to determine the basal ganglia's spatial localisation, its projections and dimensions. With their success, many physicians started using the encephalometer in Moscow.[10]

Professor G I Rossolimo was in turn inspired by their device, tried to improve upon its shortcomings, and ultimately developed a second Russian apparatus called the 'Brain Topograph.' He added an aluminium hemisphere on which a map of sulci and subcortical structures was applied, and parallels and meridians were drawn on this map at every 10°. He made three to six holes on each square of the map, and through these holes, he marked the skull surface to precisely localise the point of interest.[11]

Since both the Russian devices were not based upon the Cartesian coordinate system, they cannot be labelled as fully stereotactic, though they were a 'compass' for what was to come in modern stereotaxy. The probable reason for the lack of recognition of their contributions was their publications being in Russian and French, at a time when medical literature was predominantly in English.

Sir Victor Alexander Haden Horsley (1857–1916); Great Britain

Sir Victor Horsley started his career as a registrar surgeon at University College Hospital (UCH) and National Hospital during 1885– 1886. However, his passion for experimental neurology led him to continue his lab experiments at the Brown Animal Sanitary Institution of London and UCH.[11] He worked on animals in the lab to better understand the spatial localization of the brain, thyroid gland, pituitary gland, and rabies, and contributed immensely to neurosurgery.[12] During World War I, Sir Victor Horsley was appointed as a surgeon in the British Hospital and was responsible for developing medical facilities in the different parts of Britain and its allies. Robert Henry Clark, a physiologist at St George Hospital, London in 1876, and a mathematician with remarkable mathematical skills, initially developed an apparatus to map the brains of cats and rhesus monkeys using geometrical concepts and fixed points on the brain. Later, he joined Horsley at Brown Institute and University College, and they together created the first animal stereotactic apparatus.[11] Sir Victor Horsley later travelled to India and parts of Mesopotamia, owing to World War and unfortunately, lost his life in Amra on 16th July 1916 due to hyperpyrexia, probably due to paratyphoid A infection, which was very common at that time.[11] It was a massive loss to the neurosurgical society, and an indolent phase in stereotaxy thus began, owing to World Wars.


  Beginning of the 20th Century Top


Union, joint success, and conflict: Horsley and Clarke apparatus, 1908

If ever a 3-D technique with the integration of a Cartesian coordinate system was extrapolated to target a brain site, it was by Horsley and Clarke.[13],[14] They collaborated to create the electrolytic lesions in monkeys' cerebellar roof nuclei and developed their apparatus with a London-based instrument maker, James Swift, at the cost of £300, the details of which were published with great success in Brain in 1908.[11],[14],[15] They were also the first to coin the term 'Stereotaxis' in their final published work in Brain in 1908,[16] that corresponds to the union of two Greek words, i.e., 'stereos' and 'taxis' translating to '3-D' and 'orderly arranged'. Their apparatus [Figure 2], consisted of a brass rectangular frame fixed to the skull with rods. External skull landmarks were used to locate or target the sub-cortical areas of the brain. The intersection of the horizontal zero and frontal zero planes with the sagittal zero plane was termed as the 3-D 'zero' in space.[14]
Figure 2: Horsley and Clark's apparatus. Source: Perieira EA, Erlick AC, Green AL, Alexander L, Nandi D, Aziz TZ. Stereotactic neurosurgry in the United Kingdom: The hundred years from history to hariz Neurosurgery.63 (3):594-607, September 2008

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Despite their initial success, a conflict arose when Horsley was knighted, but Clarke wasn't. Both halted all communication and separated with their part of the apparatus. When Ernest Sachs, a pupil of Horsley, took the original Horsley-Clark apparatus[14] to America in 1911, many physicians carried out experiments to study stereotaxy further between 1931 and 1932.[17] The Clarke apparatus, intended for use in humans, was later patented in 1914, but not developed further. It was later spotted at Barrington's hospital, after which it was surrendered to the Science Museum of London.[15] After World War I, the Clarke apparatus was brought to John Hopkins Hospital to carry-out animal experiments, the culmination of which enabled the publication of the Clark stereotactic  Atlas More Details.[15]


  World War I (28 July 1914–11 November 1918) Top


The assassination of the Austro-Hungarian prince Archduke Franz Ferdinand and his wife Sophie led to the world's most vicious killing of humans in the form of World War I. The conflict between two superpowers, the Central powers (Germany, Austro-Hungarian, Bulgaria and the Ottoman Empire) and the Allied powers (Russia, France, Great Britain, Italy, Romania, Japan and the United States) killed around 40 million people. As for medicine, the necessity for three things emerged: transport vehicles (ambulances), infection prevention and control (antiseptics), anaesthesia and pain control. The use of mobile X-ray units to detect bullets and fractures, successful initiation of blood transfusion by the Canadian surgeon Bruce Robertson, use of citrate for blood preservation by the Belgian, Albert Austin, and the invention of the portable transfusion machine by an English surgeon, Sir Geoffrey Langdon Keynes, were the critical achievements of this phase.[1] Cranial surgeons' demand increased tremendously to deal with head injuries, thereby enabling greater recognition of neurosurgery.[18] Harvey Cushing ('Father of Modern Neurosurgery') and Gordon Holmes (a neurologist) served war victims at a base hospital in France in 1915, treating cranial injuries based on Cushing's eponymous classification of injuries.[19]

Mussen: A £100 purchase wrapped in a newspaper

Aubrey T Mussen, a Canadian neuropathologist who worked with Horsley and Clarke in the National Hospital, London between 1905 and 1906, purchased the first Horsley-Clarke apparatus for £100, and used it to successfully stimulate the hypoglossal nucleus of a cat's brain. He further continued his research at McGill University and published his work in Brain, 1909, but later returned to Munich to work with Professor Alzheimer for the next 5 years. In 1914, Mussen completed his atlas but could not publish it due to the emergence of World War 1. Moreover, he could not find any neurosurgeon to implement his learnings on humans.[17] He designed his human apparatus after returning from Germany to London in 1918. In 1920, Mussen moved to America to work with Adolf Meyer at John Hopkins University to remodel Clarke's apparatus and developed a few stereotaxic instruments named 'cyclotome', and 'spherotome', which resembled the modern leukotome developed by Portuguese neurologist Egas Moniz. His research on the cerebellum and red nucleus of cats and monkeys was later published as a book in 1967. However, since he found no use, during war era, for the Horsley-Clarke apparatus he had bought, he wrapped it in a newspaper [Figure 3] and stored it away in the 1940s, only to be found by his family in his attic, as shown in [Figure 4] and [Figure 5]. They later donated it to Montreal Neurological Institute in 1980 after his death. Although Mussen's design of a stereotactic apparatus for humans went unrecognized for 40 years because he could not convince a neurosurgeon to use it, he will always be acknowledged for his mighty contributions.[20]
Figure 3: Aubrey Mussen used this newspaper issue of Washington Evening Star dated 8 February 1944 (Era of World War II, readers are directed to the Headline on this front page for that matter), to wrap up the part of his stereotactic apparatus (made by Aubrey Mussen in 1918, era of World War I) only to be found by his son Guy Mussen in year 1971. Source: Olivier A., Bertnard G., Picard C., Discovery of the first Human Stereotactic and Functional Neurosurgery, Durham, N.C. 1983, Appl. Neurophy

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Figure 4: Mussen's apparatus, the first device used for human stereotactic surgery. Source: Picard C., Olivier A., Bertrand G., The first human stereotactic apparatus: The contribution of Aubrey Mussen to the field of stereotaxis.J Neurosurg 59, 673-676; 1983

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Figure 5: Picture of Mussen's stereotactic frame, clicked by Guy Mussen, son of Aubrey Mussen. The equipment is seen with fixation pins and sliding bars and probe carriers, but without the revolving arc. (Which was never made, as per the communication letters between son of Aubrey Mussen, Guy Mussen and Dr. Bertrand from McGill University, MNI). Source: Olivier A., Bertnard G., Picard C. Discovery of the first Human Stereotactic and Functional Neurosurgery, Durham, N.C. 1983, Appl. Neurophysiol. 46

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In 1971, Mussen had an exchange of letters with his engineer son, Guy Mussen, which are a testament to his exemplary ideas on the development of stereotactic apparatus and dedication towards medical science; these were later published in a series of articles. In these letters, he discussed their potential use in humans and the technique of localising and destroying tumours using galvanic currents through a 5 mm trephine in the skull.[17],[20]

Wilder Penfield (1891–1976): The Montreal procedure

A brilliant young boy from Washington achieved new milestones in cortical localisation after training under the medical stalwarts of the time: Sir William Osler, Sir Charles Sherrington, Harvey Cushing, Sir Gordon Holmes and German neurosurgeon Otfrid Foerster. After working with Foerster, he learned the Foerster technique of stimulating brain areas for excising epileptogenic foci under local anaesthesia and then evolved it further, mapping the whole homunculus and performing lesionectomy, which was termed as the Montreal procedure.[5] Further, he set up the Montreal Neurological Institute in Canada in 1934, and trained thousands of neurosurgeons worldwide in the post-World War I era. His indirect contribution to the field of stereotaxy is indubitable, and we cherish his legacy.


  World War II (11 September 1939–2 September 1945) Top


World War II was the consequence of German nationalism and Adolf Hitler's political ambitions; it commenced with the invasion of Poland on 1 September 1939. The Axis powers (Germany, Italy, Japan, and Hungary) locked horns with the Allied powers (USA, Britain, France and Russia). The alleged use of Pervitin (Methamphentamine) by German Wehrmacht troops in World War II to enhance their performance in the battlefield with reduced sleep, use of sulfanilamide powder on open cuts, and morphine analgesia to relieve pain in the battlefield (in the form of syrettes) are a few of the significant drug developments of that time. Similarly, the improved use of antiseptics, tetanus vaccination, dichlorodiphenyltrichloroethane for the prevention of louse-borne typhus, drugs for malaria prophylaxis and the introduction of sulpha drugs in 1936 and penicillin in 1939 gave tremendous relief to soldiers and also significantly reduced mortality due to infectious disease.[1] The lessons learned from the World War I were utilised in World War II with the use of various blood products, and more mobile neurosurgical units were formed for early operative intervention under Sir Hugh Cairns' guidance, which ushered in improved neurosurgical training and a better understanding of spinal cord injuries. Practices such as mandatory helmet use in civilians, inspired by the plummeting mortality among military motorcyclists using helmets, were indirect advancements in neurosurgery.[18],[21] World War II prompted the governments to invest more in research and development, especially in the USA. World War II brought the development of stereotaxy to a screeching halt.


  Beginning of the Era of Stereotactic Neurosurgery Top


Spigel and Wycis; USA: The most productive association

Earnest A Spigel, a medical graduate from Vienna, was forced to leave Austria in 1930 because of growing Nazi political influence on the country and the dawn of anti-Semitism. He joined the Temple Medical School, Philadelphia, with the help of a Philadelphia businessman who requested William Parkinson to recruit Spigel and his wife.[13],[22],[23] He became a professor in the Experimental Neurology department and started using the Horsley-Clarke stereotactic apparatus in his lab. Henry T Wycis, on the other hand, had completed his graduate studies and residency from Temple Medical School and started performing experiments in the lab with his mentor, Spiegel. In 1947, when India was at its peak in its struggle for independence, they published a seminal paper in Science describing the use of the modified Horsley-Clarke instrument in humans. To their credit, they added air ventriculography to the system with a few modifications and defined the anterior commissure and pineal gland to locate the area.[24] This concept of 'stereoencephalotomy' was based on intracerebral reference points. Together they published the first human stereotactic atlas in 1952 and described the medial thalamotomy procedure to challenge prefrontal lobotomy, a popular procedure in that era.[24],[25] Spiegel and Wycis [Figure 6] gave birth to the field of human stereotactic surgery and performed many procedures such as pallidotomy, pallido-thalamotomy, and pallido-ansotomy, and psychiatric illnesses, to name a few that lead their entry into Times LIFE magazine.[23],[26] They proposed and changed the word stereotaxic to stereotactic, combining the Greek 'stereos' with the Latin word 'tactics' (meaning: To touch).[14] This serendipitous association was possible because Spiegel migrated from Austria. Jean Talairach, a French psychiatrist, turned into a neurosurgeon to work on the stereotactic frame. In 1947, right after taking part in World War II, he invented the stereotactic frame that used landmarks detectable on air contrast radiograph to localise brain areas and performed the first successful stereotactic electrocoagulation of the Flechsig nucleus for intractable pain.[13],[24],[27] In 1949, he also introduced a double grid system through which electrodes could guide the brain and prevent image distortion by X-ray diffraction.[27] His frame's novelty lay in the fact that it could be reapplied in the operation theatre on the same coordinates as those obtained in the radiology department.[24] In 1952, he also proposed the anterior and posterior commissure as reference points for the coordinate system, which has been universally accepted as a modern stereotactic principle.[13],[28] As one of the most eminent names in modern stereotaxy, Lars Leksell of Sweden invented his stereotactic apparatus in 1949, largely influenced by the work of Spiegel and Wycis.[24] His apparatus was based on an arc-centered stereotactic approach with the Cartesian coordinate system, which minimised errors in target acquisition.[24],[29]
Figure 6: The LIFE Magazine, Page 57, issue 16 August 1948, featuring Spiegel and Wycis performing a stereotactic procedure on a patient. Source: Anonymous. New brain operation for mental illness. Times LIFE Magazine. 1948 Aug 16: 57–60

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  World War II and the Defeat of Germany and Japan Top


Interestingly, World War II has an indirect relationship with stereotaxy, as Adolf Hitler, the then chancellor of Germany, suffered from Parkinson's disease, and his erratic personality coupled with worsening of symptoms probably led to Germany's defeat in World War II.[30] Germany gradually gained a foothold in medical innovation once Traugott Riechert arrived in Freiburg in 1946. Freiburg was the first German hub for stereotaxic innovations and attracted researchers from all over Germany. Riechert developed the first stereotactic frame with physicist Wolf's help. Since it was inaccurate in its measurement; they revised it with the help of F. Mundinger, who measured the roentgenographic errors and developed the formula to correct it. Finally, the second frame was established, known as the 'Riechert-Mundinger frame'.[14],[31] Meanwhile, Japan surrendered unconditionally in August 1945, after the disastrous destruction of Hiroshima and Nagasaki by American atomic bombs. The whole country was derailed for several years in many fields, including medical science. Nonetheless, people dedicated their lives to rebuilding the nation. Professor Hitaro Nabayashi, who graduated from the University of Tokyo School of Medicine in 1946, was guided by three eminent personalities: Professor Uchimora, Professor Ogawa and Professor Tokizen. Professor Ogawa brought a drawing of the Horsley-Clarke apparatus from a lab visit in North America and handed it over to young Nabayashi because of his keen interest in extrapyramidal features and  Parkinsonism More Details. Japan was steadily recuperating from the disastrous consequences of World War II, and it took a few years to make the apparatus from the drawing. Nabayashi changed the apparatus, developed the second model, and performed the first pallidotomy in a 19-year-old athetoid boy. In July 1952, he successfully performed stereotactic pallidotomy in a patient with Parkinsonism, thus succeeding in imprinting his name in the history of stereotaxy.[32]


  Resurgent India and Stereotaxy Top


India was under British governance till 1947 and was involved indirectly in World War II once Britain declared war against Germany in September 1939. Medical science, meanwhile, was still inching towards progress until India's independence in 1947. There are reports of freehand chemopallidotomy in 1940 done by Chintan Nambiar, who was the first to start functional neurosurgery in India.[33],[34] The two legendary pioneers of stereotaxic surgery in India were Jacob Chandy and B. Ramamurthi, who started neurosurgery departments at CMC, Vellore, and Madras Medical College, Chennai, respectively in 1950.[35] The interesting circumstances surrounding the advent of stereotaxy occurred in 1960, when the Governor of Hyderabad, General Shrinagesh, invited B. Ramamurthi for dinner. In conversation, the Governor discussed his experience of having undergone surgery for Parkinson's disease at Atkinson Morley Hospital, London, performed by Lawrence Walsh, and how he has developed symptoms on the other side. Ramamurthi convinced the Governor to arrange a workshop by Lawrence Walsh and Denis Willimas (both neurologists from Britain) on movement disorder surgery. After the workshop, Walsh left his stereotactic equipment behind, thus adding a new chapter in the history of stereotaxy in India.[33] Balasubramaniam, T. S Kanaka and Kalyanraman later joined Ramamurthi in Madras Medical College, Chennai, and propelled Indian stereotaxy forward.[34] In 1959, H. M Dastur initiated stereotaxy in KEM hospital, Mumbai, and Nabayashi's visit to KEM in 1962 further led to the establishment of stereotaxy in Western India. Arjun Sehgal, who was trained in neurosurgery from Cleveland clinic, USA, started the neurosurgery department in G.B. Pant hospital, New Delhi in 1965 and developed a stereotactic device that could simultaneously target and approach both sides of the brain, nevertheless it did not gain popularity.[33] RM Varma of Bangalore pioneered skull-based stereotactic approaches to the thalamus.[34]


  Conclusion Top


The development of stereotaxy has overcome numerous hardships, from World Wars to infighting neuroscientists. The resilience of our neurosurgical forefathers has brought their vision of stereotaxy to fruition. We and our future generations certainly have a glorious history to cherish. Hopefully, the story of the birth and growth of stereotaxy will inspire future generations to pursue innovation in neurosurgery with gusto.

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Conflicts of interest

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