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Franz Josef Gall, born in 1758, studied medicine in Strasbourg and Vienna and focused his research in two areas. His most notorious research was in craniofacial morphology that gradually evolved into the pseudoscience of phrenology. His second research area was neuroanatomy. Although Gall is usually best remembered for his inglorious introduction of phrenology, his neuroanatomic contributions have more lasting significance. In this vignette we explore Gall's neuroanatomic contributions especially as they relate to brain stem anatomy. By means of blunt dissection he was the first to describe the origins of several cranial nerves, including the trigeminal nucleus. It will be apparent that Gall--his dubious introduction of phrenology notwithstanding--was a pioneer in the description of brain stem anatomy.

Trephination of the skull is one of the most fascinating and, certainly, one of the oldest therapeutic procedures known to man. After Prunières' discovery of the trephined skull at Aiguières in 1868, a plethora of information has been gathered about the procedure. There, however, exits little documentation of African trephination or its history. Using both primary and secondary sources, we have discovered that African trephination was known in the time of Herodotus, has a rich history, and is currently practiced widely throughout Africa for specific reasons. We discuss these findings as they relate to preconceived notions of trephinations in other countries and to the history of neurosurgery.

Gangliogliomas are uncommon tumors of mixed neoplastic glial and neuronal elements. Because of their low incidence, few large series exist that fully describe the clinical characteristics of patients afflicted with this tumor. We have reviewed the medical records of 20 patients at Duke University Medical Center with histologically proven gangliogliomas. These patients typically presented within the first three decades of life and their most common presenting symptom was seizures. Therapies included surgical resection, either partial or total, radiation therapy, and/or chemotherapy. Long-term follow-up was achieved by chart review and by telephone interview. Patients who underwent gross total resection alone seemed to fare the best when comparing all treatment groups, and we therefore recommend this as the main form of treatment.

Solitary eosinophilic granuloma of the skull is a rare lesion, the natural history of which has not been defined completely. By a retrospective chart review, 26 patients were identified as having a solitary eosinophilic granuloma of the skull at first presentation to our institution between 1946 and 1982. Characteristically, the patient noted an enlarging, tender skull mass during the several weeks to several months before the initial assessment. Laboratory findings were normal except for 1 case of eosinophilia. Radiographically, the abnormality consisted of a punched-out, well defined, lytic lesion most commonly seen in the parietal or frontal bone. Whole body bone scans or bone surveys were used to rule out further lesions. The definitive diagnosis was made by histological examination, which showed the characteristic histiocytes, eosinophils, and multinucleated cells of eosinophilic granuloma. The usual treatment consisted of a craniectomy or curettage perhaps followed by local, moderate dose radiation therapy. The follow-up period ranged from 1 month to 25 years and averaged 8 years; in that time, 8 patients (31%) developed additional lesions. Of these 8 patients, only 3 were older than 3 years at the time of the first recurrence. Based on a review of our own patients and those reported in the literature, we stress that a solitary eosinophilic granuloma of the skull may foreshadow future disease elsewhere and is not an easily dimissed local disease, especially in children. After the initial treatment, we recommend careful long term follow-up and treatment of additional lesions with radiation therapy.

The materials ordinarily used to reconstruct bone defects in the calvaria and facial bones either are difficult to shape, are partially resorbed by the body, or are likely to become infected if used near a contaminated area such as the frontal sinus. Calcium sulfate hemihydrate (plaster of Paris) has been known for years to have excellent reparative qualities in bone defects, but ordinarily it is quickly resorbed. Consequently, a new material, a composite of a dense form of plaster of Paris and hydroxylapatite, was devised to provide nonabsorbable hydroxylapatite particles for bone to form around and within during the phase of plaster absorption. Two types of this material were evaluated in cranial defects in cats. Each of the plaster of Paris/hydroxylapatite mixtures was placed into a surgically unroofed frontal sinus and into a contralateral parietal trephine hole in a group of 32 cats. Two cats in each group succumbed to anesthesia, leaving two sets of 30 cats. During the entire follow-up period there was only one other death, with no evidence of wound infection, wound dehiscence, implant rejection, or cerebral dysfunction among the survivors. The cats in each group were sacrificed at 1, 2, 3, 5, 7, 8, 9, 10, or 12 months after operation. Following sacrifice, both the frontal and parietal defects were exposed and examined visually, histologically, and with histomorphometric analysis for new bone formation. New bone formation was present as early as 1 month after operation and continued to increase during the 12 months of the study. Based upon these osteogenic qualities, the ease of shaping the composite, and the lack of infection in the frontal sinus region, it is concluded that this substance could be a valuable new material for human cranioplasty.

Intervertebral disc space infection is an uncommon, but serious, complication of disc surgery. By a retrospective chart review, we identified 27 patients at our institution who had a postoperative disc space infection; 14 were diagnosed and treated within the last 5 years. The characteristic symptoms were severe spinal pain and limited spinal mobility beginning 7 to 30 days postoperatively. The key physical findings were paravertebral muscle spasm and marked mechanical signs. The key laboratory findings were an elevated erythrocyte sedimentation rate and a mildly elevated white blood cell count. The diagnosis was based on the clinical presentation and early radiographic changes in the vertebral bodies adjacent to the involved disc, especially irregularities of the cortical margins seen best by tomography. Definitive bacteriological diagnosis by Craig needle biopsy was attempted in 14 patients; 7 had positive cultures and all yielded a Staphylococcus species. The usual treatment consisted of the administration of antistaphylococcal antibiotics and immobilization of the spine with a spica cast, a plastic body jacket, or complete bedrest. The final radiographic findings showed bony fusion or bridging in 19 patients, and 25 patients had a pain-free recovery after 1 to 9 months. There was 1 recurrent infection, and 3 patients eventually required an anterior discectomy and fusion. Based on a review of our own cases and those reported in the literature, we stress the importance of spinal tomography in establishing the diagnosis of postoperative disc space infection at a relatively early stage in a patient who is suspected of having this condition on the basis of typical symptoms and signs combined with an elevated sedimentation rate.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of peroneal nerve entrapment is reported in a patient with scleroderma. Compression was due to a lipoma in the popliteal fossa and resulted in increasingly severe foot-drop. Complete recovery occurred after the lipoma was resected. A brief review of peroneal nerve palsies and lipomatosis is presented.

The DREZ operation was first done in 1975 on a patient with arm pain following a brachial plexus avulsion. Since then approximately 500 patients have undergone the DREZ procedure under our care for treatment of various pain syndromes including deafferentation pain, post-herpetic neuralgia, and post-paraplegia pain. We report several modifications in instrumentation and technique. Currently, we use two types of electrodes for lesion production. The first is the standard 0.25 mm diameter, thermocouple, temperature monitoring electrode which has a 2 mm long tip for introduction into the spinal cord. A second type, recently modified from the original, is used only for lesioning the nucleus caudalis in patients with trigeminal post-herpetic neuralgia. Its tip is 3 mm long with insulation along the first 1 mm. This allows lesioning of the caudalis nucleus while sparing the more superficial spinocerebellar tracts. We no longer lesion only the dorsal root entry zones at each root level but include all the contiguous substantia gelatinosa between roots. With lesions only 1 mm apart this greatly increases the number of lesions and decreases the incidence of incomplete postoperative pain relief. In patients undergoing caudalis lesioning, we make two rows of lesions, one above the other, from C2 to slightly above the obex. This prevents sparing of the facial midline with resultant residual pain. Finally, lesions are made by heating the electrode tip to 75 degrees C for exactly 15 sec, thus allowing for a more uniform lesion. With these modifications, we have a decreased incidence of incomplete pain relief as well as a decreased incidence of complications, especially in patients undergoing caudalis lesioning.

Sarcoidosis, generally a systemic ailment, uncommonly affects the central nervous system. It only rarely affects the spinal cord alone or in combination with other areas. Syringomyelia has never been associated with sarcoidosis. We report the case of a 32-year-old man with sarcoidosis who presented with surgically verified syringomyelia. The pertinent literature is reviewed. The mechanisms by which sarcoidosis could cause a syrinx are discussed.

Traumatic sacral fractures are most often due to motor vehicle or industrial accidents and are commonly associated with pelvic, urogenital, and neurological injuries. In recent years, a more subtle type of sacral fracture, not associated with major trauma, has been described. It is an osteoporotic insufficiency fracture that presents as low back pain in elderly patients, especially postmenopausal Caucasian women. It may escape detection unless radionuclide bone scans, tomograms, or computed tomograms are obtained. The radiographic features have been detailed in various publications, but little has been reported about the clinical features, treatment, or ultimate outcome of patients with osteoporotic sacral fractures. We have reviewed the charts and radiological studies of 13 women and 3 men who sustained this type of fracture between 1983 and 1986. All of these patients were Caucasian. The average age was 71 years. The most common presenting symptom complex was diffuse low back pain accompanied by hip, buttock, or thigh pain. Pertinent physical findings were limited to tenderness on palpation of the sacrum and a decreased range of low back motion. The osteoporotic fractures were seldom noted on plain roentgenograms of the sacrum, but were readily defined by sacral tomography or computed tomography. Radionuclide bone scanning also proved helpful in making the diagnosis by localizing the process. Treatment was medical and consisted of therapies designed to reduce pain and to combat the associated osteopenia. Of our 16 patients, 11 had complete pain relief, 2 had substantial pain relief, 2 noted decreasing pain before they died of other causes, and 1 was followed less than 1 month.(ABSTRACT TRUNCATED AT 250 WORDS)

Of the various forms of neurofibromatosis, the best known are peripheral neurofibromatosis (von Recklinghausen's disease) and central neurofibromatosis. There is a rare form called segmental neurofibromatosis, in which the cutaneous and neural changes are limited to one sector of the body and with which there is usually no family history of neurofibromatosis. We report four patients with this disorder and stress the value of repetitive, limited excision of peripheral nerve tumors in their management.

Extradural spinal cysts, although unusual, are well-documented entities. The majority are of congenital origin while only a few with a clear cut traumatic pathogenesis are reported. We present a case of a traumatic extradural spinal cyst which presented as a progressive radiculopathy following a penetrating injury. We also review the literature concerning traumatic extradural spinal cysts and show that they can occur following a wide variety of spinal trauma. The trauma must involve sufficient force to cause a dural rent and iatrogenic causes are included. The differences and similarities between traumatic and congenital cysts are shown, and treatment is discussed. The prognosis following surgical resection is shown to be excellent.

Ollier's disease or multiple enchondromatosis is a deforming dysplastic disease of cartilage involving primarily the metaphyses and diaphyses of long bones. It is only rarely associated with sarcomatous degeneration of the enchondromas or other generalized neoplasms. A related disease, Maffucci's syndrome, is, however, associated with generalized tumors. We present the case of a 29-year-old, albino, black man with Ollier's disease who, as a child, underwent a number of orthopedic procedures for multiple limb deformities and fractures. At age 25, he developed hydrocephalus, progressive cranial nerve palsies, and a large enchondroma of the skull base. He subsequently underwent multiple shunt procedures and two suboccipital craniectomies. Eighteen months later, a brain computed tomographic (CT) scan revealed an intracerebellar mass, which was found to be an anaplastic astrocytoma. Two years later, he developed a right hemiparesis and sensory dysfunction with a diffuse supratentorial mass on CT scan. A stereotactic biopsy showed this to be a similar anaplastic astrocytoma. The literature concerning Ollier's disease is reviewed, and the intracerebral lesions associated with both Ollier's disease and Maffucci's syndrome are examined.

Aspergillus disc space infection is an unusual complication of the immunocompromised state. Magnetic resonance imaging may aid the clinician in arriving at a prompt diagnosis of discitis in affected patients. We report a case of systemically acquired Aspergillus discitis at multiple levels diagnosed by plain x-ray films, bone scan, magnetic resonance imaging, and biopsy. We review the literature on this subject and suggest that aggressive diagnosis with early biopsy, treatment with systemic antifungal agents, and surgical debridement of the infected disc space yield the best outcome for these patients.

Tumors derived from the established human glioma cell line D-54 MG were transplanted intracerebrally into athymic "nude" mice. All control mice developed tumors in the brain after the transplantation of 10(5) cells and died within 30 days. Tumor was purely intracerebral in the presymptomatic stages, including the time of drug treatment. The injection of serial cell dilutions reduced the tumor incidence and prolonged survival. Procarbazine (PCB), 1,3-bis(2-chloroethyl)-1-nitrosourea, diaziquone (aziridinylbenzoquinone), and cis-platinum each produced statistically significant increases in survival when administered on Day 10 after transplantation, and PCB alone cured most of the animals. These results extend the characterization of the human glioma line D-54 MG and confirm the value of the athymic mouse for the testing of chemotherapeutic agents of interest in brain tumor therapy.

Since 1924, when ependymomas were first classified as a distinctive glial neoplasm by Bailey, much has been published concerning these tumors, but there are important points of interest that are still not clear. In order to study more fully the clinical and pathologic characteristics of the ependymoma, we identified 62 patients with histologically proven neoplasms. Twenty-two were supratentorial, 21 were infratentorial, and 19 were intramedullary spinal cord tumors. These groups had mean ages of 17, 7, and 41 years, respectively, at the time of first symptoms. The presenting and accompanying symptoms were related to location and included headaches, nausea, visual changes, hemiparesis, and neck, back, and radicular pain. Neurological signs included papilledema, nystagmus, gait disturbance, cranial nerve palsies, altered mental status, paraparesis, and sensory dysfunction. Radiologic modalities of particular importance included computed tomography and myelography. Surgery and radiation therapy were the primary treatment modalities with median survival times from first symptoms being 92, 36, and 117 months for the above groups, respectively. Based on computer-generated survival curves, several characteristics significantly affected survival. These included tumor site, age, and neuraxis metastases. In patients with supratentorial tumors, cranial nerve palsies, microcystic changes, and mitotic figures were important, while in patients with infratentorial tumors, widened sutures, increased head circumference, age, epithelial features, and subependymal features significantly affected survival. Patients who had complete gross resection of a spinal cord tumor had no recurrences or mortality.