A more balanced and inclusive view of the history of temporal lobectomy
Article first published online: 20 FEB 2008
2008 International League Against Epilepsy
Volume 49, Issue 3, pages 543–544, March 2008
How to Cite
Moran, N. F. (2008), A more balanced and inclusive view of the history of temporal lobectomy. Epilepsia, 49: 543–544. doi: 10.1111/j.1528-1167.2007.01529_6.x
- Issue published online: 20 FEB 2008
- Article first published online: 20 FEB 2008
To the Editors:
I wish to make some observations on the paper “From lateral to mesial: The quest for a surgical cure for temporal lobe epilepsy” (Almeida et al., 2007). The paper arguably overemphasized the place of the work of Penfield and Jaspers at the MNI at the expense of under-recognition of other workers. This is particularly so in the case of how the importance of the medial temporal lobe in intractable epilepsy emerged and the consequent development of temporal lobectomy with inclusion of the medial structures, but also in the field of human cortical stimulation, the paper provided limited historical context.
As Almeida et al. pointed out, Penfield began cortical stimulation in 1928 after visiting Otfrid Foerster. However, the first definite instance of human cortical stimulation was that by Roberts Bartholow in 1874 in an awake subject, one unfortunate Mrs. Rafferty. This recognition of Bartholow's primacy must, however, be accompanied by the observation that the experiment was ethically reprehensible (see Morgan, 1982 for a full discussion). As early as 1886, Victor Horsley, reported amongst his series of 10 operations, a case (“O.S.H.”) with “epileptiform seizures beginning at the left angle of the mouth,” in which, no structural pathology being evident, he employed “faradism” to map out and excise the “facial centre” (Horsley, 1886). This appears to be the first instance of a stimulation-guided corticectomy (although Feindel incorrectly attributed this to Fedor Krause (Feindel et al., 1997)). Following Horsley, Fedor Krause in Berlin began similar work in the 1890s including excisions determined by cortical stimulation, later publishing a map of the human primary motor area (Penfield & Jasper, 1954; Wolf, 1992). Thus, it can be seen that this field had a rich history prior to the work of Penfield and, indeed, of Foerster.
Following on from Jasper's work on seizures of temporal lobe origin, Frederick Gibbs, in 1948, provided a coherent description of psychomotor seizures as temporal lobe seizures and demonstrated that most psychomotor seizures were associated with an anterior temporal lobe EEG focus and that around one-third of adult patients with epilepsy had this type of seizure (Gibbs et al., 1948). Bailey & Gibbs (1951) quickly translated these findings into surgical practice, initiating temporal lobe operations at The Illinois College of Medicine in 1947. Their first operations excisions were limited (“unigyrectomy,”“bigyrectomy,” or “trigyrectomy”) and determined solely by the electrocorticography (ECoG) findings, but the success rate was low and therefore, after considering a number of other experimental findings, they proceeded to more radical excisions, the “radical lobectomy”: all tissue between the Sylvian fissure & the occipototemporal sulcus, extending posteriorly at least to the level of the central sulcus and, in some cases, (depending upon the ECoG findings), up to one centimeter posterior to it; the medial structures, explicitly the hippocampus & insula, were spared for fear of producing Klüver-Bucy syndrome.53 Bailey and Gibbs believed that the results of the radical procedure were superior (“… very good to date”) and urged its adoption in all cases.
Finally, Almeida et al., in common with previous researchers, gave insufficient recognition to the work of Arthur Morris who, at Georgetown University School of Medicine, was also developing temporal lobe surgery in patients with psychomotor seizures and anterior temporal lobe foci on surface EEG (Morris, 1950, 1956). Morris's resections were remarkable in encompassing the medial temporal structures (uncus, amygdala, and 2–4 cm of the anterior end of the hippocampus) as well as the lateral cortex. Initially, Morris had based his resections upon ECoG, but found, as Bailey and Gibbs had, that epileptiform discharges invariably occurred diffusely within the temporal lobe, including the medial structures. Consequently, he took the bold step of abandoning intraoperative electrophysiological studies all together, simply performing “standard temporal lobectomy” in all patients with good results. As Almeida et al. discussed, there are ambiguities in Morris's papers such that it is not clear whether his earliest resections (i.e., pre-1950) included the medial structures.
Of 68 temporal lobe operations performed by Penfield between 1939 and 1949, the excisions were focused on the anterior and lateral temporal lobe, the uncus being excised in 10 cases (15%) and the hippocampus in only two (3%) (Penfield & Flanigin, 1950). In the 3 years subsequent to 1949, Penfield performed 81 temporal lobe operations in contrast to 68 in the preceding 10 years (Penfield & Paine, 1955). Furthermore, the uncus, amygdala, and hippocampus were routinely removed as well as the anterolateral temporal lobe anterior to the vein of Labbé, that is approximately 5 cm posterior to the temporal tip. Additionally, Penfield reoperated on “a number” of his earlier temporal lobe patients in order to excise the hippocampus, sometimes with conversion of failure to success (Penfield & Jasper, 1954). Although, Penfield ascribed this development to his recognition of incisural sclerosis as the commonest cause of temporal lobe epilepsy (Earle et al., 1953) it is not clear that hippocampal/mesial temporal sclerosis was histologically identified in Penfield's surgical specimens. In fact, it is generally accepted that this was not possible before Murray Falconer at the Maudsley Hospital developed en bloc resections that maintained the structural integrity of the mesial structures (Falconer et al., 1953).
It may not possible to be categorical as to who performed the first temporal lobectomy with inclusion of the medial structures. It does, however, seems clear that the notion of determining temporal lobe resections for psychomotor epilepsy by neurophysiologic rather than structural abnormality is more clearly attributable to Bailey and Gibbs and that Morris deserves at least equal recognition as Penfield, Bailey, and Gibbs in developing a standard operation that routinely included the medial temporal structures.
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