M Gazi Yasargil. Father of Modern Neurosurgery
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.246286
Source of Support: None, Conflict of Interest: None
Author : Larry Rogers
Year : 2015
Pages : 533
Publisher : Koehler Books, Virginia (USA)
Evolution of a surgical specialty follows genesis of a concept, an idea and a purpose, with a soul-searching query: Can it be done, or, can it be done better? The progenitor of such an idea often ploughs a lonely furrow, faces derision, battles failures and the ideas are initially junked by the ‘status quo'-ists. Neurosurgical pioneers were such giants, who dreamt with their eyes open, determined to see their aspirations realized. If Drs. Victor Horsley and Harvey Cushing were able to carve a niche in the medical arena for the distinctive field of Neurological Surgery, there were others who continued their good work, adding experience and improving outcomes. Almost half a century after Dr. Cushing, Dr. Mehmet Gazi Yasargil overcame the inertia that had crept into the field of Neurosurgery of those times, giving it a fresh breakthrough and direction, for which he richly deserves to be ranked among the greatest of Neurosurgeons.
Dr. Larry Rogers, MD, an Army surgeon who saw action in Vietnam, and was a resident of Dr. Yasargil in 1973, has brought out this superb biography of his mentor. The book evokes in the readers a sense of awe for Dr. Yasargil, who was born in a cave in the erstwhile Ottoman Empire (the modern state of Turkey), while the country faced an immense political churning. Dr. Yasargil's family was lucky to have experienced the first flush of modern ideas under the founder of Turkey, Mustafa Kemal Atatürk. Experiences of his early childhood, especially his early affinity for science and arts, coupled with a burning desire to educate himself, led to his moving away from his family before he was twenty years old. He went to Germany and Austria, doing odd jobs like being an assistant to nurses, bandaging the war-wounded, and finally managing to enroll in a medical school in Switzerland. An interesting episode of his initial experience as a surgical trainee is highlighted. “He would never forget his first experience on the operating theater. A young man had a devastating lower extremity wound. His knee was mangled and bloody from shrapnel, bone exposed, his leg flailing from his lower thigh. He was wide awake, screaming in agony as the head nurse completed the amputation. Gazi held the man's leg and foot, still in a long heavy boot and grimy, bloody pants, as the nurse ligated the artery and veins, then sawed through the femur. When he felt the full weight of the devitalized extremity in his hands, though, he stood dumbfounded, trembling as he clutched it, paralyzed in terror, pleading with nurse for guidance. He could not speak.
“Go! Put it there, idiot,” the head nurse screamed, her face a study in professional detachment, pointing at the garbage pail nearby.
It was too much for him to comprehend. He only stared at the lifeless leg. The act of surgery hadn't affected him, but the idea of discarding as garbage the part of that man's soul residing in his leg shook Gazi.”
Graduating as a surgeon, he was constantly trying to improve his surgical skills, especially performing micro-anastomosis on small blood vessels and doing autopsies. He even did a stint in psychiatry, and the autopsy of one of his psychiatric patients revealed a brain tumor. Another purpose in his life ignited since that moment, and he became determined to specialize in Neurosurgery. He, therefore, went to Professor Hugo Krayenbühl in Kantonsspital (University Hospital), Zurich. Under Professor Krayenbühl's tutelage, Dr. Yasargil mastered the techniques of Neurosurgery, as performed by Professsors Cushing, Cairns and Walter Dandy. Considerable time, however, was spent in the animal laboratory, learning vascular anastomosis and pioneering the concepts of cerebral angiography.
Extensively researched and brutally honest, the biography is not only chronicles the life and times of Dr. Yasargil, but also the trials and tribulations of a pioneer. The characters, places and events stand out in their true form, becoming alive as soon the reader becomes a part of the narrative. Dr. Yasargil had to face derision at the hands of the established titans, and his dogged perseverance led to the development of a unique personality. Thus, he would accept nothing but the best, pursuing his dreams with an uncompromising commitment, and having the keenness to develop skills that were matching his own. In the process, he earned a series of sobriquets of being difficult, temperamental, egoistic and one who demanded absolute loyalty. Following his pathbreaking description of the cerebral angiographic anatomy, he perfected the percutaneous carotid puncture for cerebral angiography, but only after he had accidentally punctured the vertebral artery and was shocked to see the angiography of posterior circulation. The incident is beautifully described in the book, “That's what he thought he had done, what he was trying to do. In actual fact, the needle tip had slipped past the carotid artery and had punctured the vertebral artery, much deeper in the neck.
He was shocked when he saw the X-ray images. He examined them first in the dark room before the developing chemicals had dried. The middle cerebral and anterior cerebral arteries were not apparent as expected. He saw the basilar artery instead, as it lay against the brainstem, along with the posterior cerebellar and superior cerebellar arteries.
He had injected the vertebral artery! He had never seen a vertebral arteriogram before.
Immediately he took the X-ray image to Krayenbühl. “Look,” he exclaimed. “The vertebral artery!”
Krayenbühl stared at the film in disbelief. It was true. The vessels of the posterior cranial fossa were clearly opacified.”
Working with Professor Krayenbühl, his skills in microneurosurgery painstakingly developed. His extensive work in the animal laboratory transformed his surgical conduct, and developed his immense patience in conducting these procedures (discarding the concept of ‘a good surgeons always being fast'). He further added the twin concepts of operating under a bright, cold light and a sharp adjustable magnification. These innovations were accompanied by standardizing the pterional approach for most of the lesions in the supra- and parasellar locations, designing modifications in the operating microscope to make it specifically suitable for Neurosurgery, designing several microneurosurgical instruments including the bayoneted fine-tipped instruments, the Malis bipolar forceps (Dr. Leonard Malis was a lifelong friend of Dr. Yasargil) and an adjustable and non-traumatizing brain retractor system, which was given the name of his daughter, Leyla. A visit to various centers in the United States further broadened his horizons, as well as led to his focusing on filling the lacunae in the field of microneurosurgery. Rogers meticulously describes his interactions and expectations from the American neurosurgeons and the latter group's skepticism regarding the introduction of microsurgery. Nevertheless, his dogged perseverance towards the development of microsurgery paid off, with the industry pitching in with an operating microscope and microsurgical instruments. What followed was a stream of neurosurgeons from across the world wanting to be trained in microneurosurgery under him, and a wealth of microneurosurgical approaches and procedures being introduced. This has been well brought out in the section of the book that describes how the well-known legends of Neurosurgery have been inspired by his innovations and surgical skills: 'On the advice of Northwestern University's venerable Dr Paul Bucy, Bob Spetzler spent his first three months at the Kantonsspital as medical student in 1970. His first taste of microsurgery was watching Yasargil, with his newfangled surgical microscope, attempt to improve on a pituitary tumor resection at the request of Professor Krayenbühl. Even with no surgical experience, young Spetzler was stunned by the visual spectacle of Yasargil mobilizing and removing tumor remnants. After seeing a few more cases, he understood that excellence in neurosurgery could best be achieved by emulating every move Yasargil made. Five years later, with some seasoning as neurosurgical resident under his belt, he returned to Zurich to get on with the serious business of striving “to the best of my ability to copy every nuance of Yasargil's genius.” Within a few years, Spetzler would rise to the top level of new microneurosurgeons forging the future of neurosurgery.'
As his friendship blossomed with other doyens of Neurosurgery like Drs. Ossama Al Mefty and Peter Jannetta, microneurosurgery, especially surgery for intracranial aneurysms, the teaching of microanatomy (especially pertaining to the subarachnoid spaces and cisterns), and the excision of spinal arteriovenous malformations became his passions in life. The episode of the initial cipping of an aneurysm and his feeling at the successful conduction of the procedure are very described: 'Quickly he removed the cotton pledgets Krayenbühl had applied and began to dissect the aneurysm's neck free of adhesions. In a minute or so, the full extent of the neck was visible. Carefully, he slipped the tines of a clip into the aneurysm's neck and released its spring. Instantly the aneurysm slumped to one side, limp. In another few seconds, he removed the temporary clips and watched the internal carotid artery refill with blood, the aneurysm still limp, now no longer a threat.
Jainini awake in the recovery room as though he had undergone the simplest of operations. Krayenbühl's happiness soared to new heights. And Gazi Yasargil, and microsurgery had cleared a very important hurdle. In the months that followed, Krayenbühl would assign him more and more difficult operations. He had only to bide his time.'
The best part of the book is definitely the honest description of Dr. Yasargil's disappointments and his unhappiness with himself at not being able to think of the concepts that Dr. Vinco Dolenc propounded in the field of cavernous sinus surgery and the exposure of basilar top aneurysms. This is well brought out in the following excerpts: ’ “Sir, my friend has brought us a patient with a basilar bifurcation aneurysm,” Dolenc explained. “I couldn't tell you about him earlier because we were working.”
“Okay. Fine. Where is the patient?”
“He is in the intensive care unit,” a nurse replied.
“Where are the X-rays?”
After examining the arteriogram on a nearby bank of view boxes, Yasargil concluded that the aneurysm was too difficult, not at all amenable to surgery. The lesion was too large, leaving insufficient space for dissection. He was convinced that the man would die if an operation was attempted.
“Okay,” Dolenc replied. He was not surprised. It was indeed a difficult aneurysm. “Sir, would you mind speaking with the patient's family?” They were fully aware of Yasargil's stature. To hear it from him would help them accept the fact that nothing could be done for their loved one.
Yasargil was as sensitive with the man's family as he was with every patient's family. He shook hands with each of them, bowing and looking into their eyes. “The surgery is too dangerous,” he said softly. “It is simply not possible.” Then, as he glimpsed Dolenc in the background, his tone changed. “of course, that is only my opinion. This man may view it differently. He just might try it. He is a fool if he will.”…
They operated late that afternoon. With Yasargil standing behind him, Dolenc slowly drilled away the anterior clinoid process on the right side, then the posterior clinoid process, finally one-half of the adjacent dorsum sellae, eventually achieving dissection space beneath the aneurysm. He had employed the technique himself a number of times, but had not been able to convince anyone else to try it…. Finally, as the aneurysm loomed into view after the cavernous sinus was opened, essentially filling the TV screen, Dolenc said, “Professor, would you scrub now. I think you should take over.”… “I can't believe how easy it was,” Yasargil said. He sounded almost disappointed. “Removing the bone gave me so much more room. I didn't think it was possible.”'
The biography brings out all facets of Dr. Yasargil's professional and personal journey, and is unsparing in detailing even his personal life, which was often stressful. Rogers has brought out the professional and human aspect of Dr. Yasargil perfectly, placing him on a pedestal with great neurosurgeons of the twentieth century, and as a pioneering spirit in developing the modern concepts in microneuroanatomy and microneurosurgery. The book is an outstanding biography of a neurosurgical giant that will inspire generations of neurosurgeons to achieve excellence, to be inquisitive, and to persevere till one achieves the desired level of perfection.