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Towards the close of the 20th century, two leading thinkers on either side of the Atlantic – Lyall Watson and Lewis Thomas - were led to generalize that the greatest discovery of the 20th century has been that of the profundity of human ignorance. Needless to emphasize, the state of ignorance would be profounder in a field that deals with the fragile and mysterious neuraxis.
In Socratic academia, the lessons, and discussions, were peripatetic – the teachers and students strolled together and raised questions and forged answers. A Mexican creed is "Asking we walk" Set below in brief is peripatesis off the beaten track by viewing some aspects of neurology and neurosurgery through unconventional lenses. The attempt has been not so much to claim knowledge but to discover and present hitherto unrecognized features.
In Nature's infinite book of secrecy
A little I can read.- William ShakespeareAntony and Cleopatra (Act 1, Sc 2, 11)
The Indian sage, Adi Shankaracharya aphorized, circa 9th century A.D. that if knowledge can be infinite, so can ignorance be. Blaise Pascal, 17th century A.D. metaphorized that knowledge is the inner surface of a sphere, whose outer surface is painted with ignorance. The more you know, yet much more you know not.
The knowledge of one's ignorance spawns admiration and a sense of wonder. What a sense of wonder brings in its wake is the double gift of humility and reverence, an affective state that finds its expression in philosophy. Alfred North Whitehead, after a full academic career of 40 years as a mathematician in England, moved to Harvard to occupy the chair of philosophy. And he explained his personal evolution thus: "Philosophy is the product of wonder… Philosophy begins in wonder. And at the end, when philosophic thought has done its best, the wonder remains." Philosophy, the dictionaries assert, is scientia scientiarum, the science of all sciences. Today, modern physics bristles more with philosophy than with physics. A similar philosophic bent can be accorded to the art of neurosurgery and the field of neurosciences. A noumenal approach going well beyond the phenomenal is overdue in the neuraxial field.
Ralph Millard's classical tome has been thoughtfully titled Principlizing Plastic Surgery. What follows is an attempt at doing so for the rapidly evolving discipline of neurosurgery. While technology surges ahead, the philosophy of neurosurgery should not lag behind.
Shakespeare's famous aphorism that "A rose by any name smells as sweet" fails to apply in many areas in medicine ailing from aneusemantics,_or improper terminology. To the traditionalists who would rather rest content with age-old, "accepted," hackneyed terms, it needs to be conveyed that a term, like the proverbial tip of the iceberg, should divergently evoke the whole conceptual substratum on which it rests, and convergently should connote the same conceptual backup. So it behooves a medical thinker to strive to replace an ill-fitting term by one less ill-fitting, euphonious, and evocative. As Lavoisier expressed:
"As ideas are preserved and communicated by means of words, it necessarily follows that we cannot improve the language of any science without, at the same time, improving the science itself; neither can we, on the other hand, improve the language or the nomenclature which belongs to it. However certain the facts of any science may be, and however just the ideas we have formed of these facts, we can communicate false impressions to others while we want words by which these may be properly expressed."
Generalizing, one can daresay that scientific understanding evolves to spawn new terms which in turn improve the science itself.
While at eusemantics, let us go to a self-evident, if banal, issue of a so-called bony foramen in the craniospinal set up. The beguiling description in Gray's Anatomy (and all other anatomic/neurosurgical texts) that the mandibular nerve passes through the foramen ovale and the vertebral artery through the series of foramina tranversaria loses sight of the fact that in vertebrate embryology, the nerves/vessels arrive first and the bones almost as a relaxed afterthought, much later. The logical, epigenetically impeccable statement would be that the foramen ovale forms round the mandibular nerve, much as the foramina transversaria do round the preexisting second part of the vertebral artery. This slight welcome twist in anatomic description removes the all too common error of CIFOTH - Cart in Front of the Horse. The deltoid muscle precedes the humerus, and the latter if at all should seek attachment to the deltoids, which in reality it does not. Nothing is attached to bone and vice versa, bone being overlaid on preexisting nerves, muscles, ligaments, and vessels. Bones form around nerves-n-vessels a sleeve, a ring, or a fissure.[1‐17]
Likewise, the term cerebrospinal fluid (CSF) is too facile and too abrupt. Neuraqua, as a neologism, sums up the vast extent of this precious fluid, conveying its existence within, through, and around the neuraxis, extending well beyond it and most commutative with the neuraxis itself. The neuraxial tissue can be seen as configured neuraqua, which in turn is fluidized neuraxial tissue, both communicative and commutative with each other.
We are now justified in questioning – and suggesting a replacement – for the term craniovertebral junction. A junction conveys static juxtaposition of similar or dissimilar parts. There is no allusion therein to the co-operative role of disparate parts. How about the phrase craniovertebral coalition! The term is pregnant with anatomic distinctiveness and functional coherence. World over, democracies run through coalitions, where avowed communists (and the like) team up with manifestly capitalists (and their like) to execute the common task of running a nation. Political coalitions are necessarily chameleonic and opportunistic, engaged more in self-serving than serving the cause they agreed to coalesce for. Craniovertebral coalition is rock-like in its loyalty and represents a marriage as old as humankind.
We can now sojourn through some new physiological, pathological, microbial, immunological, and therapeutic avenues. The cavernous sinuses – corpora cavernosa cranii – are retro-ocular lakes of blood that are specially designed to maintain in the eyes a piezostasis of its fluid systems that fluctuate the least with pressure changes in other venous sinuses. They are endowed with a network, lined, like in the corpora cavernosa caudii, with cells that secrete agents that keep the blood fluid despite stasis and sustained high pressure. (How many of us appreciate that the human phallus during erection has a pressure of over 1100 mmHg, which heightens during sexual activity solo or shared!)
The meninges – maters – can admirably be maternalized, for their many a role not generally appreciated. Neuraqual studies show that the pia-arachnoid and the choroidal plexuses have a servomechanism that steps up neuraqual production when it is being lost, and switches off its secretion when the heightened neuraqual pressure so commands. The symphony between the meninges and neuraqua gives the neuraxis a free-floating weightlessness comparable to the amnionaut called the fetus and the astronaut in the outer space.
The very appellation intervertebral for the cushion that gives the spinal column its remarkable resilience and mobility is a classic example of CIFOTHISM. By the 8th week of intrauterine life, every single "disc" is fully manifest, without a spicule of bone in the vertebrae, which develop later. Further, each disc is coplanar with its somite, compelling you to declare that each vertebral body is interdiscal, and each so-called intervertebral foramen fashions itself around the preformed spinal nerve which in no way "enters" the foramen or "exits" therefrom. The biplanarness of a "disc" has to be replaced by the 3D nature of it, urging you to call it a cushion of the back, or the pulvinot. Its collagen dutifully records the age of the person. The disc does not "degenerate" but exhibits changes consistent with age, as graying hair does. To tell a person of 70 years of age that his/her pulvinot is 70 years old is far less iatrogenic and insulting than to condemn it as degenerate.
The impartiality with which Nature treats craniovertebral coalition and its caudal counterpart is best gleamed from the fact that the so-called lumbosacral spondylolisthesis has its counterpart in TOOL – transatlantic odonto occipital listhesis. Both are "normal," for many a person with image verification of the listhesis at either end carries on remarkably undiseased through a long life. Both TOOL and LOSS (lumbar over sacral slip) illustrate a great principle – INNTOE (in nature no terror of error).
The neuraxial cytogalaxy deserves critical appreciation. Its neuronal components are the postmitotic, perennial, indivisible cells that not dividing normally cannot do so abnormally and hence cannot tumorize or cancerate. The neurons are exceptionally large cells, for the so-called nerves, cranial or spinal, are mere extensions of the body of these cells, representing as it were the neuronal veripodia (against the pseudopodia, say, of the amoeba). The so-called nerve tracts in the craniospinal axis are nothing but integral parts of neurons, making the neuraxis a gigantic syncytium, where all is but cells and no fibers. A single neurone in a whale or a squid may be 50–100 ft long. The neurons in the lumbar posterior root ganglion are 6"–8" longer than the heel-to-head height of the individual. The gigantic nature of squid neurons has been a source of Nobel awards for Sir John Eccles and his likes.
The neuroglial cells outnumber neurons tenfold. They are essentially not interneuronal glue (hence called neuroglia) but perineural to form neuron-tight insulation, and hence fit to be called insulocytes. The smaller varieties of "neuroglial" cells are intermediates between the neurone's nutrition and the proximate capillary, hence better called intermediocytes. The real glue that separates a neuron from another neuron or neuroglial cells is the universal and ubiquitous neuroqua. A more preferable name for neurogliocyts would be clinocytes (from klinos = bed) for they form a huge bed in which the neurons are clothed, rested, and nourished.
The universal commonness of head-injury and the equally surprising uncommonness of brain infections and brain abscess have enormous heuristic value. The neuraxis turns out to be highly resistant even to microbes directly inoculated into it (uncommonly) through experiments and commonly through accidents. This deliberate nonreactivity on the part of the brain to the manifest presence of microbes is its faculty of immunity. As and when a brain abscess does occur, brain exhibits reactivity that concerts with body's sense of integrity and immunity to expel the contents to the exterior, after which the faculty of reparativity and restorativity pitch in to restore the brain to status quo ante as best as possible. Abscessing and pus formation turn out to be Nature's great inventions for promoting survival in the midst of the microbial ocean that outweighs the total animal biomass – man-to-whale – by a factor of 100.
Each of us carries a microbial cover weighing 2.2 kg. Each of our body cells is outnumbered by the microbes at least ten times. This must drive home the lesson that friendship between microbes and man is a rule, enmity an exception. The so-called opportunistic infections are in reality iatrogenically opportunized infections. Our operative, antibiotic, and anticytotic adventures compel the commensals and symbionts to be driven into areas of the body that are not designed to house them. The microbes thus become opportunized and are in no way opportunistic – a game best played by our politicians and rulers. The much-maligned fungal infections are traceable to iatrogeny rather than fungal infectivity. Paul Davies in his classic The Fifth Miracle traces human ancestry not to monkeys but to microbes. A fungal cell is the earliest karyotic cell that the earth has had and for all you know if the prokaryotic microbes are our grandfathers then the karyotic fungi are our parents, too evolved and too helpful to be condemned.
Mankind, in its unbridled hubris, continues to maim humans through wars, weapons, vehicles, and machines in the vain hope that one day medical ingenuity will end in fruitful repair of neuraxial wounds with restoration of sensory and motor loss. The hope has been particularly exacerbated by the advent of stem cells as a panacea just waiting to be discovered and put to varied use.
At the Lister symposium on Wound Healing at Glasgow (1970), Bullough, the Chairman, concluded it on a fourfold note
Ambroise Pare's 16th century prayer – I dressed him, and God healed him – is as relevant today as it was many a century ago.
Wound healing in the neuraxis or elsewhere is a bridge-in-the-gap enterprise that necessitates cells doubling rapidly to fill in the gap, through multiplying fibroblasts, anglioblasts, epidermal/mucosal cells, or in some cases parenchymal cells. Neuroglia (clinocytes) can multiply, neurons cannot. Any neuraxial wound healing is a blessing endowed by angioblasts, fibroblasts, and clinocytes. It is the neuronal handicap of unmultiplicability that has set us searching for stem cells as a possible solution, accompanied by a lot of hype and hoopla, especially through the media and some undiscerning medical men.
What we have overlooked is the so-called immunological (more correctly reactivological) factor. When the thymus is maturing in utero, dividing cells from all over the fetus, present their credentials to the thymus, whereby it eliminates the lymphocytic clones that may unleash possible reaction against these cells in future. The lymphocytic cells so eliminated are the forbidden clones that the Nobelist Burnet first postulated in 1947, and were later proved to be so by Medawar, both getting the Nobel in 1960. Neurons being indivisible cannot placate the fetal thymus, which thus always harbors clones that can let loose a vicious reaction against one's neuronal cells to occasion the so-called auto-immune encephalomyelitis. The net outcome of this situation is that should the neuronal protein be leaked into circulation, while a neuraxial wound is healing, it can cause damage much greater than that inflicted by the injury. This is evident from sympathetic ophthalmitis where injury to one side uveal tract can lead to the reactive destruction of not only that eye but even the other uninjured eye. In most likelihood, Nature while repairing a neuraxial wound, first sees to it that no neuronal multiplication occurs whereby the thymus may have a taste of the neuraxial protein to precipitate a pan neuraxial crisis. Can it not be the reason why no neuron has direct access or proximity to capillary circulation, the two being widely separated by intermediocytes (or the smaller neurglial cells), the stem cell dream is likely to remain a dream, and that too for the right reasons.
We can conclude this sojourn by the humility that must guide neurosurgical therapies. Sir Harold Gillies and Ralph Millard, in their classic The Principles and Art of Plastic Surgery, have aphorized that not much has been gained in the art of surgery after the first abscess was incised by a flint stone, and the first wound sutured by a horse hair. We today have faster moving drills and saws, and unbelievably sophisticated imaging and navigation systems but our results do not excel those of pioneers like Macewan, Horsley, and Cushing, regardless of the backup of antibiotics. Our chemotherapy and radiotherapy are unashamedly indiscriminating cytotoxic agents that kill more friendly cells than the assumed foe cells. Our gamma-knife is a different modality of cutting but no way does it evoke a response from the neural tissue any different from what an ordinary knife does. Neurosurgery is more in need of humility than hubris, modesty than machines, ideas rather than imaging techniques.
The term ethics has had a chequered etiology, coming as it does from Sanskrit Svadha, meaning a self-image, a clear conviction within that prevents you from doing anything wrong even when you are not being watched, monitored, or policed. Eric Ericsson (a famed psychiatrist), and the exponent of Gandhi's Truth, summed up ethics by quoting Talmud - Do what you would be done by. And do not do unto others what you wouldn't do to yourself or your kith and kin. Vedantic teaching has underscored this objectivity time and again. Our left brain may rejoice in our worldly successes but our older, wiser, right brain would rather opt for a clear unburdened conscience, and a soft-pillow offering undisturbed sleep, so that one is free from the need of a drug or a bottle to assuage one's conscience. For our own sake, let us be ethical.