STEREOTACTIC VIGNETTES

PERSONAL MEMORIES OF THE HISTORY

OF STEREOTACTIC NEUROSURGERY

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Lauri V. Laitinen, M.D.,
Ph.D.
Emeritus Neurosurgeon,
Geta, Finland
Reprint requests:
Lauri V. Laitinen, M.D., Ph.D.,
FI-22340 Geta, Finland.
Email: lauril@aland.net
Received, December 11, 2003.
Accepted, August 3, 2004.
THIS ARTICLE SUMMARIZES the author’s personal memories of the first 50 years of
stereotactic neurosurgery. The author provides a short summary of his education and
his introduction to stereotactic neurosurgery. Some great pioneers of the field who
played an important role in his training, including John F. Gillingham, Jean Talairach,
Guillaume Guiot, Edvard Kandel, Hirotaro Narabayashi, Irving Cooper, Henry Wycis,
and Lars Leksell, are described in detail. The author then discusses his own work in the
treatment of movement disorders, chronic pain, epilepsy, and intractable psychiatric
disorders. For his contributions to the field, the author received the Spiegel-Wycis
Medal of the World Society for Stereotactic and Functional Neurosurgery in 2001.
KEY WORDS: History, Pioneers, Stereotactic neurosurgery

Neurosurgery 55:1420-1429, 2004 DOI: 10.1227/01.NEU.0000143145.00880.F4 www.neurosurgery-online.com

I
n August 1947, when I was 18 years old, I entered the
Medical Faculty of Helsinki University. Two years later,
Lars Leksell published the first article on his stereotactic
instrument (20). When I became aware of his discovery, it was
easy to understand that, for the first time in the history of
mankind, deep brain structures could be explored through a
burr hole in the cranium. Since childhood, I had been fasci-
nated by technical things, and the stereotactic technique began
to interest me. At that time, I was not aware of the innovative
paper by Spiegel et al. (24) published in 1947.
I received my M.D. degree in 1953 and training in hand
dexterity in pediatric and plastic surgery at the Children’s
Hospital of Helsinki. In 1956, I received my Ph.D. degree after
a series of animal experiments and clinical work on cranio-
synostosis (13). My training in the Department of Neurosur-
gery at Helsinki University began in April 1956.
In the meantime, but unknown to me, Leksell had continued
his stereotactic work. This is why I moved to Århus, Denmark
in 1957, where Dr. Richard Malmros was planning to begin
performing surgery for parkinsonism using Irving Cooper’s
technique. For some reason, he postponed the plan, and I
worked for 12 months in general neurosurgery. After 2 more
years of an internship in Helsinki, I worked at the National
Hospital for Nervous and Mental Diseases in London, En-
gland, from 1960 to 1961. Even though the hospital had not yet
started offering stereotaxy, several neurosurgeons in London
were performing thalamotomy, and I often went to watch
them. The most important thing for me in London, however,
was to follow the work of John Andrew and Sid Watkins on
the thalamic atlas (2). In London, I decided to definitely con-
centrate on stereotactic neurosurgery.
Toward the end of my tour in England, I spent 2 weeks in
Edinburgh to learn John Gillingham’s stereotactic technique.
His instrument, also called the Guiot-Gillingham frame, was a
little cumbersome because it required a two-stage operation,
carried out on 2 consecutive days. His technique used an
occipital sagittal approach parallel to the midplane of the
cranium. The lateral positioning for a ventrolateral thalamot-
omy was 16 mm from the midline; this was a positive feature,
because both the ventrolateral thalamus and medial pallidum
could be reached through the same trajectory tract. John
Gillingham proved to be a real gentleman. He and his associ-
ate during that time, Ted Hitchcock, became my friends for
life.
Soon after my return to Helsinki in 1961, I began to operate
on parkinsonian patients using Cooper’s primitive frame. My
first international stereotactic paper was published in 1963. It
dealt with thalamotomy and pallidotomy for spasmodic tor-
ticollis (14). Because I was the only stereotactic neurosurgeon
for the 4 million inhabitants of Finland, many parkinsonian
patients needed my help. Throughout the 1960s, I performed
as many as 200 thalamotomies a year.
In the 1950s and 1960s, Freiburg, Germany, was the leading
European center of stereotaxy. In 1963, I spent 4 months in
Freiburg. The chief of the unit was Dr. Traugott Riechert. He
had famous assistants, such as Rolf Hassler, Wilhelm Umbach,
and Fritz Mundinger. Up to five thalamotomies were per-
formed per day. One day before surgery, the patient under-
went lumbar pneumoencephalography without a stereotactic
frame. On the next day, the Riechert-Mundinger frame was
fixed on the patient’s head, and frontal and lateral x-rays were
taken. Using bony landmarks of the cranium, the surgeon

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tried to transfer the ventricular landmarks to the frame. The
task was often difficult, because the anterior and posterior
commissures were rarely visualized on the same x-ray. Sec-
ond, it was difficult to position the head in the same way for
the pre- and postoperative x-rays. There was no radiologist on
the team. All this led to poor accuracy in targeting. In Scan-
dinavia, I had been used to first-class radiology, and, in this
respect, Freiburg was disappointing for me. However, the
autumn in the beautiful upper Rhine Valley was a great plea-
sure. In the afternoons, Fritz Mundinger often took me and the
visiting Indian neurosurgeon Dr. Ram Ginde for wine-tasting
tours to famous caves on the German and French sides of the
Rhine.
Directly after my stay in Freiburg, I moved to Paris to visit
two leading French stereotactic units at the Hôpital Foch and
Hôpital Sainte-Anne. Dr. Guillaume Guiot at the Hôpital Foch
worked with Madame Denise Albe-Fessard. They introduced
me to microelectrode recording (1). At the Hôpital Sainte-
Anne, Dr. Jean Talairach, with his electrophysiologist, Dr.
Bancaud, was performing surgery for temporal lobe epilepsy.
They taught me how to use chronic depth electroencephalo-
graphic electrodes to locate deep epileptic foci. Guiot and
Talairach were wonderful hosts. I am deeply grateful to them.
In fact, I found that the few weeks in Paris were more impor-
tant for my future than the months I spent in Freiburg.
After my return to Helsinki in January 1964, I bought a
Riechert-Mundinger frame. I soon found that the phantom-
based instrument was not suitable for reaching multiple tar-
gets, which would have been required for enlargement of a
stereotactic lesion in a particular direction and for implanta-
tion of multiple depth electrodes. This forced me to design a
new frame (Fig. 1). The aim was to make use of the advantages
of the Leksell and Riechert-Mundinger frames but to omit
their shortcomings. I had the new frame completed in 1965;
because it worked well and several visiting colleagues wished
to buy it, a small serial manufacturing endeavor was started in
1967. A report on the frame was published in 1971 (15).
In 1968, I designed a new model of the frame. Initially, it
was intended to be a gamma knife. Unfortunately, the Depart-
ment of Oncology at Helsinki University did not understand
the innovative value of radiosurgery, and the instrument was
never used for this purpose. Two examples of the instrument
in which the coordinates were displayed electronically were
manufactured and sold for ordinary stereotactic surgery.
FIGURE 1. Photograph showing Laitinen’s stereoguide.
NEUROSURGERY
HISTORY OF STEREOTAXY
HIROTARO NARABAYASHI
In August 1965, Dr. Hirotaro Narabayashi visited me in Hel-
sinki. I knew him from his articles on thalamic surgery for
Parkinson’s disease and cerebral palsy as well as from his articles
on amygdalotomy for epilepsy with aggressive behavior. During
his visit, he spent 2 days at our cottage on the Gulf of Finland
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(Fig. 2). He was enthusiastic about night torch fishing. On his last
day, when he was already dressed for his flight to the Second
International Symposium on Stereoencephalotomy in Copenha-
gen, he went out for fishing during the day. Standing alone in a
small boat, he tried to harpoon a pike. A strong jerk made the
boat flip over, and he had to swim to land. Still wet in his best
suit, he walked into the cottage, where my wife tried to dry his
clothes and ironed them. His suit was still quite wet, however,
when he boarded the Copenhagen flight 2 hours later. I flew to
Copenhagen later in the evening to meet Dr. Narabayshi at a
reception. His suit was still quite wet. After his visit to Helsinki,
we became good friends.
In April 1966, Dr. Narabayashi invited me to Japan. On my
arrival in Yokohama Harbor after 2 nights’ travel on a Soviet
steamer from Nahodka in Siberia, two geishas welcomed me
with flower garlands. They showed me into a flower-
decorated Opel Kapitän car and escorted me to my hotel in
Naka-Meguro, Tokyo. Dr. Narabayashi, who came from a
wealthy family, was at that time one of the few Japanese
doctors who had a car. He not only had a big German car but
a private driver. The Gajoen Kanko Hotel had been used as a
U.S. military hospital after the World War II. Later on, it had
been rebuilt with wings in the original Japanese and Western
styles. I chose the Japanese style and soon got used to sleeping
on the tatami.
My 6 weeks with Narabayashi at his private neurological
clinic in Naka-Meguro were most rewarding. Dr. Narabayashi
had a heritage in surgery. One of his ancestors, Dr. Chinzan
Narabayashi, had founded a school of surgery in the 17th
century (7). Hirotaro Narabayashi had started his medical
career in neuropsychiatry. In 1949, he had become interested
in stereotactic surgery and designed his first frame. His
private neurological clinic had 10 beds, an operating theater,
FIGURE 2. Photograph showing Hirotaro Narabayashi with Laitinen’s
two children in 1965 on a remote islet of the Gulf of Finland.
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LAITINEN
and a combined neurophysiology-physiotherapy room.
Narabayashi’s stereotactic frame was somewhat similar to
Cooper’s Model II frame, being semistereotactic; the brain
target could be reached only after repeated angular
adjustments of the probe direction, using frontal and lateral
radiographic controls. This deficit was compensated for by
first-class neurophysiological corroboration using semimicro-
electrode recordings of the target area. Narabayashi’s pa-
tients came from diverse areas of Asia. Most of them had
Parkinson’s disease or cerebral palsy. He also carried out
amygdalotomy for violent behavior of oligophrenic or epilep-
tic origin. In addition to his private surgery at the neurological
clinic, Narabayashi was professor of neurology at the Jun-
tendo Medical School. Originally, he was a specialist in psy-
chiatry and neurology. His introduction to neuropsychiatry
was thus similar to that of Ottfried Foerster of Breslau,
Georges Schaltenbrand of Würzburg, and Albrecht Struppler
of Munich.
Narabayashi’s hospitality was generous. Once a week, he
invited me to a geisha dinner at his favorite teahouse. When I
went to check out of the Gajoen Kanko Hotel after staying
there 7 weeks, the smiling cashier told me that the bill had
already been paid. After my stay in Tokyo, Narabayashi pro-
posed that I should have a holiday for 1 week at a traditional
Japanese inn in Kyoto. Some years earlier, he had operated on
the son of the famous geisha Kishida for epilepsy. The inn had
only one guest at a time. Four generations of geishas served
me. Kishida took me on daily sightseeing tours inside and
outside Kyoto, twice to Micador geisha theater performances,
and to dinners at the eminent teahouses of Ponto Cho and
Gion. At the end of my stay, when I wanted to pay for the
week’s extraordinary service, Kishida told me that everything
had already been paid for. Such was the amazing extent of this
great Japanese man’s hospitality.
Dr. Narabayashi was one of the most frequent speakers at
international meetings (Fig. 3). When he passed away on
March 18, 2001, stereotactic neurosurgery lost a great pioneer.
EDVARD KANDEL AND THE SOVIET
UNION IN THE 1960s AND 1970s
When planning my trip to Japan in 1966, I decided to travel
through the Soviet Union. First, I wanted meet with Professor
Edvard Kandel in Moscow. Second, I wanted to get a correct
FIGURE 3. Photograph showing Laitinen (left) with Hirotaro Narabayashi
(right) and Blaine Nashold (center) in 1981 in Umeå.
1422 | VOLUME 55 | NUMBER 6 | DECEMBER 2004
impression of Siberia, the Asian part of the Soviet Union,
which the Communist propaganda claimed to be the paradise
of the world.
I took a night train from Helsinki to Moscow, where an old
ambulance with an elderly female driver was waiting for
me in the morning. She took me to the neurological clinic
in Volokolamskoye Chaussee, the historical road used by
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Napoleon’s army and planned to be used by Hitler’s army 130
years later. The Russian welcome party, with a vodka and
brandy breakfast, was unforgettable. Professor Schmidt, the
head neurologist, and Professor Kandel, the head neurosur-
geon, then showed me the hospital. Dr. Kandel was born to a
Jewish family in 1924 in Riga, Latvia. After beginning his
neurosurgical career at the Burdenko Institute of Moscow, he
became the first Russian to specialize in stereotactic neurosur-
gery. He had recently left the Burdenko Institute and had
moved to the neurological clinic. He had constructed a stereo-
tactic instrument rather similar to MacCaul’s frame. For lesion
production, he used liquid nitrogen connected mechanically
via a 2.6-mm-thick, solid, thermoinsulated probe. The brain
around the probe tip could be frozen to ⫺11°C to ⫺12°C (10).
In the afternoon, the same ambulance took me to the
Domodedovo Airport for my flight over the Ural Mountains
to Chabarovsk, the capital of eastern Siberia. The Soviet pro-
paganda had praised the richness and splendid development
of Siberia. The fact was something quite different and much
worse than what I could have imagined. The main street of
Chabarovsk, which had 300,000 inhabitants, resembled a scene
straight out of Eisenstein’s Battleship Potemkin: in front of the
houses, reasonably well-preserved antique gods and god-
desses of white marble stood side by side. On the other side of
the houses, however, the timber walls, unpainted and badly
rotted, needed massive logs placed against them to prevent
the houses from falling down. A taxi driver showed me all
this. In the evening, he took me to the Ussuri River, a few
miles outside Chabarovsk, to give me a look at Red China on
the other side of the river. All along the Chinese riverside,
thousands of Mao’s soldiers formed a continuous light chain
with torches in their hands to demonstrate the power of Red
China. In 1966, relations between the Soviet Union and China
were extremely inflamed.
Another proof of Soviet misery awaited me the next day,
when I took the train from Chabarovsk to Nahodka on the
Pacific Coast. The railway station at Chabarovsk was filled
with cattle wagons inhabited by people, which extended for
several miles. A chimney on the roof and a junk heap along-
side a simple ladder to the windowless wagons indicated that
people, most likely prisoners, lived in this primitive way. My
suspicion proved true when the train passed cornfields in
which groups of men and women walked in single file, fol-
lowed by armed soldiers. At some railway stations where the
train stopped, a great number of young people begged for
cigarettes. These youngsters were probably delinquent boys
and girls from Moscow or Leningrad who had been sentenced
to Siberia for anti-Soviet behavior. Their knowledge of foreign
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 HISTORY OF STEREOTAXY

languages, including English, French, and German, gave evi-
dence of their level of education.
My second trip to Moscow took place 5 years later when I
received an invitation to attend the First International Neuro-
surgical Congress of the Soviet Union in 1971. Dr. Kandel had
asked me to talk about cingulotomy, a controversial topic,
because Stalin had forbidden lobotomy and its modifications
Henry Wycis spent a week with us. He attended my surgery
every morning. Seated behind me when I operated, he told me
about his life. He was quite happy about the long-lasting
cooperation with Dr. Spiegel.
Henry Wycis was obese and suffered from Pickwick syn-
drome. Often, in the midst of his story during my surgery, he
would suddenly fall asleep. Ten to 20 seconds later, he would

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in the Soviet Union in 1945. Notwithstanding the ban, some wake up and continue his story as if nothing had happened.
neurosurgeons had performed psychiatric surgery in the Henry Wycis often dined with us in the evenings. He liked
1960s, but they had called it “surgery for epilepsy.” sitting at the piano and playing his favorite music by Chopin
As an official guest of the Soviet Union, I had received a and Rachmaninov (Fig. 4). He also told of his yearning for his
piece of paper, a pomaga, from the Soviet Academy of Science family’s ancient home country, Poland. He was moved when
with a statement that I had to be treated in the best possible my wife gave him a piece of salt crystal from the Vilicka salt
way during my stay. All Soviet citizens were asked to help me mine in southern Poland, which we had recently visited.
whenever I needed assistance. For my cingulotomy talk, I had Henry Wycis’ poor health caused him to fall ill during his
shot a 36-mm movie demonstrating the surgery. It was return flight to the United States, and he needed hospitaliza-
dubbed into Russian. However, to test the tolerance of Soviet tion in Copenhagen. I did not get any answer to my letter to
censorship, I chose as background music Igor Stravinsky’s him a couple of weeks later. He died on June 30, 1972.
Sacre du Printemps, which I knew had been banned as being
counterrevolutionary. On the morning of my presentation, I
joked with my wife and asked her to guess which one, the MY SPECIAL INTEREST
sound or the light, would be removed from the movie. When
By the end of the 1960s, I had carried out 2000 thalamoto-
my presentation began, the chairman of the session apolo-
mies for Parkinson’s disease, pain, cerebral palsy, multiple
gized and told me that the sound system of the lecture hall did
sclerosis, essential tremor, psychiatric disorders, and epilepsy.
not work. As a result, the movie would be mute. I had to
For a while, I used microelectrode recordings during thalam-
describe the surgery in English. Dr. Igor Ilinsky translated it
otomy, but their locating value was not as good as electrical
simultaneously into Russian.
macrostimulation or impedance recordings. The impedance
When I returned to my hotel in the afternoon, where my
technique proved valuable in locating the borderlines between
wife was waiting for me, I asked the floor guard, an elderly
the white and gray matter, mainly between the internal cap-
woman, for the room key. She told me in a rude way that I had
sule and the thalamus or the pallidum. I found that a feeding
no room in the hotel. When I told her that my wife was
current frequency between 1 and 10 kHz resulted in the best
waiting for me in our room, she said: “The woman in the room
and sharpest difference (25%) between the gray and white
is not your wife. She is a fine lady. She is just now sleeping and
matter (18). Since then, in my hands, the impedance recording
must not be disturbed. You are not her husband. You have to
has been a most valuable guide to determine when the stereo-
leave the hotel immediately. If not, I shall call the police.”
tactic probe passes the borderline between the white and gray
Now, I took the pomaga from my pocket and showed it to her.
matter. This method was particularly valuable during pal-
The poor woman’s behavior changed immediately. She bowed
lidotomy, for which it was important to know, without micro-
deeply and apologized for her great mistake. She gave me the
room key and said: “Please enter quietly. The lady is asleep.”
Thus, the pomaga seemed to open any door in the Soviet
Union.

HENRY WYCIS
In 1947, Dr. Henry Wycis, together with Dr. Ernst Spiegel
and co-workers, had constructed the first human stereotactic
instrument (24). Thereafter, he carried out a large number of
stereotactic interventions for various clinical conditions. He
also held the office of Secretary of the International Society of
Stereoencephalotomy.
In September 1970, when Henry Wycis wanted to retire as
secretary of the organization, he came to Helsinki to ask me
whether I would like to take over the job. Because my appoint-
ment at Helsinki University Hospital did not permit external
work, I declined but proposed that Dr. Philip Gildenberg FIGURE 4. Photograph showing Henry Wycis playing Rachmaninov in
would be the right man to become the new secretary. 1970 in Helsinki.

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LAITINEN

electrode recordings, when the surgical probe penetrates the

pallidal margins. Unfortunately, the most common radiofre-
quency lesion generators, such as that of Radionics Inc. (Bur-
lington, MA), use a less effective feeding current in the Wheat-
stone bridge, which provides a difference of only 5% and is
useless for locating the borderlines of the pallidum.
In 1967, I was fortunate to find an excellent young neuro-

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psychologist, Dr. Juhani Vilkki, who used psychometric tests
to quantify some effects and side effects of surgery. We used
an electronic device to measure simple and complicated motor
performance time of the hands. Another motor test was the
Purdue Pegboard Test, which was excellent for measuring
dexterity of the hands. We found that a left thalamotomy
worsened the coordination of the right hand. A most striking
deterioration was observed in the assembly test of simulta-
neous coordinated function of both hands; in addition, the
assembly test of alternating movements of the hands demon-
strated worsening after unilateral thalamotomy. The harmful FIGURE 5. Photograph showing Marwan Hariz (left) and Laitinen
motor effect of thalamotomy was permanent: several years (right) in 1983 in Umeå.
after unilateral surgery, the baseline dexterity of the hands
remained slower in surgically treated patients than in age-
matched nonsurgical patients. Furthermore, the thalamotomy
patients responded less frequently to l-dopa than the patients
who had not undergone surgery. Thus, we could document
that thalamotomy always increased the bradykinesia of the
opposite hand after the tremor was gone (16).
For cognitive tests, we used the Word Fluency Test, Colored
Word Test, and Token Test, which demonstrated that a left
thalamotomy in right-handed patients caused verbal deteriora-
tion. A right thalamotomy resulted in visuospatial worsening
when studied with the Face Matching and Face Recognition
Tests. When we presented our findings at the International Con-
gress of Parkinson’s Disease in 1972 in Zürich, my neurosurgical
colleagues said that Laitinen was a poor surgeon. They had never FIGURE 6. Photograph showing Ron Tasker, who visited several times,
encountered complications of this type. I remember well, how- with Kerstin Laitinen in 1981.
ever, that some neurological colleagues contacted me after my
talk and told me that our quantitative observations had con-
firmed their subjective clinical findings. Sophiahemmet Hospital, I carried out 600 pallidotomies for
In 1978, I left Helsinki and moved to Bergen in Norway, where Parkinson’s disease, some thalamotomies for multiple sclero-
I had been asked to build up a stereotactic unit. It was thought sis and essential tremor, posteromedial hypothalamotomies
that the unit would be ready by the end of the year, but I soon for restless behavior, and capsulotomies for obsessive-
realized that the plan would be much delayed. Therefore, I left compulsive disorder. In 1998, I retired from surgery and
Bergen in January 1980 and moved to Umeå, a university town started a new life of reading, fishing, and gardening in the
close to the polar circle of northern Sweden. In Umeå, I was lucky rocky archipelago of the Baltic Sea just east of Stockholm. I
to find two excellent co-workers, Dr. Marwan Hariz and Dr. donated my stereoguide to the Leksell Museum at the Karo-
Tommy Bergenheim (Fig. 5). Together with them, I carried out a linska Hospital (Fig. 8). For 22 years, the instrument had
large number of stereotactic and functional operations for differ- guided me in more than 2000 stereotactic interventions.
ent indications. In late 1984, we began to test Leksell’s old and
almost forgotten pallidotomy. After 7 years of follow-up, we
analyzed the results and published our findings (17). DEEP BRAIN STIMULATION FOR
Umeå often had top neurosurgeons as visitors (Fig. 6). In CHRONIC PAIN
1986, our department organized the First Arctic Stereotactic
Workshop. Many worldwide leading stereotactic neurosur- In the 1960s, Dr. Gabriel Mazars in Paris began to use deep
geons joined us (Fig. 7). brain stimulation (DBS) in the treatment of chronic pain. His
One year later, I moved to Sophiahemmet Hospital in Stock- reports stimulated other neurosurgeons to start using DBS. I
holm, where I worked for 11 years until my retirement. At had my first case in 1968. I implanted a chronic steel wire

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 HISTORY OF STEREOTAXY

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FIGURE 7. Photograph showing participants of the First Arctic Stereo- Standing, behind them, are Hariz and Tasker. Sitting are Kelly, Oje-
tactic Workshop in June 1986 in Umeå. Standing in the first row, from mann, Martín-Rodríguez, Mundinger, Laitinen, Kerstin Laitinen, Sieg-
the left, are Spännare, Apuzzo, Cosman, and Heilbrun. Sitting in the fried, Hitchcock, Barcia-Salorio, van Manen, Ohye, and Meyerson.
first row, from the left, are Fodstad, his secretary, and Narabayashi. Edvard Kandel is not pictured.

electrode in the pulvinar of a man who had phantom limb

pain. Electrical stimulation gave the patient a sensation of
pleasure, which he told me was similar to the effect of alcohol:
1 mA of current intensity gave him the same feeling as if he
had just had a pint of beer, 2 mA made him feel that he had
just had a glass of whisky, and 4 mA produced a sensation of
being happily drunk. He had no side effects, and he could
perform well in psychometric tests. In fact, he became ad-
dicted to the effect, and after 4 weeks of repeated stimulations,
the steel wire contacts had melted away by electrolysis. New
attempts at DBS were unsuccessful. A report of the case was
not published. Since then, like most stereotactic neurosur-
geons, I have used extradural spinal electrostimulation and
DBS for treatment of various types of chronic pain.

PSYCHIATRIC SURGERY
An important factor in the birth of stereotactic surgery at
FIGURE 8. Author in foreground with Leksell’s first stereotactic device in the end of the 1940s was the need to replace the lobotomy by
background (above) and his personally designed instrument (below). precisely placed stereotactic lesions in some frontal and fron-

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LAITINEN

tothalamic pathways. Thus, Spiegel and Wycis, Talairach, and

Leksell performed their first stereotactic applications for treat-
ment of psychiatric illness. Even Narabayashi, another pioneer
in the field, who was originally a neuropsychiatrist, designed
a frame in 1949. Soon afterward, in the early 1950s, the devel-
opment of psychopharmacology and its dramatic beneficial
effects in psychotic illnesses seemed to make psychosurgery

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superfluous. Nevertheless, Leksell, who, more than most of
us, worked in a contemplative and critical way, continued
carrying out psychosurgery throughout the 1950s. The psychi-
atrist Torsten Herner (9) analyzed his work.

Anterior Capsulotomy
At the International Congress of Neurology meeting in 1949
in Paris, Talairach reported on the positive effects of stereo-
tactic capsulotomy (25). It is likely that Leksell was present at
the meeting, and in 1952, he started a series of 116 capsulot-
omies in Lund, Sweden. Herner (9) found that more than 80%
of the patients had improved.
Most patients can return to a normal life after capsulotomy
(4). The lesions are placed between the head of the caudate
nucleus and the putamen in the anterior limb of the internal
capsule. It is likely that capsulotomy interrupts a reverberat-
ing vicious cycle, which the patient cannot stop voluntarily.
Apart from fatigue, which may be long-lasting, capsulotomy
guided by magnetic resonance imaging rarely has any side
effects. In my personal series of more than 100 patients, none
had a complication but some complained of tiredness lasting
for several weeks or even months after surgery.
Cingulotomy
In the United States, cingulotomy, originally proposed in
1937 by Papez (22), seems to be the most common psychosur-
gical approach. In 1962, Foltz and White (8) reported that
cingulotomy was effective in chronic pain patients who had
depression and drug addiction. Later, some American neuro-
surgeons claimed that cingulotomy was also effective against
obsessive-compulsive disorder (3). However, their documen-
tation was not convincing. Many of their patients had required
two or even three surgical attempts, which gradually included
the corpus callosum and parts of the supracingulate white
matter (21).
In the late 1960s, I tried cingulotomy in 52 patients in whom
the lesions were strictly restricted to the cingulum. To visual-
ize the cingulum and locate the lesions correctly, we carried
out pneumoencephalography and/or carotid angiography
(Fig. 9). The results were poor (19). Even Kelly and Mitchell-
Heggs (11) found that cingulotomy alone was not an effective
treatment in obsessive-compulsive order. When they added
small frontal mediobasal lesions to the cingulotomy lesions,
the results were much better. They called the operation a
“limbic leucotomy.” Gunvor Kullberg (12) in Lund found that
cingulotomy was less effective than capsulotomy. It is recom-
mended that those who are interested in a critical analysis of
cingulotomy read the report of the National Commission (21).
FIGURE 9. A, pneumoencephalographic images showing the cingulotomy
target (large stars) between the sulcus corporis callosi and sulcus cinguli.
B, carotid arteriographic images showing the same target between the peri-
callosal (pc) and callosomarginal (cm) arteries.
Posteromedial Hypothalamotomy
In 1962, Keiji Sano (23) introduced posteromedial hypo-
thalamotomy for the treatment of restless and agitated behavior
in erethic children. Small lesions, 3 to 4 mm in diameter, are
placed close to the wall of the third ventricle, an area supposed
to be adrenergic. In the late 1960s, I found that Sano’s hypo-
thalamotomy had a good calming effect in young schizophrenic
patients who experienced sudden episodes of restlessness and
agitation. Such episodes are quite common in hebephrenic pa-
tients. Intraoperative electrical stimulation of such a patient,
when anesthetized, causes pupillary dilation. Simultaneously,
the heart rate and blood pressure rise. The metabolic rate, as
measured from carbon dioxide of the end-expiratory air, also
increases. After the creation of small radiofrequency lesions, the
sympathetic hyperactivity is reduced.
The results of hypothalamotomy are good, and most pa-
tients can leave the mental hospital and be rehabilitated. In
fact, this operation, still little known by psychiatrists, is one of
the most rewarding stereotactic approaches that neurosur-
geons can offer.
ST. BARNABAS HOSPITAL IN NEW
YORK CITY
In 1967, I read in a newspaper about Dr. Stanley Stellar’s
experiments with laser surgery. Because I had no experience
with lasers, I flew to New York to see Dr. Stellar at St.
Barnabas Hospital in the Bronx. I found an intelligent and
serious neurosurgeon who was approximately 60 years old.
Using stereotactic guidance for a ruby laser, he shot brain
targets of animals from a distance of approximately 4 m. The

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problem with the ruby laser was its uncontrollable power.
The laser beam crushed the skull bone on its way toward the
target. Soon, Stanley Stellar began experiments with gas laser
techniques such as carbon dioxide, in which field he again
became a pioneer. He moved from St. Barnabas Hospital to
Saint Barnabas Medical Center in Livingston, NJ, where he
continued his laser research. Since our first meeting in 1967,
my family and I have met Stanley Stellar and his wife Rosetta
many times in Europe and in the United States (Fig. 10).
Several times, we stayed in the Stellars’ home in Englewood,
NJ, during our visits to New York.
At St. Barnabas Hospital in the Bronx, I also met Dr. Irving
Cooper. I had used his instrument in the early 1960s. Dr.
Cooper was charming and enthusiastic, loved by many pa-
tients but hated by several colleagues. His autobiography, The
Vital Probe, illustrates this clearly (6). By the time of my first
visit to meet Cooper, he had operated on more than 5000
parkinsonian patients, with most of these operations per-
formed on the thalamus (26).
My impression of Cooper was ambivalent. I admired his
wide knowledge of anatomy and physiology and his rapid-
ness to adapt surgery for new applications in various move-
ment disorders. Possibly because of his extensive writing and
surgical productivity, he had some shortcomings. He seemed
not to have had time to read European or Japanese publica-
tions. Therefore, he did not know that Talairach, Leksell,
Riechert, and Narabayashi had used pallidotomy and thalam-
otomy years before him. From this shortcoming, it followed
that Cooper never used a proper stereotactic instrument, just
a probe carrier, which caused inaccuracy in targeting. A good
example of such targeting error was his thalamotomy per-
formed in 1954, which he reported in Science as being a suc-
cessful pallidotomy (5).
Cooper’s colleague was an experienced neuropsychologist, Dr.
Manuel Riklan, but the team’s analyses of the side effects of
surgery confused me. Why did they not notice that a left thalam-
otomy in right-handed patients invariably causes verbal deteri-
oration? In addition, they did not report on visuospatial defects
after a right thalamotomy. It is possible that Riklan had to please
Cooper, who was too busy with surgery to participate personally
in neuropsychological testing of the patients. Therefore, some
side effects of thalamotomy probably remained unknown to him,
FIGURE 10. Photograph showing Stanley and Rosetta Stellar sitting
between Kerstin Laitinen and Blaine Nashold in 1969 in Helsinki.
NEUROSURGERY
HISTORY OF STEREOTAXY
as may have been the case for most of us. In my opinion, Cooper
was too honest to attempt to hide the side effects. Apart from his
poor stereotactic instrumentation, I was impressed by his surgi-
cal dexterity and speed.
My next visit to St. Barnabas Hospital took place in 1969. Dr.
George Cotzias had recently documented the reversal of parkin-
sonian symptoms after oral administration of l-dopa, which
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caused a dramatic decline in the number of thalamotomies. I
noticed that Cooper’s earlier vitality had deteriorated; he was
depressed, and I tried to encourage him. Thereafter, I met Cooper
at several international meetings. In late November 1985, I had
agreed to meet him in Florida. When I arrived in Miami and tried
to call him on the telephone, I did not get any answer. The next
day, I read in a local newspaper that Irving Cooper had died.
Two months later, another pioneer neurosurgeon (in fact, the
greatest of them all), Lars Leksell, died.
In 1982, during a visit to St. Barnabas Hospital in New York, I
heard on a television program about a new method, said to be
revolutionary, for the treatment of certain types of movement
disorders and epilepsy. The neurosurgeon was Dr. Joseph Waltz,
a younger co-worker of Cooper and Stellar during the 1960s. He
had begun to treat spasmodic torticollis, spasticity, and epilepsy
by electrical stimulation of the upper cervical spinal cord and
cerebellum. Dr. Waltz received me kindly and sent me to his
young technician, who was responsible for the daily stimulation
testing of the patients. The technician showed me 20 patients
with implanted electrodes. He told me that the most crucial
factor for successful treatment was the correct choice of stimula-
tion frequency: it had to be 1408 Hz. When I asked whether 1410
Hz would do the same, the answer was no. The technician also
told me that he himself had had epilepsy, which Dr. Waltz had
cured by cerebellar implantation of chronic electrodes. The good
effect had lasted for almost 2 years before new seizures occurred.
A computed tomographic study had revealed a temporal lobe
astrocytoma, which was removed. Since then, he had not needed
electrical stimulation. When I asked him about the postoperative
analysis of the patients, he told that he just asked them how they
felt when they were leaving the hospital. I wondered how many
neurosurgeons in the world had heard of and tried the same
technique. Negative results are seldom reported, which can eas-
ily lead to a vicious circle. I knew too well that we neurosurgeons
had a tendency to be herd animals and to see the emperor
dressed in golden clothes, albeit he is naked.
CLOSING REMARKS
In this article, I have recalled some memories from the early
years of stereotactic neurosurgery. For me, these years were
stimulating. I met many wonderful people. Many of the ste-
reotactic pioneers have already left this world. All of them, as
well as those remaining who are not mentioned here, deserve
my respect and gratitude. Finally, I would like to remind
younger readers of Lars Leksell’s policy: read and think more,
write less, and write only about the important findings.
VOLUME 55 | NUMBER 6 | DECEMBER 2004 | 1427
LAITINEN
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17. Laitinen LV, Bergenheim AT, Hariz MI: Leksell’s posteroventral pal-
lidotomy in the treatment of Parkinson’s disease. J Neurosurg 76:53–61,
1992.
18. Laitinen L, Johansson GG, Sipponen P: Impedance and phase angle as a locating
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1428 | VOLUME 55 | NUMBER 6 | DECEMBER 2004
COMMENTS
I n my opinion, Dr. Laitinen will be most remembered for the
fact that he resurrected the posterior lateral pallidotomy
procedure that had originally been developed by Lars Leksell
in the 1950s. This procedure helped many Parkinson’s disease
patients in the 1990s. I was happy to be included in the First
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Arctic Stereotactic Workshop in 1986.
Patrick J. Kelly
New York, New York
D r. Lauri Laitinen is a world-renowned second-generation
pioneer in stereotactic neurosurgery, who, among many
other things, constructed one of the most reliable stereoguides
on the market and reinvented Leksell’s pallidotomy for Par-
kinson’s disease. In 1970, 10 years before Dr. Laitinen joined
us, the University Hospital of Umea in Northern Sweden
bought his stereoguide, and the first thalamotomy was per-
formed there on a Parkinson’s patient in March 1971 by Dr.
Carl-Axel Thulin, who had studied stereotaxy with Dr.
Riechert in Freiburg and Dr. Narabayashi in Japan. The first
international visitor to the recently opened department was
Dr. Ohye, Narabayashi’s assistant, in 1970, followed by Dr.
Narabayashi himself in 1976. During the 1970s, stereotactic
procedures for movement disorders and epilepsy as well as
psychosurgery were performed with the Laitinen stereoguide
on a weekly basis in Umea (1). When Lauri came on board in
1980, he immediately began developing a noninvasive and
accurate stereoadapter for his frame, which he integrated with
computed tomography to calculate the coordinates. I remem-
ber him in the beginning sitting in his office with pieces of
wood that he put together with screws and nails. Thanks to his
invention, intraoperative ventriculography became obsolete.
The First Arctic Stereotactic Workshop, which was orga-
nized by Lauri and myself in June 1986, was attended by most
of the prominent neurosurgeons in the field (Fig. 7). The
success of the meeting may be partly because there were only
85 participants, the reason for which was the Chernobyl acci-
dent 2 months previously, which caused many cancellations.
My first interaction with Lauri was in 1972, when I had a
summer job as County Doctor near Vasa, Finland. In a nursing
home, I found a middle-aged lady who had Parkinson’s dis-
ease and had been placed there because of severe tremor,
which required her receiving constant assistance in her daily
activities. I referred her to Lauri in Helsinki, where she shortly
afterward underwent a successful thalamotomy with com-
plete elimination of her tremor. One week after surgery, she
was back home and out of the nursing home. A few years
later, I had the pleasure and opportunity to visit and work
with Lauri at Tölö University Hospital in Helsinki.
Dr. Laitinen has interacted on a personal as well as a pro-
fessional level with practically all the pioneers of stereotactic
neurosurgery. His anecdotal and well-written recollections are
important, not only for the history of stereotaxy, but even
www.neurosurgery-online.com

more so for the legacy of the many great persons who paved
the way.
Harald Fodstad
New York, New York
1. Fodstad H, Strandman E, Karlsson B, West K: Treatment of obsessive com-
pulsive states with anterior capsulotomy or cingulotomy. Acta Neurochir
(Wien) 62:1–23, 1982.
L auri Laitinen, also known as Lassi, has long been one of the
more quietly colorful characters in stereotactic history, as
evidenced by this contribution. He was instrumental in the
development of functional neurosurgery in Scandinavia. He
has always been innovative and critical, immediately identi-
fying the essentials and rejecting the flamboyant excesses that
detract from progress.
Functional neurosurgery went into a hiatus after the intro-
duction of l-dopa in approximately 1968. Even when it be-
came apparent that the drug was not the panacea that was
originally thought, provided only temporary relief, and in
itself caused severe side effects, neurologists were reluctant to
admit that there was still a place for stereotactic surgical
management of Parkinson’s disease. Laitinen almost single-
handedly revived the field of functional neurosurgery when
he published, in 1992, a review of Leksell’s pallidotomy pa-
tients in the Journal of Neurosurgery (1) and in a Proceedings
volume of Stereotactic and Functional Neurosurgery (2). The
impact of those publications has produced a resurgence in
surgery for Parkinson’s disease that continues to grow a de-
cade later. When I wanted to adopt the newly revitalized
pallidotomy, it was Laitinen whom I visited to observe the
technique and nuances with which he operated, in the Sophia-
hemmet, the same hospital in which, incidentally, Leksell had
shown me the prototype of the gamma knife in 1968. Laitinen
used his own minimally invasive stereotactic frame. Patients
received minimal sedation, and he spoke kindly and directly
to them throughout the efficient and rapid procedure, ensur-
ing both their cooperation and a good intraoperative clinical
NEUROSURGERY
HISTORY OF STEREOTAXY
evaluation. He measured impedance as the electrode was
advanced. Although expert in the technique, he did not use
microelectrode recording, and his results equaled or exceeded
those of more elaborate techniques that later became popular,
documenting that microelectrode recording was not neces-
sary. On postoperative rounds, he spoke to patients and fam-
ilies as much as a friend as their surgeon; in all, he presented
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the ideal of what a surgeon ought to be. He later was instru-
mental in my becoming the Opponent for the Ph.D. defense of
his protégé, Marwan Hariz, who has inherited Lassi’s critical
analytical nature.
My friendship with Lassi Laitinen goes back to the earliest
meetings in stereotactic surgery. I was always impressed with
the unique view many of his presentations revealed at meet-
ing after meeting, and we never failed to share a drink at the
end of the day. Among the most important things he taught
me were how to catch a salmon using a fish eye for bait (at his
rustic fisherman’s cottage on the North Sea island of Öland) or
how to turn salmon into lox (when he visited our home in
Houston).
Reviewing his travels in this presentation on the history of
stereotactic surgery is not a digression. Visiting one another’s
institution was the way stereotactic surgery was cross-
fertilized and spread in the early days. Not only did that
convey much more than could be gleaned at a meeting in an
out-of-town conference center, but it also allowed the sharing
of ideas and attitudes that could only be passed from friend to
friend. Scientific progress has perhaps slowed as means of
communication have become more impersonal and sterile.
Philip L. Gildenberg
Houston, Texas
1. Laitinen LV, Bergenheim AT, Hariz MI: Leksell’s posteroventral pallidotomy
in the treatment of Parkinson’s disease. J Neurosurg 76:53–61, 1992.
2. Laitinen LV, Bergenheim AT, Hariz MI: Ventroposterolateral pallidotomy
can abolish all parkinsonian symptoms. Stereotact Funct Neurosurg 58:14–
21, 1992.
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