Chapter 1. History of neurosurgery

The separation of neurosurgery into a separate medical specialty occurred at the turn of the 19th and 20th centuries, but its roots go back to ancient times. The most ancient skulls with traces of trepanation go back to 12−10 thousand years BC in the Peruvian necropolis left over from the Inca civilization (2000 BC); approximately, 10% of skulls have traces of trepanation, and the nature of bone changes indicates that most patients successfully underwent surgery (Fig. 1.1).

Fig. 1.1. Skull with traces of trepanation and signs of bone regeneration from the Peruvian necropolis

On the territory of Russia (Gorny Altai), three skulls with traces of trepanation dated 5th–3rd centuries BC were found, with two of them showing signs of bone regeneration.

About 1/3 of trepanations were performed for traumatic brain injury (TBI). Indications for skull trepanation in the remaining 2/3 of cases remain unclear. Trepanation was carried out by scraping the bone, using chisels, cutters and conical cutters.

The Incas also carried out the plasty of bone defects with gold or silver plates. The first description of skull trepanation is given by Hippocrates in the essay “On head wounds”. In the Middle Ages, the trepanation technique did not undergo significant changes, but trepanation was often performed for the treatment of mental illnesses, and often charlatans turned out to be at the operating table (Fig. 1.2).

Fig. 1.2. I. Bosch. Extracting the stone of stupidity

In the history of medieval Russia, only trepanations related to TBI are reported. The first proper neurosurgical manual (Tractatus de Fractura Calve sive Cranei a Carpo editus) was published in 1518 in Bologna by Berengario da Carpi (1470−1550) (Fig. 1.3, 1.4). The work is devoted primarily to the description of the successful treatment by the author of a fracture of the occipital bone in Lorenzo de Medici, but there are also generalizing recommendations.

Fig. 1.3. The title page of the world’s first monograph on neurosurgery. In: Berengario da Carpi. Tractatus de Fractura Calve sive Cranei a Carpo editus. Bologna: Impressum per Hieronymum de Benedictus, 1518

Fig. 1.4. Tools for trepanation dated the beginning of the 16th century (from the same book)

Ambroise Pare made a great contribution to the development of trepanation techniques (Ambroise Pare, 1510, according to other sources 1509 or 1517−1590). He described in detail the tools and methods of trepanation, removal of an osteomyelitically affected bone, drainage of subdural hematomas and empyemas, proposed a technique for reposition of depressed skull fractures (Fig. 1.5).

Fig. 1.5. Ambroise Pare. Portrait and illustrations of trepanation techniques. In: Pare A. The Works of That Famous Chirurgion Ambroise Parey Translated Out of Latine and Compared with the French by Thо. Johnson. London: Richard Coates, 1649

The development of neuroanatomy in the 17th century is connected primarily with the name of Thomas Willis (1621−1675). “Cerebral anatomy” (Cerebri Anatome) published by him in London in 1664 (Fig. 1.6) was considered by contemporaries to be the most accurate guide. Willis was also the first to propose the term “neurology”, understanding it only in the anatomical sense, that is, as the science of neurons (and not as a clinical discipline).

Fig. 1.6. a — Thomas Willis; b — the first image of the arterial circle of the brain. In: Willis T. Cerebri Anatome: cui Accessit Nervorum Descriptio et Usus. London: J. Flesher, 1664

Simultaneously with anatomical science, surgical technique developed. The book by Johannes Schultes (1595−1645) Armamentarium Chirurgicum, translated from Latin into many languages, contains descriptions and images of many tools used for trepanning at that time, among which there are similar to modern raspators, elevators, pliers (Fig. 1.7, 1.8).

Fig. 1.7. Types and techniques of trepanation. In: Scultetus J. Armamentarium chirurgicum XLIII. Ulm: Typis&Impensis Balthasari Klihnen, 1655. The main indication for trepanation, as can be seen, were craniocerebral injuries. A cruciform incision of the skin without subsequent suturing provided drainage of the wound.

Fig. 1.8. Instruments for trepanation and correction of depressed skull fractures developed by Schultz (from the same book)

By the beginning of the 18th century, in European countries, the handicraft manufacture of medical instruments has given way to industrial. In Russia, the manufacture of medical instruments was also established; and since 1738, all full-time doctors including military ones had full-fledged (for their time) surgical kits, including trepanation instruments. In 1744, Martin Shein published the first Russian anatomical atlas.

In the 18th century, skull trepanation was traditionally used for TBI, and every certified doctor was obliged to own its technique. Among the examination questions on surgery, skull trepanation was given priority. At the same time, there was no fascination with trepanation as a panacea, as evidenced by those that have come down to us (in the comments to “Surgery” of Platner, compiled by Martyn Shein few clinical descriptions of 1744−1757. In one of these descriptions, it is reported that the wounded man “had his head broken... the skull in the brain was depressed to the depth of two fingers”; in the Admiralty HospitalThe dura mater, “these fragments were removed with great difficulty, the dura mater was found torn here”; the wounded, “being used... by chief physician Martyn Shein who scooped up to four ouncesThe Russian ounce of mass was 29.86 g. of the brain itself, recovered after two months and eight days, his brain was filled, and the dura mater in the broken hole attached”.

The second half of the 18th century was characterized by further progress of medical science and practice. The concept of pathological anatomy of Giovanni Battista Morgagni (1682−1771), linking each nosology with a specific pathological substrate, changed the philosophy of all European medicine and, among other things, justified the expediency of removing a tumor of any localization (Fig. 1.8, 1.9).