Neurosurgery Before Neurosurgery

A 16th century depiction of trephination in the home: Note the man warming the cloth dressing, the woman praying, and the cat catching a rat in the operating room (sterilizing technique not included).

For most modern folk, it is difficult to embrace how neurosurgery existed well before anesthetization, asepsis, and cerebral localization—three techniques that arrived in the last century and a half. Perhaps the thought of early renaissance doctors boring into your skull with a hand drill while you actively participate in the operation is unsettling for today’s pampered patients. Well, I am here to drill holes in your preconceived notions about the history of neurosurgery with the help of Eugene S. Flamm, M.D., who presented “Neurosurgery Before Neurosurgery: The Formative Years 15-17-1867” last Thursday at Columbia University.

Flamm, Chair of the Department of Neurological Surgery at Albert Einstein College of Medicine, has dedicated his life to teaching the next generation of neurosurgeons, making him an authority on modern neurosurgery. What makes him a phenomenal doctor is his genuine curiosity and passion for how the history of his discipline shapes its current form.

The first known non-magical medical treatise on surgery is the Edwin Smith Papyrus, which dates back to 1500 BCE, 1000 years before Hippocrates. The papyrus contains 48 case histories of patients, including details on how to sew sutures, examine visual and audio perception, and how to treat gaping fractures to the skull. These neurosurgical techniques proved successful:  Some trepanned (drilled into) Egyptian skulls from the era show bone regrowth at the site of the drilling, an indication of patient survival.

Standing surgeryGuy of Pavia’s Anatomia, c. 1345: The short-lived regin of standing neurosurgery.

By the late Middle Ages and early renaissance (1300s-1500s), most doctors ascribed to the “Cellular Theory of Brain Function.” But the first cell wasn’t discovered until 1665, thus these big brain cells were actually ventricles—cerebrospinal fluid filled pockets within the brain. While ventricles are essential to the healthy operation of a brain, they are devoid of neurons. The flaw of the “cellular theory” is analogous to someone looking at a car and saying that the airbags and bumpers are what allow the vehicle to run—they help provide safe cushioning and support for the driver, but they do not drive the car.

Regardless of their understanding of brain function, the ability of Renaissance artists and doctors to draw the structures of the brain is breathtaking, and to this day would take great skill to mimic.

Da vinciLeonardo De Vinci c. 1489: Note the carefully drawn blood vessels and ventricles. De Vinci injected molten wax into his cadavers to determine the structure of these circulatory structures.

DryanderDryander, 1537: This anatomical drawing was one of the first to show what is directly under the dura layers of the brain.

In the 17th century, the demands of burgeoning international trade brought about improvements to neurosurgery. Among them being the one-hand operated trepanning drill, ideal for neurosurgery amidst choppy seas. Dr. John Woodall, a 17th century English military surgeon wrote a manual on British Naval medicine and surgery, which was one of the first medical treatises to stress  how important it is to “…make experience first on a calves head or sheep head…” before attempting neurosurgery on a human patient. Thankfully this advice has stuck to this day.

The 18th century was dominated by French neurosurgeons, among them Dr. Matthaus Gottfried Purmann, who revolutionized the efficacy of trepanning. Most notably, Purmann distinguished a patient’s initial loss of consciousness (often caused by some sort of head trauma) from the patient’s second loss of consciousness (often occurring days later), which he correctly determined was from a second “extravasation” (his words) now understood to be the brain’s delayed inflammatory response to the earlier infection. Purmann discovered that just before the second loss of consciousness is the best time to relieve pressure in the brain by trepanning. Flamm considers Purmann a hero for his intuition.

By the 1800s Dr. Joseph Lister (the man behind the mouthwash) began to promote the idea of sterile surgery, reducing the risk of post-surgical infection. As for anesthesia, new methods in chemistry brought about morphine and nitrous oxide (laughing gas). During the 1900s electromagnetic imaging brought with it x-ray machines and eventually the device indispensable to the modern neurosurgeon, the MRI. These three developments: asepsis, anesthetization, and imaging are critical to modern surgery, but so too are the footsteps leading up to these discoveries.

All too often we forget about the shoulders upon which we stand. Flamm pointed this out to me after the presentation without losing a drop of his charismatic wit: “[Early doctors] didn’t know what they were doing, but ultimately they were respected by the community and gave piece of mind and hope to those in need. The same situation happens to doctors today.”

– Charles Jake Sadle

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