Other than the isolated cases found in these remaining papyri, little can be gleaned from them on the actual practice of neurosurgery.⁹ It is evident from these writings that the Egyptian physician recognized head injury and would elevate a skull fracture if necessary. At the same time, if the injury appeared too be too severe, no treatment was advocated. The early “neurosurgeon” had to wait until the development of the Greek schools of medicine, for it was then that the management and codification of head injury were first formulized.

Classical Period—Greek and Byzantine Neurosurgery

Hippocratic School

The intellectual evolution of neurological surgery originated in the golden age of Greece with the founding of the Alexandrian school in 300 BC. For the first time, open anatomic dissection was incorporated into formal lectures,¹⁰ and the concept of a surgeon performing surgery on the head and spine became formalized. Because of both sporting injuries, in particular, gladiator injuries, and wars, head injuries appear to have been plentiful and provided opportunities to develop the early skills of neurosurgery.

The earliest medical writings from this period are those of Hippocrates (460-370 BC), the most celebrated of the Asclepiadeans (Fig. 1-2).¹¹^–¹³ Classical philologists think that many of the writings attributed to Hippocrates, however, were composed by members of the Hippocratic school. The Hippocratic collection presents clinical cases based mainly on observation, and in most cases only the simplest of theories are offered. There are a number of neurological cases within the Hippocratic corpus. In reviewing these cases one finds a rather sophisticated understanding of head injury. Hippocrates was the first to describe a number of neurological injuries, most resulting from battlefield injuries. The vulnerability of the brain to injury was categorized by location, from lesser to greater, with injury to the bregma being represented as a higher risk than one to the temporal region, which in turn was more dangerous than an injury to the occipital region.¹⁴^–¹⁶ Hippocrates devoted a full chapter to injuries of the head, De Capitis Vulneribus, a work that deals with the diagnosis and management of head injuries. The work divides head injuries into five categories based on details of the skull fracture and is the first systematic work devoted to head injuries. Five types of fractures are described: linear fracture, contusion, depressed fracture, hedra (or dent) occurring with and without fracture, and contrecoup fracture.¹⁴ There is nothing to suggest that the neurological condition of the patient had any bearing on the surgical indications. Surgery was advised according to the type of fracture. The greater the injury to the skull, the less the need for trephination. The technical aspects of the process of trephination are presented in a curious mixture of sound advice and incomprehensible admonitions.

FIGURE 1-2 Title page from the first printed edition of the writings of Hippocrates—1525.

(From Panourias JG, Skiadas PK, Saklas DE, et al. Hippocrates: a pioneer in the treatment of head injuries. Neurosurgery. 2005;37:181-189.)

These Hippocratic writings contain numerous anatomic descriptions, even though human dissection appeared to not be routinely practiced. The Greeks were also without an anatomic vocabulary, which was not introduced until Galen standardized use of the Latin language in medicine. These deficiencies retarded the development of standardized anatomic procedures and the practice of surgery. Despite these drawbacks, there are within the Hippocratic writings a number of interesting neurological case studies that reflect a view of the early practice of neurosurgery (Fig. 1-3).

FIGURE 1-3 A, Bust of Aesculapius. B, The Temple of Aesculapius with the temple in the background. The gate to the bottom left is a speaking hole through which the temple priests would communicate to the sick patients in the underground corridors.

One of earliest descriptions of subarachnoid hemorrhage appears in the Aphorisms:

When persons in good health are suddenly seized with pains in the head, and straightway are laid down speechless, and breathe with stertor, they die in seven days, unless fever comes on.¹³^,¹⁷

Hippocrates and his followers also warned against incising the brain because convulsions can occur on the opposite side and make the prognosis especially serious. Hippocrates advised against making an incision over the temporal artery because this could also lead to contralateral convulsions. In reviewing the writings of the Hippocratic school we find the simple concepts of cerebral localization demonstrated. Also well understood was the concept of a potential critical prognosis in head injury and that sometimes it was best not to operate. In this early era of medicine, the risk for infection, lack of antiseptic technique, and minimal anesthesia prevented generations of surgeons from performing any serious or aggressive surgical intervention for head injury.

Herophilus of Chalcedon (ca. 300 BC)

From the region of the Bosporus, among the crowded schools of Alexandria, came Herophilus, a pupil of Praxagoras and Chrisippus and a member of the educated dynasty of Ptolemy. According to his writing, Herophilus performed dissection on humans, not on animals as was the common practice then.¹⁸^–²⁰ Herophilus and Galen later were key figures in the task of developing an anatomic nomenclature and in forming a much needed language of anatomy. In examining the nervous system, Herophilus’ neurological contributions included anatomically following the origin of nerves to the spinal cord. He was the first to recognize the difference in motor and sensory tracts. He made a further important differentiation between nerves and tendons, thereby correcting a common earlier error. Herophilus was the first to detail the anatomy of the brain ventricles and venous sinuses. The description of the “confluens of the sinuses,” or torcular Herophili (torcula means wine press), comes from his early investigations. The first description and naming of the choroid plexus (plexus choroides) come from Herophilus, and it was so named because of its resemblance to the vascular membrane of the fetus. He gave the first detailed account of the fourth ventricle and of that peculiar arrangement at its base, which he called the calamus scriptorius because it “resembles a pen in writing”—Aναγλυϕη τχ χαλαµχ. Among his many other contributions was recognition of the brain as the central organ of the nervous system and the seat of intelligence.¹⁹

Herophilus was not without errors in his writings. Perhaps the worst was his introduction into the anatomic literature of one of the longest-standing errors—that of the rete mirabile, a structure present in ungulates but notably lacking in higher primates. In ungulates this structure acts as an anastomotic network at the base of the brain, a structure that the Greeks incorporated into the early physiologic theories of brain function.²¹ The rete mirabile was later elaborated in further detail by Galen of Pergamum and codified by Islamic and medieval writers. This anatomic error remained firmly embedded in the anatomic literature until the 16th century, when it finally became challenged in the accounts of Andreas Vesalius (1514-1564) and Giacomo Berengario da Carpi (1460-1530).²²^–²⁴ Both these writers, who performed their own human dissections, clearly recognized that the rete mirabile did not exist in humans. It is possible that the human cavernous sinus confused the early writers and they in turn thought that this represented the rete mirabile.

Aulus Aurelius Cornelius Celsus (25 BC–50 AD)

Celsus (Fig. 1-4A) was neither a physician nor a surgeon, but rather an intellectual patrician and a medical encyclopedist who attempted to compile all the important writings of his time. His writings had an important early influence on medicine and surgery. As counselor to the emperors Tiberius and Caligula, Celsus was held in great esteem. His book on medicine titled De Medicina²⁵^,²⁶ (Fig. 1-4B) is now considered one of the most important early medical documents after the Hippocratic writings. As a result of this work originally being lost, Celsus was one of the few major authors not transcribed by the Islamic/Arabic writers. This changed in 1443, when an early Celsus manuscript was uncovered by Thomas Sarazanne (later Pope Nicolas V) and reintroduced to the medical community. With the introduction of movable type, Celsus’ work became the first medical manuscript to be printed (1478), even preceding the writings of Hippocrates and Galen. In Book 4, Chapter 10, we find his classic description of inflammation: notae vero inflammationes sunt quattuor, rubor, et tumor, cum calore et dolore.

FIGURE 1-4 A, Portrait of Celsus. B, Title page from a 1542 edition of Celsus’ writings.

Celsus made a number of interesting early observations related to neurosurgery. Book VIII, Chapter 4 contains one of the earliest descriptions of an epidural hematoma resulting from a ruptured middle meningeal artery.²⁵ In head-injured patients, Celsus recommended that the surgeon always operate on the side of greater pain. The trephine should always be placed at the point where the pain is best localized. Celsus described a technique for a craniotomy that involved drilling a number of holes and then connecting them with a hammer and chisel. The chisel had a protective blade that separated the dura from the bone and prevented injury to it during the surgical dissection. However, he regarded the operation of trephination as the ultimum refugium, to be used only when all conservative measures had been exhausted.

Several interesting neurological conditions are described in De Medicina, including accurate descriptions of hydrocephalus and facial neuralgia. Following earlier writings, Celsus clearly recognized that a high cervical spine fracture could lead to vomiting and difficulty breathing. Injury to the lower lumbar spine could cause weakness or paralysis of the legs, as well as urinary retention or incontinence.

Galen of Pergamum (129-200 AD)

Galen of Pergamum, whose name comes from “galenos,” meaning calm or peaceful, is remembered as a powerful personality, an original investigator, and a leading proponent of the doctrines of the Hippocratic and Alexandrian schools (Fig. 1-5). Galen began his writing career at the age of 13 and continued to add to the literature until his death at the age of 70. In the end, his writings remained the most extensive in size, scope, and influence in early antiquity. Galen’s prodigious output accounts for of all the surviving medical writings of antiquity (Fig. 1-6).²⁷

FIGURE 1-5 Portrait of Galen.

FIGURE 1-6 Title page from the collected works of Galen.

(From Galen of Pergamum. Omnia Quae Extant Opera in Latinum Sermonem Conversa (Quinta ed). Venice: Apud Juntas; 1576-1577.)

Galen’s life and activity fortunately occurred during the reigns of two of the greatest Roman emperors, Antonius Pius (86-161 AD) and Marcus Aurelius (121-180 AD). Galen became the physician to the gladiators of Pergamum and as a result saw and treated many traumatic injuries. From both his surgical experiences and anatomic studies, he made contributions to the fields of neurology, neurosurgery, and neuroanatomy. In his writings Galen differentiated between the pia mater and the dura mater and gave one of the earliest accurate descriptions of the corpus callosum, the ventricular system, the pineal and pituitary glands, the infundibulum, and what we now call the aqueduct of Sylvius. Nearly 1600 years before the Scottish anatomist Alexander Monro (Secundus) (1733-1817), Galen described the structure now called the foramen of Monro. He performed a number of anatomic experiments, including early studies on the effects of transection of the spinal cord.²⁸^,²⁹ From these studies Galen was able to describe the specific loss of function below the level of transection. In a now classic experiment he sectioned the recurrent laryngeal nerve in the dog and found that hoarseness occurred (discussed further in Chapter 7, see also De Usu Partium, Book VII, Chapter 11 ,Chapter 12, Chapter 13, Chapter 14, Chapter 15, Chapter 16, Chapter 17, Chapter 18).²⁸ Galen was the first to provide an early classification of the cranial nerves. In his original classification he described 11 of the 12 cranial nerves; however, by combining several, he arrived at a total of only 7. In his descriptions he regarded the olfactory nerve as merely a prolongation of the brain and hence did not considered it a cranial nerve.²⁸ Galen published a number of interesting views on higher cortical functions and embraced the concept that the brain was responsible for intelligence, fantasy, memory, and judgment. These views were original and represented an important departure from the cardiocentric teachings of the earlier medical and philosophical schools such as Aristotle’s. Galen challenged Hippocrates’ view that that the brain was only a gland and instead attributed to the brain the powers of voluntary action and sensation (encephalocentric), this last being a remarkable advance in thinking for the period.

From a series of anatomic studies, Galen provided some of the earliest observations on cervical spine injury and the resulting disturbance in arm function. Further study of spinal cord injury led to his elegant description of what we now call “Brown-Séquard” syndrome (i.e., hemiplegia with contralateral sensory loss in a hemisection of the spinal cord).²⁹ Galen provided one of the earliest clinical descriptions of hydrocephalus and clearly recognized its poor prognosis. Using his extensive experience with head injuries, he provided innovative arguments for elevation of depressed skull fractures, fractures with hematomas, and comminuted fractures. Galen was more aggressive in his treatment by recommending the removal of bone fragments, particularly those pressing into the brain. In describing surgical techniques, he detailed a safer and more reliable use of the trephine and in particular argued for continuous irrigation during trephination to avoid delivering excessive heat and injury to the underlying brain. Galen, following or adapting earlier Hippocratic views, reiterated the concept the dura should never be violated by the trephine.

Galen was clearly a great physician, surgeon, and early innovator in medicine. Unfortunately, the historical world, in particular the Byzantine world, later accepted Galen’s writings as the only true authority. As a result, Galen’s writings attained the status of unchallengeable medical dogma. Thus, his work on neurology and neuroanatomy remained essentially unchallenged for the next 1500 years. For all practical purposes, relevant new investigations ceased altogether from Galen’s death until the Renaissance. Some writers have pointed out that Galen was literally canonized by Arabic/Islamic writers and later by physicians of the Middle Ages. Consequently, a number of Galen’s errors remained part of the anatomic literature (e.g., rete mirabile). Each of these errors or incorrect beliefs was carefully repeated and scribed by subsequent Islamic and medieval physicians and surgeons. Because of the strength of Galen’s views, no one was willing to challenge what were clearly anatomic and scientific errors, all of which had a stultifying effect on science and medicine for 1500 years.

Paulus of Aegineta (Paul of Aegina, 625-690?)

Illustrated in Figure 1-7A, Paul of Aegina was a brilliant 7th century Byzantine Greek physician and surgeon who also trained in the Alexandrian school. He was an influential compiler of works in both the Latin and Greek schools; his writings, especially the Medical Compendium in Seven Books (Fig. 1-7B), was being consulted until well into the 17th century, with a translation in English appearing in the 19th century.³⁰^,³¹ His skill as a surgeon, described in Book VI, clearly details an unusual understanding of surgical principles. His skills became contemporary legend, which brought him patients from far and wide. Although Paul venerated the teachings of the ancients as tradition required, he introduced his own techniques with good results. His classic work The Seven Books of Paulus Aegineta contains an excellent section on head injury and use of the trephine.³⁰^,³¹ Paul of Aegina classified skull fractures into several categories: fissure, incision, expression, depression, arched fracture, and in infants, dent (what we now call a ping-pong fracture). In dealing with fractures he used an interesting skin incision: two incisions intersecting one another at right angles and forming the Greek letter χ, with one leg of the incision incorporating the scalp wound. For the comfort of the patient undergoing trephination, he stuffed the patient’s ear with wool so that the noise of the trephine would not cause undue distress (see Book VI, Section XC).³¹

FIGURE 1-7 A, Portrait of Paul of Aegina. B, Title page of the collected works of Paul of Aegina.

In a contemporary discussion on hydrocephalus, Paul of Aegina introduced the intriguing concept of traumatic birth delivery and intraventricular hemorrhage being related; it would appear that he was the first to suggest the possibility that an intraventricular hemorrhage and its “inert fluid” might actually cause hydrocephalus:

The hydrocephalic affection occurs in infants, owing to their heads being improperly squeezed by midwives during parturition, or from some other obscure cause; or from the rupture of a vessel or vessels, and the extravasated blood being converted into an inert fluid [see Book VI, Section III, page 250].³¹

One of the reasons for Paul of Aegina’s long-standing influence was that several of his manuscripts survived and were continuously recopied by amanuenses over the centuries. In these manuscripts are offered a number of surgical instruments that he specifically designed for neurosurgical procedures, including elevators, raspatories, and bone biters, among other tools. He also introduced trephine bits with conical styles to reduce the risk of plunging, along with different biting edges. In retrospect, it appears that he probably had better surgical outcomes because of his sophisticated wound management by making use of wine-soaked dressings (helpful in antisepsis, although a concept then unknown) and by stressing that dressings should be applied with no compression on the brain itself.

The Greek and Byzantine periods proved for medicine and surgery to be eras of intense scholarship and original investigation and produced a group of physicians and surgeons who were deeply interested in better management of their patients. As we have seen, individuals such as Galen of Pergamum, Paul of Aegina, Herophilus, and members of the Hippocratic school all attempted to improve the management of head injuries and at the same time uncover the principles of brain function. Unfortunately, as we shall observe in the next section, during the prescholastic period of the Islamic and late Byzantine era, neurological investigation and the development of new surgical techniques were seriously impaired because of the scholarly ex cathedra elevation of these earlier writers. Although there were some exceptions, they were distinctly uncommon.

Islamic/Arabic Medicine—Prescholastic Period

After the great Greek and Roman periods of medicine, the intellectual centers of the discipline shifted to the Islamic/Arabic and Byzantine cultures. This era of influence lasted from approximately 750 AD until 1200 AD, when the medievalist era began. During this same period Europe was intellectually quiescent and unimaginative, having been overrun and ruled by barbarians (Huns, Goths, and Norsemen), individuals not known for endeavors in high scholarship. Unfortunately for neurosurgery, this was a dormant period, a dormancy that prevailed in all facets of surgery. The Islamic/Arabic schools were satisfied to codify the surviving manuscripts from the Greek and Roman period. In some rare cases remarkable insights were offered, but this was a rather rare phenomenon. However, because of their impressive zeal, the best of Greek medicine was made available to Arabic readers by the end of the 9th century and remained available into the Middle Ages. Unfortunately, rigid scholastic dogmatism characterized these learning centers. Rather than offering innovation, the “writers” became copyists of the great works of the antiquities. As a result of their efforts, we now have a surprisingly large number of manuscripts that have been translated from Latin, Greek, and Hebrew into Arabic, and because of their dedication and persistence, they systemized a body of knowledge that could easily have been lost into antiquity. Unfortunately, as copyists these writers frequently added their own “favorite” or contemporary view of the manuscript and, as a result, lost some of the originality in translation. In fairness to them, they had a critically important role in this period of civilization, claiming the only camp of learning; in Europe at this time, having been overrun by barbarians, the lamp remained unlit.

A number of contemporary writers have offered the view that it was the religious influence of the Koran that caused the absence of originality and progress in Islamic/Arabic medicine. It has often been commented on that the Koran forbade dissection; this is only partially correct. Some dissection was allowed and reported by writers of this time. However, as a practical consideration, this part of the world had a hot climate, which led to rapid putrefaction of cadavers and made anatomic dissection undesirable. The opinion of these schools was that the Greeks had already accomplished most of the anatomic studies of interest, so the Islamic student of medicine felt no need to duplicate these earlier and more superior efforts. There were rare exceptions, some of which we will discuss here.

In Islamic/Arabic medicine the concept of a physician doubling as a surgeon was rarely acceptable. The more typical practice was that the physician would confine himself to writing learnedly and assign the “menial tasks of surgery” to an individual of a lower class, typically an apprentice surgeon. As a result of this “declassification” of the surgeon to a mere plebian, the advances in surgery and anatomy developed by the great Alexandrians, among others, were ignored or lost. Fortunately, the writings of men such as Galen of Pergamum and Paul of Aegina were saved and translated into Arabic, but little new was added.

The dominant period for Islamic scholarship in medicine was from the 10th through the 12th centuries. Several medical giants rose to prominence during this period; among the most illustrious scholars were Avicenna (980-1037), Rhazes (865-925), Avenzoars (d. 1162), Albucasis (1013-1106), and Averhose (1126-1198). In reviewing the writings of these great physicians one sees an extraordinary effort to canonize the writings of their Greek and Roman predecessors. Rather than innovation, they became the guardians and academics of what now became the Hippocratic, Greek, and Galenic writings, which became dogma.

One of the most beneficial teaching methods, and a quite modern one, did arise during the Islamic/Arabic period—the concept of bedside medical care and teaching. The paucity or lack of anatomic dissection, along with the prevalent view of the practice of surgery as an occupation done only by individuals of inferior status, reduced any preoccupation with surgical art. Another unfortunate surgical practice that occurred during this period was reintroduction of the Egyptian technique of using hot cautery for control of bleeding. Hot cautery was also used in lieu of the scalpel to create a surgical incision, the results of which often proved unfortunate for the surgical patient (Fig. 1-8).

FIGURE 1-8 Image from a later copy of an Avicenna manuscript demonstrating a physician applying cautery to a patient’s leg.

We will review some of the writings of the significant scholars of this period, starting with those of Rhazes (Abu Bakr Muhammad Ibn Zakariya, 865-925). Rhazes was a scholarly physician, learned in diagnosis and exclusively loyal to Hippocratic teachings. Rhazes developed a considerable reputation that led him to becoming a court physician. He was not a surgeon, although he wrote on surgical topics.³² Rhazes was an early believer in the concept of “concussion” and advocated surgery for penetrating injuries of the skull in a period when surgical outcomes were almost always fatal. Rhazes believed that head injuries were among the most devastating of all injuries. In the case of skull fractures, which could be permanently damaging to the patient as a result of compression of the brain, his surgical advice would be that depressed fractures needed to be elevated.

Among the most influential physicians of this period was Avicenna (980-1037), physician and philosopher of Baghdad and known as the chief or “second doctor,” the first being Aristotle (Figs. 1-9 and 1-10). Avicenna’s writings and translations clearly extended the original Greek influence with a force so persuasive and durable that it remained the dominant scholarship until well into the 18th century. His greatest contribution is the detailed translation of Galen’s collected works, the Opera Omnia. Avicenna’s major work, Canon Medicinae, was an encyclopedic effort founded and clearly based on the writings of Galen and Hippocrates.³³ The Greek word Canon refers to a straight rod, a carpenter rule, or standard of measurement. Accordingly, Avicenna’s work became the “rule,” the codification of Galen and Greek medicine. In reviewing the Canon, a number of interesting neurological discussions are found. Avicenna provides an early and accurate clinical understanding of epilepsy, for which his treatment consisted of administering various medicaments and herbals, with good results. It appears that Avicenna conducted anatomic studies, although he does not discuss this directly. He gives a correct anatomic commentary on the vermis of the cerebellum and the “tailed nucleus,” now known as the caudate nucleus. Recent reviews of Avicenna’s writings on the treatment of spine injuries and stabilization reveal remarkably modern views for this era.³⁴^–³⁶

FIGURE 1-9 Unpublished manuscript leaf from a later collection of works by Avicenna showing him participating in an anatomic dissection.

FIGURE 1-10 Title page of Avicenna’s Canon.

(From Avicenna. Liber canonis, de medicinis cordialibus, et cantica. Basel: Joannes Heruagios; 1556.)

Although Avicenna was clearly the “second doctor,” it was Albucasis (Abu Al-Qasim or Al-Zahrawi, 936-1013), a learned Islamic Moorish Spaniard, who was clearly the surgeon of the times (Fig. 1-11). In the Islamic tradition, Albucasis was both a great compiler and a serious scholar whose writings (some 30 volumes) were focused on surgery, dietetics, and materia medica. Albucasis’ insights into the importance of surgery are clearly revealed in his introduction to the Compendium.³³ In the introduction he discusses the question why the Arabs had made so little progress in surgery. He attributed this lack of progress to a lack of anatomic study and inadequate knowledge of the classics. He clearly believed that anatomic studies were the key to learning and certainly key in performing surgical interventions. Although his thoughts on anatomic studies were excellent, Albucasis unfortunately popularized the frequent use of emetics as prophylaxis against disease, a form of barbaric medical treatment that survived in the form of “purging” until well into the 19th century. So influential were Albucasis’ surgical writings that they remained in use in the schools of Salerno and Montpellier for 500 years and had an enormous influence on medicine in the Middle Ages.

FIGURE 1-11 An allegorical scene of Albucasis operating in the field on an injured soldier—here he is removing an arrow from the chest. It was described in the 17th century Scultetus monograph on surgery.

(From Scultetus J. . Armamentarium Chirurgicum XLIII. Ulm: Balthasar Kühnen; 1655.)

In the final section of the Compendium there is a lengthy summary of contemporary surgical practice.³⁸^–⁴⁰ Also included in this part of Albucasis’ work is a unique collection of illustrations of surgical instruments. Their appearance here had lasting influence, with his style of instruments being used extensively in the schools of Salerno and Montpellier and later having important influence in the medieval period. Many of the instruments illustrated in the Compendium appear to have been designed by Albucasis. He clearly describes their design along with technical aspects of their use. Following on the earlier writings of the Greeks, he provides a novel design for a “nonsinking” trephine. The description of this instrument and others became classic and formed the template for many later instruments. An early and apparently unique technical innovation involved placing a collar on the trephine in a circular fashion, an ingenious design to prevent plunging into the brain. Some of the instruments were clearly copied from those described earlier by Paul of Aegina, but their practical use was further enhanced by their inclusion in the Compendium.

In reviewing Albucasis’ treatise on surgery, we find an extraordinary work. The text is rational, comprehensive, well illustrated, and designed with the intent to educate the surgeon on the details of each treatment, not even neglecting the types of wound dressings to be used. In reading Albucasis’ techniques of brain surgery, not all was well for the patient. In fact, the modern reader can only wonder how patients would allow themselves to undergo some of these surgical practices. For chronic headache, he applied a hot cautery to the occiput and burned through the skin but not the bone. Another headache treatment he described required hooking the temporal artery, twisting it, placing ligatures, and then ripping it out. Albucasis identified and described various types of spinal injury. He recognized the seriousness of spinal injury, particularly dislocation of the vertebrae. In patients with total subluxation, he appreciated that the prognosis was essentially terminal, with patients having involuntary activity (passing urine and stool) and flaccid limbs. Albucasis was innovative in dealing with lesser spinal injuries. He described and illustrated the methods and splints that he used for reduction of such injuries. To the modern reader some of these techniques seem to be dangerous, especially stabilizations that required an aggressive combination of spars and winches and “stretching” of the spinal column. Following earlier Greek and Byzantine views, Albucasis thought that bone fragments in the spinal canal should be removed. In reviewing skull fractures, he has an elegant discussion of the pediatric ping-pong fracture of the skull:

This is a fracture due to a fall or a blow from a stone and the like, making a dent in the surface of the bone and a hollow at the site as occurs in a bronze bowl when a blow falls on it and a portion of it is pushed in. This mostly occurs in heads who bones are soft, as those of children.³⁸

The treatment of hydrocephalus was a vexing problem for surgeons and physicians because its outcome was almost always fatal. Albucasis recommended drainage of cerebrospinal fluid (CSF) in patients with hydrocephalus via a series of drains and wicks. He designed a lenticular-shaped surgical tool to make the puncture, which was performed over the anterior fontanelle. Having nicely detailed the technique, he blithely notes that the outcome is almost always fatal. What is interesting to note is that he attributed the poor outcomes not to the surgery but rather to “paralysis” of the brain from relaxation. Albucasis is clever in pointing out to the reader that one must pick the site for drainage carefully. Never cut over an artery because the potential hemorrhage can rapidly lead to death. In recent years, some authors have advocated treatment of hydrocephalus by “binding” the head with tight wraps. Albucasis was advocating this form of treatment more than a thousand years ago. For a child with hydrocephalus, he would “bind” the head with a wrap and then put the child on a “dry diet,” with limited fluid intake to dehydrate the child—in looking back, a rather progressive and reasonable treatment plan for this disorder.³⁸^,³⁹

Middle Ages—The Age of Medieval Medical Scholasticism

In the early Middle Ages, the influence of the Islamic/Arabic schools on medicine was beginning to lessen, along with a geographic switch in which intellectual centers for medicine were now returning to Europe. With the advent of medieval scholasticism, a new school of thought developed in which philosophical and metaphysical explanations and dialectic interpretations became prominent. One of the preeminent schools proposing this view was the School of Salerno in what is now Italy (Figs. 1-12 and 1-13).⁴¹ In much of Europe, despite the fact that barbarians were still in control, physicians were being trained and libraries were being built and expanded. At the School of Salerno, an early leader in developing medical scholasticism was Constantinus Africanus—magister orientis et occidentis (1020-1087).⁴² Constantine, a Magistri Salernitani, provided an important bridge in medicine by introducing the scholarship of Islamic/Arabic medicine there and eventually to all of Europe. Constantine received his medical education in Baghdad, where he learned the prevalent views of Islamic medicine. He moved to a monastery at Monte Cassino, where in the tradition of this period he translated Arabic manuscripts into Latin. Modern scholars believe that his translations included inaccuracies and introduced errors into the medical literature. Recent studies suggest that Constantine was a plagiarist and unreliable translator. Nonetheless, one cannot underestimate his contributions by providing the earliest transfer of Arabic/Islamic medical literature to Europe. In looking back, what we see are Greek texts originally translated into Arabic and now being translated into Latin, with the legacy of Galen and other early writers remaining firmly entrenched as dogma. Rather than providing or developing new ideas, the classical texts in medicine remained fully in control of medical dogma. One can only imagine how much medical and surgical knowledge was lost or distorted by inaccuracies in these successive translations. Constantine did make a key contribution to medieval medicine when he reintroduced anatomic dissection with an annual dissection of a pig, but the findings were compared with those recorded in the Greek classics. If the prosector’s findings did not match the ancient texts, they were simply ignored! Constantine was clearly a learned man, but his style of teaching became typical of the Medieval Ages; extensive compilations and translations were undertaken, but original thought or advances in knowledge were absent. In the Middle Ages the School of Salerno lead the way and was followed by the great medical schools at Naples, Bologna, Paris, and Montpellier, the early pillars of medieval medicine.

FIGURE 1-12 Constantine the African lecturing at the School of Salerno.

FIGURE 1-13 Title page from a collection of the works of Constantine the African—1536.

(From Constantinus Africanus. Constantini Africani Post Hippocratem et Galenum. Basel: Henricus Petrus; 1536.)

An unusual and remarkable book was produced during this period—Regimen Sanitatis Salernitum, a work that first appeared in the 12th century and was later republished in 140 different editions extending well into the 19th century.⁴¹ This book summarizes the Salernitan school directions for maintenance and care of patients in medicine. In Europe a strong educational system was being developed, but medicine remained cloaked in the literature of the classical Greeks and Islamic writing; for the most part, surgical education and surgical practice continued to be treated as an avocation limited to uneducated barber-surgeons and apprentices. However, there were talented surgeons who escaped the norm and produced original surgical works and practices.

Roger of Salerno (Ruggiero Frugardi, fl. 1170) is considered the first learned medieval European writer on surgery (Figs. 1-14 and 1-15). Roger was educated in the Salerno tradition and followed many of its teachings. His book on surgical practice, Practica Chirurgiae,⁴³ offers techniques of interest to neurosurgeons. An example was his technique for checking for a tear of the dura and leakage of CSF in a patient with a skull fracture. To detect a leak, Roger would have the patient hold his breath and strain (i.e., Valsalva maneuver) and then look for air bubbles around the fracture site, a clear sign of a leak. He was a pioneer in the techniques of managing peripheral nerve injury. In a severed nerve, he argued for reanastomosis of the nerve ends with close attention paid to their alignment. In dealing with the large bleeding veins of the neck, he urged direct ligation with suture rather than cautery. Several chapters of his text are devoted to the treatment of skull fractures. Much of the technique described mirrors the views of earlier classical writers, but the style is clearer and more succinct. An example of this style is seen in this short description of the management of various skull fractures:

FIGURE 1-14 Roger of Salerno’s demonstration of brain and skull surgery.

(From the Sloane manuscript, 1977—Courtesy of the British Museum.)

FIGURE 1-15 An early medieval manuscript on the writings of Roger of Salerno in which is demonstrated the “professor and student,” a reflection of the educational style of this period.

(From the Sloane manuscript, 1977—Courtesy of the British Museum.)

When a fracture occurs it is accompanied by various wounds and contusions. If the contusion of the flesh is small but that of the bone great, the flesh should be divided by a cruciate incision down to the bone and everywhere elevated from the bone. Then a piece of light, old cloth is inserted for a day, and if there are fragments of the bone present, they are to be thoroughly removed. If the bone is unbroken on one side, it is left in place, and if necessary elevated with a flat sound (spatumile) and the bone is perforated by chipping with the spatumile so that clotted blood may be soaked up with a wad of wool and feathers. When it has consolidated, we apply lint and then, if it is necessary (but not until after the whole wound has become level with the skin), the patient may be bathed. After he leaves the bath, we apply a thin cooling plaster made of wormwood with rose water and egg.⁴³^,⁴⁴

A 12th century manuscript owned by Harvey Cushing and attributed to Roger of Salerno has recently been translated. It contains an early description of a soporific for pain relief for use in surgery. Roger was particularly fond of citing the writings of Albucasis and Paul of Aegina. He strongly favored therapeutic plasters and salves but was not a strong advocate of the popular application of grease to injuries of the dura. He advocated the use of trephination for the treatment of epilepsy, although he is not clear why this technique would work. Chapters 1, Chapter 2, Chapter 3, Chapter 4, Chapter 5, Chapter 6, Chapter 7, Chapter 8, Chapter 9, Chapter 10, Chapter 11, Chapter 12, Chapter 13 (capita 1-13) detail contemporary surgical treatment of scalp wounds and fractures of the skull. One of his most significant errors in surgical practice was the concept that provoking suppuration of pus in a wound encouraged healing. This introduced the concept of “laudable pus” in wound healing and delayed good wound care until Lister and 19th century antisepsis.

An unusually talented and inventive medieval surgeon from Bologna was Theodoric of Cervia (Borgognoni, 1205-1298). In contrast to Roger of Salerno, Theodoric was a pioneer in the use of aseptic technique—not what we would refer to as the “clean” aseptic technique of today but rather a method based on avoidance of “laudable pus.” Theodoric thought that he had found the ideal principles for good wound healing, which included control of bleeding, removal of contaminated or necrotic material, avoidance of dead space, and careful application of a wound dressing bathed in wine, the last providing a degree of antisepsis. He also argued for primary closure of all wounds when possible and avoiding “laudable pus.”

For it is not necessary, as Roger and Roland have written, as many of their disciples teach, and as all modern surgeons profess, that pus should be generated in wounds. No error can be greater than this. Such a practice is indeed to hinder nature, to prolong the disease, and to prevent the conglutination and consolidation of the wound.⁴⁵^,⁴⁶

Theodoric’s surgical work, which was first written in 1267, provides one of the best reviews of contemporary medieval surgery.⁴⁵ He is also remembered as one of the earliest writers to include illustrations of his techniques. His recommendations called for meticulous (almost Halstedian) techniques with gentle handling of surgical tissues. Theodoric believed that aspiring surgeons should train only under competent masters. In the field of head injury, he argued that parts of the brain could be removed through a wound with little effect on the patient. In the treatment of skull fractures, he strongly argued for elevating depressed fractures. He advocated avoiding punctures of the dura because they could lead to abscess, convulsions, and bad outcomes. For pain relief during surgery, he developed his own “soporific sponge” that contained opium, mandragora, hemlock, and other less important ingredients applied to the nostrils, and once the patient fell asleep, he began surgery. Opium was probably the key ingredient.

William of Saliceto (Guglielo da Saliceto, 1210-1277) was a uniquely skilled Italian surgeon of the 13th century and a professor at the University of Bologna. His book on surgery, Chirurgia (or Cyrurgia), was completed in 1275, and in it we find highly original concepts that are not totally based on previous classical writings but in which the influence of Galen and Avicenna are clearly present.⁴⁷ This book was written by William for his son Bernardino. The observations offered are based on his own surgical cases. Book IV contains the earliest known treatise on surgical and regional anatomy. His most significant contribution for this era was probably his decision to replace cautery with the surgical knife.

De anathomia in communi et de formis membrorum et figures que sunt considerande in incision et cauterizatione.⁴⁷

He describes interesting and unique techniques for primary peripheral nerve suture repair. In this pre-Harvey era he distinguished arterial from venous bleeding by the “spurting” of blood. He also put forth interesting neurological concepts, such as that the cerebrum governs voluntary motion and the cerebellum involuntary function.

Leonard of Bertapalia (1380?-1460) was a prominent 15th century Italian surgeon and writer. Leonard established an extensive and lucrative practice in the area of Padua and in neighboring Venice. At a time when anatomic dissection was rarely practiced in Europe, he became one of the earliest proponents of the study of anatomy. In 1429 he offered a course of surgery that included the dissection of an executed criminal. He devoted a third of his book to surgery on the nervous system and head injuries.⁴⁸^,⁴⁹ He considered the brain the most precious of organs and regarded it as the source of voluntary and involuntary functions. In reviewing his treatment of skull fractures, he would always avoid materials that might generate pus. He argued for never placing a compressive dressing that might drive bone into the brain and proposed that if a piece of bone pierces the brain, the surgeon should remove it.

Leonard put together a set of rules to guide the practice of 15th century surgeons that have modern tones—rules still applicable 5 centuries later.

To be the perfect surgeon, you must always bear in mind these eight notations, and remembering them you will be preferred to others.

The first task to become a good surgeon should be to use his eyes.

Second, you must accompany and observe the qualified physician, seeing him work before you yourself practice.

Third, you must command the most gentle touch in operating and treating lest you cause pain to the patient.

Fourth, you must insure that your instruments be sharp and unrusted whenever you cut anywhere.

Fifth, you must be courageous in operating and cutting but timid to cut in the vicinity of nerves, sinews and arteries, and, so as not to commit error, you should study anatomy, which is the mother of this art perform your surgery cleverly and never operate on human flesh as if you were working on wood or leather.

Sixth, you must be kind and sympathetic to the poor, for piety and humility greatly augment your reputation and the sick will more freely commit themselves to your care.

Seventh, you must never refuse anything brought you as a fee, for the sick will respect you more.

Eighth, you must never argue about fees with the sick, or indeed demand anything unless it be previously agreed upon, for avarice is the most ignoble of vices and should you be so inflicted, you will never achieve the reputation of a good doctor.⁴⁹

Lanfranchi of Milan (d. 1306) was a pupil of William of Saliceto and often referred to as the father of French surgery. Lanfranchi advocated his teacher’s use of the knife in place of the burning cautery. Although born and educated in Italy, he had to leave Italy for France to avoid political strife. In his Cyrugia Parva we find a number of interesting surgical techniques. Lanfranchi perfected the use of suture for primary wound repairs.⁵⁰ He was among the first to relate the direct effect of head injury to brain function. Hippocrates was the first to articulate the concept of commotio cerebri, but it is to Lanfranchi that we owe the first modern characterization of what is now called a cerebral concussion. For surgeons he developed a series of guidelines for trephination in skull fractures and “release of irritation” of the dura. Because of the dangers of skull surgery, Lanfranchi argued for using the trephine only when absolutely necessary; otherwise, he evoked the skills of the “Holy Ghost” to provide cure. Among his innovative surgical techniques was the development of esophageal intubation during surgery, a technique not commonly practiced until the 19th century. As an educated surgeon and a “Surgeon of the Long Robe” (i.e., academic), he attempted to elevate the art and science of surgery above the mediocre level of the menial barber-surgeon (“Surgeons of the Short Robe”). Lanfranchi also argued against the separation of surgery and medicine, advocated since the time of Avicenna, for he thought that a good surgeon should also be a good physician.

After Lanfranchi came another important figure in the history of French medicine and surgery—Henri de Mondeville (d. 1317). Educated in Paris and Montpellier, Henri later went on to become a professor at Montpellier. He was strongly motivated to elevate the profession of the surgeon and clearly detested the barber-surgeon: “Most of them were illiterates, debauchees, cheats, forgers, alchemists, courtesans, procuresses, etc.”⁴⁶

In 1306 Henri undertook the task of developing a new treatise on surgery for the education of his students at Montpellier. Unfortunately, because of tuberculosis and ill health, the manuscript was never completed. Ironically, the edited portions were not published until 1892, when Professor Julius Pagel of Berlin completed the task.⁵¹ Henri adopted and followed a number of the views of Lanfranchi. He was a believer in clean wounds and avoiding “laudable pus.” Unfortunately, Henri would be the last surgeon in this era to argue for avoiding “laudable pus”; after him, surgeons returned to the older belief of pus developing in a wound being a good sign of healing. Henri offered originality in wound management by advocating for healing by primary intention—”modus novus noster.” In the surgical treatment of wounds, he encouraged the removal of foreign bodies and the use of wine dressings in wound care. Henri was clever in designing a number of surgical instruments. He is remembered for the design of a needle holder and also a forceps-type instrument for extraction of arrowheads. He argued against elevating skull fractures if there was no injury to the overlying soft tissues. He believed that nature would do a better job at healing the fracture by natural union. It was his opinion that unnecessary exploration and probing of the wound would only cause more injury than natural healing—in retrospect a rather brilliant insight into wound care (Fig. 1-16).⁴⁶

FIGURE 1-16 Surgical instruments designed by Lanfranchi are illustrated here in this early 1519 book.

(From Lanfranchi of Milan. Chirurgia. In: Guy de Chauliac Cyrurgia et Cyrurgia Bruni, Teodorici, Rolandi, Lanfranci, Rogerii, Bertapalie. Venice: Bernardinus Venetus de Vitalibus; 1519.)

No history of surgery can be complete without a discussion of the contributions of Guy de Chauliac (1300-1368) (Fig. 1-17).⁵² This surgeon was clearly the most influential European surgeon of the 14th and 15th centuries. He was so highly respected that he became the physician for three popes at Avignon (Pope Clement VI, Innocent VI, and Urban V) and leading surgeon and educator at the school of Montpellier. Guy was educated at Toulouse, Paris, Montpellier, and Bologna. He was an early proponent of anatomic dissection of a human cadaver. He states: “In these two ways we must teach anatomy on the bodies of men, apes, swine, and divers other animals, and not from pictures, as did Henri de Mondeville who had 13 pictures for demonstration of anatomy.”⁵³ His writings were popular and continued to exert an influence on surgery until well into the 17th century. His principal didactic surgical text was scribed in 1363 and titled the Collectorium Cyrurgie.⁵³ There are 34 known manuscripts of this work, with the first printed edition appearing in 1478, and more than 70 editions followed. In promoting surgeons as more skilled individuals (versus “mechanics,” i.e., barber-surgeons), he stated four conditions that must be satisfied for a practitioner to be a good surgeon: (1) the surgeon should be learned; (2) he should be an expert; (3) he must be ingenious; and (4) he should be able to adapt himself (from the introduction of Ars Chirurgica). For the modern neurosurgeon, Guy provides an interesting discussion of techniques that he devised for the treatment of head injuries. Before beginning surgery the head needs to be shaved. Shaving of the hair will prevent hair from getting into the wound and interfering with primary healing. For depressed skull fractures, Guy preferred to put wine-soaked cloths into the injured site to assist healing. He categorized head injuries into seven types and discussed the management of each in detail. Scalp wounds required only cleaning and débridement, whereas a compound depressed skull fracture must be treated by means of trephination and elevation. Skin closure was done by primary repair and for which he claimed good results. To help control excessive bleeding and provide hemostasis, he used egg albumin.

FIGURE 1-17 Title page from collected works dealing with the surgical writings of a number of medieval surgeons, including Guy de Chauliac.

(From Guy de Chauliac. Chirurgia magna. In: Guy de Chauliac Cyrurgia et Cyrurgia Bruni, Teodorici, Rolandi, Lanfranci, Rogerii, Bertapali. Venice: Bernardinus Venetus de Vitalibus; 1519. See also Leonardo, RA: History of Surgery. New York, Froben Press, 1943:116.)

As England was moving away from the barbarian invasions and into the Middle Ages, university education in England began to become comparable to the European model. The leading surgeon of this period in England was John of Arderne (Arden, 1307-1380), who trained as a military surgeon and saw much war experience. In 1370 he came to London and joined the Guild of Military Surgeons. He adopted the phase “chirurgus inter medicos,” or a surgeon among physicians. His manuscript on surgery was written about 1412.⁵⁴ This manuscript, De Arte Phisicali et de Cirurgia, was translated into English by D’Arcy Power in 1922, a valuable addition to the English literature on early surgery.⁵⁵ His writings suggest that he was a skilled surgeon and had a number of practical insights into what could or could not be done surgically. He was a firm believer in clean hands and well-shaped nails for surgery, although some writers have thought that this was more for social reasons than for surgery.⁵⁶ In addition, he would bathe his open wounds with an irrigation fluid that contained turpentine, a useful surgical antiseptic for keeping wounds clean. Most importantly, John of Arderne was a firm believer in education and learning. The surgeon must also “always be sober during any surgery as drunkenness destroys all virtue and brings it to naught.”⁴⁶

In reviewing the late Byzantine/Islamic and Medieval period we see an era of great misguided intellectual activity, an era of innovative somnolence where originality of thought is concerned. Clearly, the educators had more faith in the teachings of antiquity. From the fall of the Roman Empire until the beginning of the 16th century, anatomy and the practice of surgery, with rare exceptions, lay dormant, chained to a staunch Galenic and Hippocratic orthodoxy. The transliteration of medical manuscripts from Latin, Greek, and Hebrew into Arabic and back into Latin resulted in many errors of translation and interpretation. The combination of a lack of anatomic knowledge and poor surgical outcomes naturally led physicians to recommend against operating on the brain, except in simple cases. A review of the work done by the surgical personalities described previously reveals that despite a period of intellectual paralysis, there still existed a number of prominent personalities who did make advances. Monastic recluses in often-inaccessible mountain retreats carefully guarded medical knowledge, yet some surgeons nonetheless succeeded in mastering their art in the midst of intellectual darkness.

The history of medicine consists of a successive series of intellectual movements proceeding from different centers and each engulfing its predecessor.⁵⁷

Origins of Neurosurgical Practice in the Renaissance

With the origins of the Renaissance came innovations in surgical concepts and techniques. Beginning in the mid-15th century, physicians and surgeons introduced basic investigative techniques to learn human anatomy and physiology. Of enormous significance was the introduction of routine anatomic dissection in medical schools. Moving away from subservience to the medievalists, great figures such as Leonardo da Vinci, Berengario da Carpi, Nicholas Massa, Andreas Vesalius, and others explored the human body without being encumbered by the erroneous writings of earlier authors. Codified anatomic errors, many ensconced since the Greco-Roman era, were now being corrected. A better understanding of human anatomy led to a change in epistemological presuppositions and in turn resulted in a great surge of interest in surgery. Putting the teachings of antiquity aside, surgeons went forward with great vigor and enthusiasm to unravel the human fabric. This shift from the somber and somnolent medieval period to the enlightened, radically inventive Renaissance made it possible to lay the early foundations of modern neurosurgery.

Any discussion of Renaissance surgery and anatomy has to begin with Leonardo da Vinci (1452-1519), the quintessential Renaissance man (Figs. 1-18 to 1-20). Multitalented and recognized as an artist, an anatomist, and a scientist, Leonardo went to the dissection table to better understand surface anatomy and its relationships to art and sculpture. From his studies Leonardo is now recognized as the founder of iconographic and physiologic anatomy.⁵⁷^–⁵⁹ For the neurosurgeon, Leonardo provided the earliest, albeit crude, diagrams of the cranial nerves, the optic chiasm, and the brachial and lumbar plexuses. He developed a wax-casting technique that allowed him to understand the anatomy of the ventricular system. To do this he took a fresh brain and poured liquid wax into the ventricles; a hollow tube was inserted to allow egress of the air. Leonardo’s experimental studies included sectioning a digital nerve and noting that the affected finger no longer had sensation, even when placed in a fire. Leonardo was not a surgeon, but he gave an important impetus to the study of anatomy and defining correct anatomic relationships—vital concepts for any surgeon. Unfortunately, Leonardo’s great opus on anatomy, which was to be published in some 120 volumes, never appeared.⁶⁰ His anatomic manuscripts circulated among the artists in Italy throughout the 16th century, only to be lost and then discovered in the 18th century by William Hunter. These anatomic works had a profound influence on artists and physicians and subsequently on the development of modern anatomic studies. Leonardo, as a founder of modern anatomy, provided a creative spark to re-explore the human body by hands-on dissection.