Trepanation – history and pictures
Trepanation is a surgical manipulation, consisting of drilling the skull or other bones. Everywhere in the world, where traces of old civilizations have been found, there is evidence of cranial trepanation. The largest deposit of trepanation skulls in the world is in the Parkas` and Parahamats` tombs in Peru (3000 years BC). A skull with plastic of a silver plasty and twice trepan Indian skull have been found there, which were probably made because of injuries in various battles. In antiquity “tools” of flint, deer horns and tortoise shells have been used, and trepanation was made by scraping or rotating the tool in a circle.
The papyruses “Ebers” and “Edwin Smith”, which contain the most precise written data about ancient Egyptian medicine, contain descriptions of 15 injury types of the skull and the spine. The terms brain and brain curves are mentioned for the first time in these documents, the connection between brain injury and hemiparesis on the opposite side are described here, it is written about neck rigidity, paraplegia and urinary retention in medullispinal injury. There are also defined the indications for surgical and conservative treatment of the skull and spinal cord traumas, as well as their prognosis. For example, in the papyrus “Edwin Smith” it is written that the slow pulse and fever in skull fractures talk about forlorn case, but deafness and aphasia are sign of fracture and contusion in the temporal lobe.
There is indisputable evidence today that trepanations were made even in the Stone Age. The first trepanations were made because of religious motives and they are manifestations of the ideas of the supernatural, because the trepanation was aiming to remove the “evil spirit” in some diseases – insanity, epilepsy, idiotism. There is data about the performance of ritual trepanation. In the museum Gimel in Paris, a prayer rosary is kept, which consists of 106 rondeli, taken by trepanation of Tibetan hermit monks when they were still alive, who were having “holy” spiritual qualities. Gradually, these pure religious ritual indications have passed in medical, and trepanation has started to be used in convulsions, headache, cerebral trauma and the other mental diseases.
The history of trepanation goes back to Hippocrates (460-377 years BC), who examined the brain as an addition to the spinal cord and place of thoughts and feelings. His treatise “The head wounds” is a landmark creation in the neurosurgery at the dawn of medical knowledge and practice. Hippocrates gives the first classification of cerebral traumas and defines rules for their treatment. According to him, the trepanation indicators are:
- Depression (sagging) of the bone.
- Flowing of blood or pus from the cranial fractures.
- Presence of “fluid” in the skull.
The rule which is valid until today is ascribed to Hippocrates – Ossicullum quod premit exemere (the bones pressing the brain must be removed).
In the first century of the new epoch, some new anatomical, physiological and neurosurgical knowledge have been accumulated. Claudius Galenus (130-201) proved that the brain is an organ of feeling and thinking. He was the first experimenter in this field, and the creator of many instruments for skull trepanation. With the decline of the Roman Empire, the medical knowledge known by then had been forgotten for centuries. Only in Athens, Alexandria and Constantinople some of the medical knowledge and surgical experience from antiquity have been kept.
While in Europe the surgery fell behind under the religion influence, the nations of the East that have been keeping the medical knowledge of antiquity, have progressively developed the medical theory and practice. In 927 in India two surgeons – Chahaka and Sashruta, made with great success the first historical operation of a brain tumor. At the same time the famous Arabian surgeon Abulkasis was trying to treat hydrocephalus by trepanation and dura opening, in order to remove the fluid which was accumulated in excess. The initial results were bad and the patients died of infection.
One important area, where the neurosurgery achieved success, is exactly the treatment of hydrocephalus and inborn malformations of the CNS. Variety of cerebrospinal fluid drainages started from 1898, when Ferguson put a tubule in the lumbar region through the vertebra towards the peritoneal cavity. In 1932 ventricolocisternotomy was presented– one physiological operation in which the obstruction of CSF flow is rounded by the means of a tubule. After that there were studies that followed, demonstrating that the key to success in CSF – drainage systems is in the unidirectional valves, constructed of inert materials. In 1956 the valve of John Holter was created, which has gone through different improvements and modifications and finally in the 60’s it was introduced and widely used for the different types of valvular shunt systems. One of the greatest surgeons of the XIV century – Gui de Chauliac (1298 – 1368) has successfully resected parts of the brain in traumatic injuries. He is famous for curing the terrible headache of Pope Clement IV-th by trepanation.
In the Renaissance epoch, Andreas Vesalius (1515-1564) described the cerebral ventricles, but he believed that they were filled with air. He became famous for the operation which he made to Don Carlos – he got out an abscess from the temporal lobe. Later Varoli (1543 – 1576) paid attention to the fact that the cerebral ventricles are not filled with air but with liquid, which is produced by plexus chorioideus. Ambroise Pare (1517-1590), a surgeon who was famous in the whole world, made the first laminectomy in 1549, which was because of pressure on the spinal cord from bone fragments. He commanded and applied with success cranial trepanation.
Hunter is a one of the first, who paid attention to the surgical removal of the brain tumors. In 1725 Cat operated spinal tumor, and in 1775 the Swede O. Acrel operated infiltrated brain tumor with a good result. At the same time during the XVI and XVII century some quackish and dangerous operations for the health appeared. Unscrupulous “false-surgeons” made trepanations for removing from the brain of the so called “stone of madness”, in patients with epilepsy and neuropsychiatry disorders.
With the development of asepsis, haemostatic and anesthesia, an unprecedented push was given to the surgery and its branches. Therefore the XIX century is considered as the beginning of the modern neurosurgery. For the development of this specialty, the new diagnostic tests and methods have particularly helped. In 1918 ventriculography and pneumoencephalography were introduced, 1921 – myelography, 1924 – electroencephalography, 1927 – brain angiography. The study of cerebral localization of the functions of different brain centers was determined and developed.
The real bloom of modern neurosurgery is associated when the operating microscope was put into practice and the creation of microsurgical techniques. The first micro – neurosurgical procedure on a person is considered to be the embolectomy (removal of the embolus) of the middle cerebral artery, performed in 1960. Microsurgery is widely used, giving opportunities for radicalism and much better performance in all neurosurgical operations. Transsphenoidal access to the hypophysis is established thanks to microsurgery. Advantages of the microscope in the surgery of peripheral nerves are entering more widely in the practice. Gradually but quickly, micro-neurosurgery becomes routine surgery technique that the present neurosurgery would be unthinkable without it.