Nine centuries of cranial surgery

Abstract

José María López Piñero is emeritus professor of the history of medicine at the Institute for the History of Science and Documentation “López Piñero”, University of Valencia. Since 1959 he has published almost 100 books on the history of neuroscience, Spanish medicine, and science from the 16th-19th centuries. At the beginning of this millennium Albucasis, a key person in the evolution of cranial surgery, neurosurgery's main historical root, died in Córdoba, which at that time was the capital of Muslim Spain and one of the centres of medicine, science, and culture. In the surgical part of his vast medical treatise, Albucasis systematically reviewed classical Greek surgery, from the followers of Hippocrates to Galen, Byzantine surgery, and elements of the classical surgery of India. He enriched his writings with personal contributions, especially about operating techniques and instruments. For craniectomy he recommended the use of knives in the weaker bony areas and for inexperienced surgeons. Otherwise he recommended various drills, almost all “unsinkable” (with a little protecting wheel) over the extremity to avoid injuring the dura mater. Albucasis' original Arabic text was translated into Latin under the title Chirurgia by an Italian, Gerardo da Cremona in 12th-century Toledo. Albucasis' Latin translation was adopted at the University of Bologna, the original nucleus of European surgery in the early Middle Ages. The foremost cranial surgeon in Bologna was Guido Lanfranco, who died in 1306. He trepanned the skull to treat wounds to the head when bony splinters were situated below the skull or if the dura had suffered a puncturing injury. He also attempted to suture severed nerves. University training of surgeons started in Bologna, and here began also, at the beginning of the 14th century, dissection of corpses for the sake of anatomical teaching. Both novelties spread to other Italian universities, to Montpellier, and to some Spanish ones during that century and the next. Elsewhere in Europe dissection of corpses became institutional only later and surgeons continued to train as simple craftsmen until the 18th century. For this reason, with a few exceptions such as Ambroise Paré, the main contributions to cranial surgery during the Renaissance were made by university-trained surgeons. Men like Giovanni Andrea della Croce (1573) who renewed the instruments and the operating technique of trepanning or Andrés Alcázar (1575) who introduced rigorous attention to neurological symptoms before considering surgery indicated. In general, during the 17th century surgery hardly advanced. Two complex historical events concurred in the making of neurosurgery: the development between the 17th and the 19th century of the surgical revolution, and of the neurosciences—ie, of its technical and scientific foundations. Notoriously, the milestones of the surgical revolution include the introduction in the 18th century of operating techniques based “on topographical anatomy, and in the 19th century of inhalational anaesthesia, especially after William T G Morton (1846), and the new antiseptic era ushered in by Joseph Lister's research. Descriptive neuroanatomy, which was the weakest aspect of the works of Vesalius and of other morphologists of the Renaissance, developed during the time between the 17th-century treatises by Thomas Willis (1664) and Raymond Vieussens (1685) and the first decades of the 19th century, with the contributions, among others, of Félix Vicq d'Azyr, Luigi Rolando, Charles Bell, and Samuel T yon Sömmering. Later, at the turn of the 19th century, with Santiago Ramón y Cajal's neuron theory, neurohistology was to join microscopic anatomy based upon cellular theory. Experimental neurophysiology's initial milestone was Bell and Magendie's law (1811-22), which culminated 100 years later in the reflexological research of Charles S Sherrington and Ivan P Parlor. Investigations about cerebral localisation of functions became closely linked to neurosurgery once the area for articulate speech had been identified by Paul Broca (1861). The pathology and the clinical study of the nervous system were addressed in various treatises during the first half of the 19th century. However, it was not until its final years, under the impulse of Jean M Charcot, Ernst Leyden, and John H Jackson, that it began to rely systematically upon the microscopical examination of lesions, experimental investigations of dysfunction and the causes of diseases. During the same period, a number of general surgeons, among them Victor Horsley and Ernst yon Bergmann, did the first important neurosurgical procedures. Neurosurgery became a self-standing specialty during the first decades of the 20th century. Its starting point can be identified with the works of Harvey Cushing (1869-1939), the first neurosurgeon strictly speaking and founder of the oldest neurosurgical society (1920). During the late 20th century, neurosurgery became an exciting discipline and is now exploring areas Albucasis could not have imagined.