The first modern brain surgery

“Trepanation” of the cranium was thought to be the first neurosurgical procedure. Its use was mainly for headaches, seizures, mental illnesses, bad spirits and traumatic brain injuries. Together with cranioplasty, it seems that they have been performed since the period of Inca, counting that head and spinal cord injuries existed since the beginning of time.

The first modern brain surgery in the United States is credited to Drs. Hirschfelder and Morse, who removed a patient’s brain tumor on February 25, 1886. The actual operative procedure recorded was performed by John Frederick Morse. Hirschfelder’s paper represents the first report in the history of America neurological surgery of an attempt to remove a tumor of the brain.

This operation followed fourteen months after the first recognized resection of a primary brain tumor in history was performed by Mr. Rickman Godless in London, England, November 25, 1884. This operation was carried out at the suggestion of Dr. A. Hughes Bennett, a neurologist at The Hospital for Epilepsy and Paralysis, Regents Park, London, England.

Early in 1887 the first well-documented total removal of an unequivocal brain tumor in America was carried out in New York City by Robert F. Weir. The patient died during the immediate postoperative period.

In the early 1900s Harvey Williams Cushing, “the father of neurosurgery,” performed the first successful operations for brain tumors.

Harvey Cushing brought modern neurosurgery into the world. Since then, neurosurgery has reached such levels of development that it may considered to be one of the most futuristic specialties of all times. In 1937 Walter Dandy performed the first aneurysm clipping.
The first modern brain surgery

The use of anaesthetics before 19th century

From ancient times anesthesia in surgery has been attempted by various agents or anaesthetics.

From 9th to 13th century, the soporific sponge was the usual mode of providing pain relief during surgery. Mandrake leaves, black night-shade, poppies and other herbs were boiled together and cooked onto a sponge.

Prior to surgery, this sponge was moistened and held over the face to induce unconsciousness. Nitrous oxide first accurately investigated by Sir Humphrey Davy in 1799. He experimented freely with it upon himself and others and ascertained its remarkable property, when inhaled of annulling pain.

Ether was administered from the early 1840s, but the impact on general medical practice began after William Thomas Green Morton publicly administered ether to Gilbert Abbot in 16th October 1846 at Massachusetts General Hospital, Boston.

In 1858, Benjamin Ward Richardson published his studies using an apparatus that sprayed ether topically and froze the peripheral nerves by evaporation.

In 1847 James Simpson discovered the benefits of chloroform while experimenting with chemicals at home with some doctor friends. He later used it for women giving birth, and the idea spread to other operations.
The use of anaesthetics before 19th century

Antiseptic practice in surgery

Greek medicine used wine and vinegar in wound dressing. Alcohol gained favor and around 1820 iodine became popular in France for treating wounds.

Charles White (1728-1813) of Manchester emphasized the importance of cleanliness in obstetrical practice while Oliver Wendell Holmes (1809-1894), in a paper On the Contagiousness of Puerperal Fever in 1843, argued that women in labor should not be treated by a doctor who had recently conducted an autopsy or how had treated a patient with puerperal fever.

Germ-theory first came to the attention of medical practitioners in the controversies over antiseptic surgery that began in Britain in the late 1860s. Joseph Lister accepted Louis Pasteur’s notion that microorganisms were involved in suppuration and began developing the elements of antiseptic wound management in 1865.

Joseph Lister

By the end of the decade, Lister has created an elaborate surgical protocol incorporating antiseptic sprays and dressings, particularly of carbolic acid.

As early as 1874, Pasteur had suggested placing the instruments in boiling water and passing them through a flame; heat sterilization of instruments was accepted by Robert Koch in 1881.

Primed with the science of bacteriology and knowledge of Pasteur and Koch’s laboratory autoclaves surgical heat sterilization emerged in France and Germany between 1883 and 1893.

Neuber of Kiel was probably the first to autoclave operating gowns in 1883 and then advocate sterile caps and rubber shows in 1886.

In 1867, Lister published Antiseptic Principle of the Practice of Medicine. Within five years, surgeons using Lister’s antiseptic techniques were able to reduce the surgical mortality rate from nearly 60 percent all the way down to 4 percent. By the time Lister retired in 1892, antiseptic surgery had established itself.
Antiseptic practice in surgery

Theodoric Borgognoni (1205-1298)

One of the most important medieval surgeons, also known as Teodorico dei Borgognoni, Teodorico of Lucca, and Teodorico of Cervia, Theodoric Borgognoni was born in Lucca (Tuscany) in 1205. He was the last of the five children of the Luccan surgeon Ugo Borgognoni (d. c. 1259).

Theodoric was a medieval Italian surgeon who anticipated Henri de Mondeville, Paracelsus and Lord Joseph Lister in suggesting that cleanliness was of major importance in wound healing.

Theodoric moved to Bologna in 1214 when his father was hired as town physician, possibly at the instigation of count Rodolfo Borgognoni.

Theodoric learned the art of surgery from his father, an art he exercised with notable success both inside and outside the monastery. Though he joined the Dominican Order and later became a bishop, Theodoric continued to practice surgery and composed a textbook on the subject.

He compiled a Surgery in 1267 in which he proposed that the common practice of promoting suppuration in a wound by probing, packing and dressing was worse than useless. Indeed, he recommends that ‘all wound except bruises ought to be dried out’.

Theodoric Borgognoni was also an advocate of anesthesia and there is evidence that attempts were made to induce a state of unconsciousness to allow surgery to be carried out. Opiates and other plant extracts, including hemlock were soaked into a sponge which was then held under a patient’s nose.
Theodoric Borgognoni (1205-1298)

A Course of Treatment by Egyptian Doctors in 1300 BC

Medical practice in Egypt was based on specialization, so that there were different doctors for the eye, teeth or head. Egyptian doctors also were well aware of their limitations, however, and were told not to inflict unnecessary suffering on their patients, so there were many case where they had to say at least – ‘An ailment not to be treated’. They were recommended to take note of the treatments and medicines they used and of their effects, so that they had a record for similar cases in the future.

There were medicines to be taken internally, other to be applied to the outside of the body, and others still to be inhaled. Egyptian ingredients that can be identified today appear to be sound herbal remedies. However, some medicines had ingredients such as mice, beetles and dung, which aimed to drive out the demons causing the illness.

The Egyptians had a remarkable knowledge of the way the body worked, and knew about its internal arrangements through mummifying the dead. For them, the heart was the most important organ; they knew that it pumped blood round the body, and that the pulse ‘spoke the messages of the heart’. They also knew that injuries to one side of the brain affected the opposite side of the body.

In ancient Egypt, head wounds were treated buy application of a piece of meat on the first day, followed by a linen cloth soaked in honey or fat. With skull fractures, the patient was advised to maintain a sitting position, supported by bricks on either side.

Unlike the Mesopotamian medical traditions, Egyptians were surgically oriented and reset fractured, treated wounds and trephined the skull.

Doctors sometimes used surgery as well as medicine to treat patients, and opened injured skulls to relieve pressure in the brain. Before an operation the surgeon gave his patient a drink, presumably a painkiller, ‘to render it agreeable’. In the New Kingdom the painkiller might have been opium, imported from Cyprus.

There is evidence of opium use by ancient Egyptians in 1300 BC for the treatment of ‘excessive crying in chidlren’, and opium-soaked sponges were used to facilities surgery.

Because of the importance the Egyptians attached to ritual purity the surgeon and his assistants washed themselves and purified the instruments in fire before the operation. Both of these would cut down the risk of infection.

There is not much evidence of formal hospitals per se; Egyptians physicians, however, made house calls, had officially assigned duty stations at temples, and formally assigned to military units.

The Egyptians were a deeply religious people and prayers would always be used as well as medicines, even for the simplest ailments. In difficult cases, magic might be employed. It was also possible to visit temple of a deity associated with medicine, such as Imhotep, which had priests trained as a doctors.

At some temples the sick could spend a night close to the god’s sanctuary. During such stay, called ‘incubation’, the patient might be cured by the deity, or dream of the god and receive instructions for treatment. Even if no help was forth coming, the sufferer was spiritually comforted.
A Course of Treatment by Egyptian Doctors in 1300 BC

First caesarian birth in Europe

European Renaissance period saw a revival of interest in medicine after the Dark Ages.

Caesarian section is the important surgical procedure in obstetrics. It can be traced to a 700 BC Rome, when the procedure was first used to remove infants from women who died late in pregnancy.

In 1500, Jacob Nufer, farmer from Sigershauffen, Switzerland, successfully performed the first known caesarian in Europe on his wife, after doctors were unable to help her. This legend is one of the most commonly repeated stories and it’s supposed to refer to the first caesarian carried out on a live women.

The maternal mortality rate was high up to the end of the nineteenth century, most often because of hemorrhage and infection.

The first modern caesarian section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881. He successfully used a lower uterine incision for caesarian section.
First caesarian birth in Europe

Trephination of the skull

Trephination of the skull
Undoubtedly the most extraordinary story in the history of surgery is that, long before man could read or write, as long ago as 10,000 BC, surgeons were performing the operation of trephination or trepanning – boring or cutting out rings or squares of bones from skull – and just as remarkably, their patients usually recovered from the procedure.

Although the word ‘trepanation’ and trephination’ today are interchangeable in common practice, trepanation comes form the Greek trypanon, meaning a borer, while trephination is or more recent French origin and indicates an instrument revolving around a central spike.

Trepanation thus connotes scraping or cutting, while trephination describes drilling the skull, as in modern neurosurgical operations.

Different techniques of trepanation in ancient times, and in recent primitive communities, involved scraping away bone, making a circular groove so that a central core of the bone would loosen, boring and cutting away the bone, or making rectangular interesting incisions in the skull.

This story begins in 1865 when a general practitioner Dr Prunires, who was also an amateur archeologist, discovered in a prehistoric stone tomb in Central French a skull which bore a large artificial opening on its posterior aspect.

With it, he found a number of irregular pieces of bone which might have been cut from another skull.

He postulated that the skull had been perforated so that it might be used as a drinking cup.

Soon after this, a number of other holed skulls were found in other parts of France and Professor Paul Broca (1824-1880), a distinguished French physician, suggested that these opening were the result of an operation of trepanation and that the instrument employed was a flint scraper.

Broca suggested that survivors of operation were endowed with mythical powers and that, when they died, portions of their skull, especially those that included a part of the edge of the artificial opening, were in great demand as charms.

Following these discoveries, thousands of such specimens have been discovered from many parts of the world: the United Kingdom, Denmark, Spain, Portugal, Poland, the Danube Basin, North Africa, Palestine, the Caucasus, all down the Western coastline of the Americas and especially in Peru, where more than 10,000 specimens have been excavated.
Trephination of the skull

Medicine in Mesopotamia

Medicine in Mesopotamia
Civilization as we recognize it today with cities, organized agriculture, government and a legal system dates back some 6000 years to the Valley of the Nile and the adjacent land of Mesopotamia between the Tigris and Euphrates.

Great Kings arose, such as Sargon of the city of Akkad (around 2350 BC), who subjugated the whole of Sumeria and Hammurabi (around 1900 BC), who established his capital at Babylon.

In time, Babylon was conquered by Tiglath-Pileser, king of the northern neighbor Assyria, with its capital at Nineveh around 1100 BC.

The medicine of Mesopotamia was primarily medico-religious. Practitioners were priests and were ruled by the strict laws include in the code of King Hammurabi.

This code, carved, on a black stone about eight feet high which was discovered at Shush in what is now Iran in 1901, can be seen today in the Louvre Museum in Paris.

His code details family law, the right of slaves, the penalties for theft and rewards for success and severe punishment for failure on the part of the surgeon.

There are evidence from these writings that surgical conditions such wounds, fractures and abscess were treated. Thus it can be read:

If a doctor heals a free man’s broken limb and has healed a sprained tendon, the patient is to pay the doctor five shekels of silver.

If it is the son of nobleman, he will give him three shekels of silver.

If the physician has healed a man’s eye of a severe wound by employing a bronze instrument and so healed the man’s eye, he is to be paid ten shekels of silver.

If a doctor has treated a man for a severe wound with a bronze instrument and the man dies and if he has opened the spot in the man’s eye with the instrument of bronze but destroys the man’s eye, his hands will be cut off.

If it were not for Hammurabi’s code of law, all memory of surgery in Babylon, nearly 4000 years ago, would have been lost.

Surgery as a craft was hardly worth mentioning only when it became of interest to the law was it engraved in stone.
Medicine in Mesopotamia

Surgery in Prehistoric Times

Surgery in Prehistoric Times
The word ‘surgery’ derives from the Greek cheiros, a hand and ergon, work. It applies therefore to the manual manipulations carried out by the surgical practitioner in effort to assuage the injuries and diseases of his or her fellows.

There seems no reason to doubt that since Homo sapiens appeared on this earth, probably some quarter of a million years ago, there were people with a particular attitude to carry out such treatments. After all, there is an innate instincts for self preservation among all mammals, let alone man, so that a dog will lick its wounds, limp on three limps if injured, hide in a hole if ill and even seek out purging or vomit making grasses and herbs if sick.

Palaeopathologists have, however discovered abundant evidence in excavations of ancient skeletons that fractures, bone diseases and rotten teeth tortured out oldest ancestors. Of course, animals were subject to all sports of diseases. Indeed, a bony tumor was obvious in the tail vertebrae of a dinosaur that lived millions of years ago in Wyoming. Other excavations also reveal that injuries were inflicted by man upon man and that broken bones were splinted and skull operated upon.

Injuries inflicted by falls, crushing, savage animals, and by man upon man, demand treatment; among primitive tribes in the aforementioned studies, open wounds were invariably covered by some sort of dressing. This might take form of leaves, parts of various plants, cobwebs, ashes, natural balsams or cow dung.

Indeed, even in a recent times, the use of dung as a dressing for the cut umbilical cord in West Africa village babies still took place and was responsible for many cases of ‘neonatal tetanus’ from the tetanus spores that are almost invariably present in faeces.

Among Masai of East Africa, wounds were stitched together by sticking acacia thorns along the two edges of a deep cut and then plaiting the thorns against each other with plant fiber. In both India and South Americans termites or beetle were employed to bite across the edges of the wound whose lips were held together by the surgeon.

The bodies of the insects were then twisted off, leaving the jaws to hold the laceration closed, remarkably like the metal skin clips employed in operating theaters today. Splints of bark or soft clay were used to immobilize fractured limps and such bark splints have been excavated from ancient Egyptian burial sites.

Apart form dealing with wounds and fractures, early surgeon carried out three types of operative procedure, namely cutting for the bladder stone, circumcision and trephination of the skull.
Surgery in Prehistoric Times

History of Anesthesiology

History of Anesthesiology
Anesthesiology is a knowledge or study how to have a condition of having sensation blocked. Other definition is “reversible lack of awareness”. This will allow patients to undergo surgery and procedures without feel pain.

In ancient Incas, shaman coked up chewed coca leaves and drilled holes in the heads of their patients while splitting into the wounds they’d inflicted.

Dated in 4200 BC, Sumerian people used opium poppies as herbal remedy. Opium then was introduced to China in 330 BC and India in 600 BC.

Assyrian and Egyptian physicians obtained artificial sleep for their patient by quickly compressing the Carotid vessels of their neck. This practice was followed as well by the Greek physicians. Arab translation of the Greek medicine helped to make Islamic physicians supreme in the middle ages.

Abulcasis and Avicenna wrote about anesthesia in their book: Al-Tasrif and The Canon of Medicine. Baghdad at that time became the world’s leading medical and drug center. With the skill of the Arab Alchemists, the art of drug making began to evolve into the science of Pharmacology. Western physicians emerging from the Middle Ages found the Arab pharmacopoeia, in which a list of medicinal plants composed the anesthetic armamentarium.

British Chemist Humphry Davy in 1799 discovered a nitrous oxide or a laughing gas that have anesthetic quality. The discovery was ignored until Connecticut dentist Horace Wells began to experiment using nitrous oxide as an anesthetic during tooth surgery.

In 1846, dentist, William Thomas Green Morton performed the first public demonstration of diethyl ether (then called sulfuric ether) as an anesthetic agent, for a patient undergoing an excision of a vascular tumor from his neck. Chloroform was introduced as a surgical anesthetic by Scottish obstetrician James Young Simpson in 1847. Although it can eased pain of labor, chloroform had higher risks than those associated with ether.

The first effective local anesthetic was cocaine. Isolated in 1859, it was first used by Carl Koller, at the suggestion of Sigmund Freud, in ophthalmic surgery in 1884.

Chemical substance that has a morphine-like action, Opioids was first used by Racoviceanu-Piteşti, who reported his work in 1901.
History of Anesthesiology