Fig. 1.1
(a) A human skull from Peru dating to about 600 A.D. In the occipital bone is a trephination done for unknown reasons. The well-healed bony margins indicate the “patient” survived the operation. From the author’s collection. (b) A skull with a large right occipital trephination done for unknown reasons. Along the lower edge of the trephination are signs that show healing, so it is likely the patient survived this procedure. Courtesy of the Museum of Man collection, San Diego, California
The only accounts of posterior fossa surgery from the Greco-Roman era appear in the writings of Galen of Pergamon (130–200 A.D.), from an area of what is now Turkey [3–6]. In Galen’s writings on anatomical procedures, he describes a series of animal dissections in which he exposed the cerebellum and the fourth ventricle, investigations which were done in the second century A.D. Using primarily the rat, he made a linear incision from the inion down to the foramen magnum. Galen studies were done in living animals with bleeding being controlled by finger pressure and scalp retractors. The craniectomy was done with a series of chisels, especially designed for this operation. After the skull bone was removed, Galen described the pulsating brain, especially seeing it rise up out of the craniectomy when the animal was agitated. Galen’s technique of opening the dura was no different than what we do today. Galen used a small hook to elevate the dura away from the cerebellum and then incised it with a sharp knife carefully avoiding any of the venous sinuses, overlying cortical vessels, and the cerebellum. Galen pointed out in his discussion of the surgery that problems like cessation of breathing could occur along with motor or sensory loss. The voice could become hoarse and even death could occur. From experimentation, Galen noted that compression of the fourth ventricle could lead to severe impairments and even death. It is well known that Galen was a surgeon to the gladiators, so it is possible that he was involved in the treatment of traumatic injuries to the posterior fossa; whether he ever operated on these types of injuries is open to conjecture. Interestingly, Galen describes in his anatomical dissections splitting the vermis to expose the fourth ventricle in living animals. Galen carefully adds his comment that severe neurological impairments can happen with this technique; nevertheless, it was a useful way to expose the floor of the fourth ventricle. Galen was the first to describe the calamus scriptorius, which is seen on the floor of the fourth ventricle using this surgical exposure. Galen, throughout his writings, noted that knowledge of the surgical anatomy was absolutely key for the surgeon; without this knowledge, the surgeon would be prone to serious errors and bad outcomes. Unfortunately, much of Galen’s animal anatomy was incorrectly transliterated into human anatomy and then carried forward by various translations (e.g., Latin, Greek, and Arabic) to the time of the Renaissance. As we shall see, it was the Renaissance artist that led the drive to first understand and describe human anatomy from hands-on dissections of humans Fig. 1.2.
Fig. 1.2
An early English translation of Galen’s writing including his “office of a chirurgion” in which he details his surgical techniques along with general works on medicine [5]
1.3 The Sixteenth Century: The Origins of Modern Anatomy and Surgical Investigation
At the end of the fifteenth century, the intellectual currents in Europe were undergoing profound changes. With the introduction of the printing press and moveable type, books could be more easily and cheaply produced. As the intellectual shackles of the Middle Ages were being removed, physicians were beginning to rely more on what their eyes taught them at the bedside. The previously held concepts of the early anatomists like Galen of Pergamon and others would be challenged in their accuracy. One of the most important intellectual currents in surgery and medicine at this time were the schools of anatomical studies like Michelangelo, Titian, and Leonardo da Vinci among others [7, 8]. In an attempt to provide more realistic surface anatomy of the human, these individuals were doing hands-on dissection unencumbered with the earlier medieval anatomical texts and doctrines that were rife with errors. The “typical” surgeon at the beginning of the sixteenth century was nothing more than an unskilled and poorly educated barber surgeon. This surgeon could cut your hair, remove a tooth, and repair a hernia. There were a very few surgeons with either prominent personalities or formal education. The “educated” surgeon having learned medieval dogma remained buried in conjecture and training from centuries of beliefs based on earlier Greco-Roman and later Byzantine teachers and translators who continued to translate and repeated the errors of the past surgical history. In learning and then following these antiquated surgical writings, medieval surgeons often found themselves in conflict with their own bedside observations. As a result of these common conflicts of written text versus what was actually being seen in the anatomical amphitheater, a number of innovative personalities dually learned their surgical material not only as surgeons but also as anatomists. Within the origins of the intellectual climate of the Renaissance, we begin to see profound changes in learning, particularly in the anatomical investigations of the human body.
With the early origins of the Renaissance, we see a renewed interest in human anatomical dissection, anatomical dissections and drawings which at this point had been almost frozen in time for some 1400 years dating to the time of the Alexandrians. From the Byzantine era and through the Middle Ages, anatomy was based on the previous writings of the giants such as Galen of Pergamon who performed their anatomical dissections on nonhuman subjects and then morphing this information to “human” anatomy. Ironically, it was the Renaissance artist followed by sixteenth-century anatomists and surgeons that led the movement in anatomy away from subservience to the medievalists. With great figures like Leonardo da Vinci (1452–1519), Berengario da Carpi (1470–1550), Johannes Dryander (1500–1560), Andreas Vesalius (1514–1564), and others that was to lead to a new movement based on a hands-on anatomical dissection of the human body. As a result, previous codified anatomical errors, many ensconced since the Greco-Roman era, were to be slowly corrected over the next several centuries. These changes in studies from codified manuscripts to a new and more accurate human anatomy also led to a surge of interest in surgery. The Renaissance surgeon, like the artist, became interested in trying to unravel the intricacies of the human body – without this foundation of knowledge, it would be impossible to correctly treat a disease much less perform a surgical resection. In the area of posterior fossa anatomy and surgery, a number of important Renaissance figures played pivotal roles in bringing forward posterior fossa surgery as both an art and a science.
While neither a surgeon nor a physician, Leonardo da Vinci (1452–1519) made enormous contributions to both medicine and surgery. Leonardo was the quintessential Renaissance man. Recognized as an artist, an anatomist, and a scientist, Leonardo learned human anatomy, both surface and deep to better provide more realistic artistic creations. Leonardo’s anatomical studies were extremely important in providing an early emancipation from the previous medieval teachings. Leonardo’s output in anatomical studies led to some 750 separate anatomical drawings. To modern scholars, Leonardo is now considered the founder of iconographic and physiologic anatomy [9–11].
Some of the earliest anatomical drawings on posterior fossa anatomy appear in Leonardo’s anatomical studies [9]. To Leonardo we owe the earliest surviving illustrations of the cranial nerves. Figures 1.3 and 1.4, Leonardo did not describe all 12 of the cranial nerves though he was the first to provide some reasonably accurate diagrams. To Leonardo we owe the first illustrations of the ventricular system. Using a uniquely designed “wax casting” of the ventricular system, Leonardo was able to detail the anatomical landmarks of these cavities including the fourth ventricle (see Fig. 1.3c). Leonardo’s “wax casting” technique was quite innovative and involved removing the brain from the skull and injecting melted wax through the fourth ventricle. Mental tubes were placed in each of the lateral ventricles to allow air to be released. Once the injected wax hardened, the brain was removed leaving behind a wax casting of ventricles.
Fig. 1.3
(a) An early copper engraving of Leonardo da Vinci (from the collection of author). (b) Leonardo’s sketches of the “wax casting” of the ventricles of the brain. In these drawings, the third and fourth ventricles are anatomically outlined for the first time. In the bottom image is an early and rudimentary drawing of the cerebellum and brain stem [9]. (c) Da Vinci anatomical illustrations of the ventricular system – enlarged from b. There are the earliest known anatomical drawings of the cerebral ventricles – for the first time demonstrating the third ventricle, aqueduct of Sylvius and the fourth ventricle [9]. (d) Leonardo’s “layered” anatomical studies on the skull, brain, and cranial nerves, what would appear to be the earliest “realistic” anatomical demonstrations of the cranial nerves [9]
Fig. 1.4
Leonardo’s view of the ventricular system with the cranial nerves detailed at the skull base and exiting to supply the face, mouth, tongue, etc. [9]
In Leonardo’s anatomical studies are several investigations that deal with the posterior fossa and its anatomy. His interest in these studies is not clear, as the findings would not have impacted theoretically on his artwork. Leonardo was also not a surgeon so there would not have been any surgical benefit from these studies. Yet his inquisitive mind provides for us some of the earliest and, at the time, the most accurate views of the posterior fossa. Unfortunately, Leonardo’s great opus on anatomy, to be published in some 20 volumes, did not appear in print until the twentieth century [9, 10]. Leonardo’s anatomical manuscripts did circulate in Italy throughout the sixteenth century among the artistic community; thanks to a close friend and companion, Francesco da Melzi [8]. Leonardo’s manuscripts appear to have disappeared from general circulation in the latter half of the sixteenth century, only to be rediscovered in the eighteenth century by William Hunter (1728–1793), a collection that is now part of the Windsor Castle collection, owned by the Queen of England, Elizabeth II. William Hunter was clearly awed by what he saw in Leonardo’s drawing and he wrote of his views in a now rare series of eighteenth-century lectures on anatomy – Hunter comments that Leonardo “…was the best anatomist, at that time in the world” [12]. I have included the title and the comment by Hunter on this collection and the anatomy – the first sighting and investigations of these important anatomical illustrations since the sixteenth century. The real mystery is how these important drawings ended up in Scotland in the Windsor Castle collection (Fig. 1.5).
Fig. 1.5
(a) Title page from William Hunter’s lecture on anatomy in which he announced the discovery of Leonardo’ long-lost anatomical drawings which, for reasons that are not well known, ended up in the Windsor Castle collection in Scotland [12]. (b) Hunter’s description of the manuscripts and his initial thought of getting them published, an event that was not to happen until the turn of the twentieth century [12]
An interesting historical vignette was William Hunter’s comment made upon seeing Leonardo’s anatomical drawings: (In speaking of Leonardo) “Those very drawings and the writing, are happily found to be preserved in his Majesty’s great collection of original drawings. Mr. Dalton, the King’s librarian, informed me of this, and at my request procured me the honor of leave to examine them. I expected to see little more than such designs in Anatomy, as might be useful to a painter in his own professions. But I saw, and indeed with astonishment, that Leonardo had been a general and a deep student. When I consider what pains he has taken upon every part of the body, the superiority of his universal genius, his particular excellence in mechanics and hydraulics, and the attention with which such a man would examine and see objects which he was to draw, I am fully persuaded that Leonardo was the best Anatomist, at that time, in the world. We must give the fifteenth century the credit of Leonardo’s anatomical studies, as he was 55 years of age at the close of that century” ([12], p 39).
The earliest printed work to appear on neurosurgery, in this case a monograph on head injury, was published in 1518 by Berengario da Carpi (1470–1550) [13, 14] (see Figs. 1.6 and 1.7). This book was published as a result of Berengario’s success in treating a prominent Italian nobleman – Lorenzo dé Medici, Duke of Urbino. Lorenzo was involved in a joust and sustained a serious cranial injury to his occipital bone and posterior fossa from which he survived. Shortly after this episode, Berengario was visited in a dream by a man wearing a cap adorned with a rooster feather and golden-winged sandals (i.e., Hermes Trismegistus, or the Third Mercury). Hermes encouraged Berengario to a write a treatise on head injuries. Within this monograph are the earliest published surgical details dealing with head injuries and their treatment. Berengario designed his own surgical instruments for operating on the skull and brain. Illustrated in this monograph are trephine braces with interchangeable drill bits of different designs (Figs. 1.6 and 1.7). Berengario has an interesting writing style, a style that is verbose, pompous, and would be considered rather audacious by today’s standards. Yet within this treatise are descriptions of his early surgeries which are provided with descriptions of the patients, methods of treatment, and clinical outcomes. As a result, this work remains the best account of sixteenth-century brain surgery and the earliest to deal with any form of posterior fossa surgery.
Fig. 1.6
(a) Portrait of Berengario da Carpi, author of the earliest printed work on injuries to the brain. (b) Title page from Berengario’s Tractatus [13]. (c) From Berengario’s Tractatus showing his design of what we now call a “Hudson Brace” – designed to perform trephinations and with an interchangeable burr design [13]. (d) An illustration from Berengario’s Tractatus showing his various bur designs for performing trephinations, many designed to prevent “plunging” into the brain during the trephination [13]
Fig. 1.7
Skull from Lorenzo da Medici showing the injury sustained to the posterior fossa during a jousting event – Berengario attended his surgery and care and from which the patient survived what should have been a lethal injury (Courtesy of the University of Bologna Library Museum)
Berengario besides being an innovative surgeon was also an excellent anatomist. Like Leonardo, Berengario provided one of the earliest and most complete discussions of the ventricular system. In his anatomical work Isagoge Breves published in 1522 [15], Berengario provided the earliest accurate descriptions of the sphenoid sinuses, pineal gland, choroid plexus, auditory ossicles, and lateral ventricles. Recent historians consider the anatomical illustrations in this volume to be the first anatomical illustrations published based on actual hands-on anatomical dissections.
In researching the early anatomical illustrations of the posterior fossa, a work that stands out was authored by Johannes Dryander (Johann Eichmann) (1500–1560), professor of surgery from Marburg, Germany. This richly illustrated the work which first appeared in 1536 as a small monograph with limited illustrations. Dryander expanded this book further in 1537 and added additional illustrations [16, 17]. Within the 1537 edition are 16 plates showing successive layers of the traditional dissection of the brain as described by Galen in the second century. Of importance to this chapter are the earliest realistic illustrations of the anatomy of the posterior fossa along with a primitive numbering of the cranial nerves. Illustrated by Dryander were nine cranial nerves as originally described by Galen in the second century A.D. (see Figs. 1.8 and 1.9). Dryander details the earliest known description of tentorium, the structure separating the cerebellum from the cerebrum. This book was heavily influenced by the writings of Galen and earlier medieval scholasticism, but despite these criticisms, this work can be considered the first textbook of neuroanatomy and the first to show somewhat realistic illustrations of the posterior fossa. Following a recently established Renaissance tradition, Dryander performed his own public dissections of the skull, dura, and brain without the use of dissector though referring at times to Galen’s printed observations [17].
Fig. 1.8
(a) Portrait of Dryander, an early anatomist who provided some of the earliest anatomical descriptions of the posterior fossa and the cerebellum. From the author’s personal collection. (b) Title page from Dr Dryander’s 1537 work on the anatomy of the skull and brain [16]
Fig. 1.9
(a) From Dryander’s work on human anatomy detailing the human skull and accurately reflecting the sutures outlining the posterior fossa along with suboccipital cervical junction [17]. (b) Dryander provides in this drawing the earliest detailed illustration of the posterior fossa including the details of the cerebellum and brain stem along with the middle and anterior fossae [17]
A landmark figure of the sixteenth century, both in anatomy and surgery, was the Italian physician and anatomist Andreas Vesalius (1514–1564). Vesalius argued strongly that the physician/anatomist must perform his own animal and human dissections. In 1543, at the young age of 28, Vesalius published his magnum opus De Humani Corporis Fabrica in Basel, Switzerland [18]. This folio volume is full of original and insightful anatomical observations and descriptions. Vesalius was a virulent critic of the early anatomists and their errors, in particular the writings of Galen. The Fabrica was done in collaboration with John Stephen of Calcar and the school of Titian. Vesalius adopted the viewpoint of earlier giants like Berengario da Carpi that the surgeon must do his own dissections and then detail his own observations. In the elegant engraved title page of the Fabrica, Vesalius shows himself in an elaborate anatomical theater standing alongside a cadaver that he is in the process of dissecting sans dissector (Figs. 1.10, 1.11, and 1.12).
Fig. 1.10
From the title page of 1543 De Humani Corporis Fabrica in which we see Vesalius (the bearded figure) standing alongside a human cadaver that is undergoing a public dissection [19] (courtesy of the Cambridge University Library – Cambridge, England)
Fig. 1.11
(a) Early hand-drawn sketch illustrating the anatomy of the posterior fossa showing the cerebellum and brain stem being rotated forward, up, and out of the skull base. A primitive rendering of the cranial nerves is seen in the upper left figure. From the personal collection of the author. (b) Early hand-drawn sketch illustrating the anatomy of the posterior fossa seen from an inferior view. The cranial nerves have been outlined along with the optic chiasm and the cerebellum. From the personal collection of the author
Book VII (Libri VII) of this magnum opus provides for us a detailed anatomical discussion of the brain and posterior fossa, each illustrated with excellent anatomical renderings. Ironically, the description of the cranial nerves remained heavily influenced by the anatomical numbering originally provided by Galen of Pergamon with nine cranial nerves described instead of 12. We have included two anatomical figures that show the posterior fossa exposed by elevating the cerebellar hemispheres up and exposing the brain stem and cervicomedullary junction. Figure 1.13b details the brain stem and cranial nerves in a rather primitive design. Vesalius notes that to get the best anatomical material, one should be friends with the judges so that the best and freshest of beheaded cadavers can be obtained immediately upon the execution of the criminal. Two eponyms employing Vesalius’s name are still in use, and both involve the posterior fossa and skull base: the foramen of Vesalius, a small opening between the foramen ovale and the foramen rotundum. A small emissary vein which runs within the foramen of Vesalius is called the vein of Vesalius. These anatomical structures are actually anatomical variants in that they are seen in only about 10 % of anatomical dissections.
Fig. 1.13
(a) Drawing of the skull base with the brain and cerebellum removed exposing the brain stem and cranial nerves – a drawing felt to have been done by Vesalius [18]. (b) Drawing of the brain stem outlining the floor of the fourth ventricle, the colliculi, and inferior portion of the thalamus, surprising anatomical detail for this period [18]
Another remarkable work on human anatomy and especially neuroanatomy was printed in Paris, France, in 1546 by Charles Estienne (1504–1564) [20]. In reviewing this work, we see interesting and, in some cases, quite striking illustrations of the brain and in particular the posterior fossa. For the reader, the illustrations are quite imaginative with anatomical figures posed against elaborative Renaissance backgrounds that include noble living rooms and villa grounds. In reviewing Estienne’s writing, he is clearly strongly under the influence of Galen’s writing on anatomy. In addition, the anatomical descriptions do not come to the level of writings of Vesalius (Figs. 1.14 and 1.15).
Fig. 1.14
(a–b) An anatomical scene from Estienne richly detailed anatomy book showing the anatomy of the brain in cross section including the cerebellum; image “b” is the figure enlarged showing better detail of the posterior fossa [20]
In reviewing the contributions of this period, an important surgical personality was Ambroise Paré (1510–1590) whom most historians considered the father of modern surgery [21–23]. Paré began his studies as a barber surgeon, starting at the age of 19 as a surgical dresser in a Paris hospital (Fig. 1.16). A common theme for surgeons was to train as a military surgeon; battlefield experience provided the ultimate surgical education. Paré was never formally trained in Latin and published his works in French, some of which were translated into English. As a result of Paré not publishing in Latin, rather in the vernacular, it led to a wider dissemination of his surgical works among barber surgeons and further enhanced his influence in the sixteenth century. From his successes as a military surgeon, Paré went on to become a much sought-after surgical figure among the European royalty. One of his most well-publicized surgical cases dealt with a head injury sustained by Henri II of France. Paré attended the King and was also present at the autopsy. Paré discovered that Henri II had developed a subdural hematoma. Paré then recorded his clinical observations from the head injury and the resultant posterior fossa compression which included headache, blurred vision, vomiting, lethargy (i.e., weakness), and decreased respiration. Paré postulated that the injury was due to a tear in one of the bridging cortical veins, and this he confirmed at autopsy [23].
Fig. 1.16
In this introduction, Paré clearly outlines the “proper duties” of the surgeon, comments that still remain true today [21]
In Book X, of the Collected Works [21], Paré provides commentary on dealing with injuries to the brain and surgical techniques in treating these injuries. To assist the surgeon, Paré provides detailed discussions on the use of trepans, shavers, and scrapers (see Fig. 1.17c). Infections of the skull were common, and he describes techniques on how to remove an osteomyelitic bone and how to incise the dura and evacuate blood clots and pus. Paré’s military experience led him to advocate wound debridement, emphasizing that all foreign bodies must be removed from the wound site. Paré’s most humanitarian advance in surgery was the serendipitous discovery that boiling oil (previously poured into open surgical wounds) should not be used in gunshot wounds. Instead, he made a dressing made of egg yolk, rose oil, and turpentine, which he found led to much improved wound healing. A long common method of controlling surgical wound bleeding was the application of the red-hot iron cautery to bleeding vessels. Paré replaced this barbaric treatment of cautery with the use of ligatures placed around the bleeding vessels which led to not only better bleeding control but also substantially better wound healing.
Fig. 1.17
(a) Title page from Paré first English edition of his collected surgical writings. [21]. (b) Vignette from the upper left corner of title page with a portrait of Paré and a trephination scene [21]. (c) Paré illustrates his surgical instruments that he used for trephining the skull. A rotating hand brace along with various different drill designs allowed for more accurate hole placement and less risk of plunging [21]
1.4 Seventeenth Century: An Age of Advancing Individual Scientific Endeavors in Anatomy and Physiology of the Brain
The seventeenth century was an important period in the historical development of surgery; a period where both anatomy and physiology of the brain was being conceptualized for the first time. As the growth of both medicine and science took off exponentially with the contributions of Isaac Newton (1642–1727), Francis Bacon (1561–1625), William Harvey (1578–1657), and Robert Boyle (1627–1691), physics, experimental design, the discovery of the circulation of the blood, and physiological chemistry were introduced. We also see for the first time the development of the scientific societies (e.g., the Royal Society of London, the Académie des Sciences in Paris, and the Gesellschaft Deutscher Naturforscher und Aerzte in Germany). These societies and the inherent intellectual interchange would lead to dramatic advances in both medical and scientific education.
Reflecting back upon the seventeenth century, this was clearly the century that provided the first investigational studies leading to a modern understanding of the anatomy of the human brain. There turns out to be several individuals that contributed significant roles in understanding the structural anatomy of the human brain. One of the premier investigators was Englishman Thomas Willis (1621–1675), of the “circle of Willis” who published in his classic in 1664 a work he entitled Cerebri Anatomie [24]. In reviewing the text of the Cerebri Anatomie, the reader can clearly glean his methodical attention to anatomical detail. The book is provided with skillfully designed anatomical illustrations that provided then the most accurate detailed anatomy of the brain. Willis details a series of physiological demonstrations that clearly showed that when parts of the “circle of Willis” were tied off, the anastomotic network would still provide blood to the brain via collaterals. For the first time, we are seeing anatomical structures of the brain clearly detailed and often forgotten, much of this was due to collaborative skills of Sir Christopher Wren (1632–1723) who drew the illustrations for the Cerebri Anatomie (Fig. 1.18).
Fig. 1.18
(a) Portrait of Thomas Willis drawn during the time of writing of the Cerebri Anatomie. From the author’s personal collection. (b) Title page from the first quarto edition of Cerebri Anatomie printed in London in 1664 [24]. (c) Willis illustration of the “circle” which accurately details the posterior fossa, in particular the pons, brain stem, and the folia of the cerebellum. The cranial nerves also have better detail when compared to previous anatomical works [24]
For the surgeon, Cerebri Anatomie was among the first richly illustrated anatomical works to provide an accurate outline of the surface anatomy of the brain and the cranial nerves. The detail provided in the illustrations of the cerebellum and brain stem is considerably better detailed when compared to earlier anatomical works. In addition to his anatomical investigations, Willis introduced the concept of “neurology,” or the doctrine of neurons, though he used the term in a purely anatomical sense. The word “neurology,” in its modern usage, did not enter general nomenclature until Samuel Johnson defined it in his dictionary of 1755 [25]. Neurology would later come to encompass the entire field of neurological anatomy, function, and physiology.
While there were a number of important neuroanatomical works that came out in this period, one important book that is of posterior fossa historical interest was written by Humphrey Ridley (1653–1708) [26]. Ridley was educated at Merton College, Oxford, and at the University of Leyden, where he received his doctorate in medicine in 1679. At the time Ridley’s work on the brain appeared, many of the ancient Greek views of the brain still prevailed. Anatomy of the brain was now shifting away from the “cell-doctrine theory,” a concept that held that the functions of the brain were within the ventricles, not in the brain matter itself, concepts dating back to the Greco-Roman era. Ridley’s anatomical studies were conducted on freshly executed criminals which helped significantly in the anatomical investigations due to the vascular engorgement of the brain that occurred secondary to hangings. From his studies came the first descriptions of the cavernous sinuses, described by him after injection with mercury and wax. Ridley provided an even more complete description of the circle of Willis with better anatomical descriptions of the posterior cerebral and superior cerebellar arteries. Ridley nicely detailed the transverse and lateral venous sinuses with the dura removed. The third cranial nerve is shown correctly as traversing in between the superior cerebellar artery and posterior cerebral artery, the first time this cranial nerve anatomy is correctly illustrated. It should be noted though that Ridley’s cranial nerve descriptions followed the earlier Galenic tradition, describing only nine cranial nerves. In reviewing Ridley’s cross sections of the cerebellum and brain stem, we find anatomical drawings clearly superior to Willis, and in these drawings, he outlined the deep nuclei in the cerebellum. Not well known it is to Ridley that we owe the first description of a pineal region tumor in a patient that developed an obstructive hydrocephalus. Ridley’s description is interesting to review:
In an hydropical Brain of a strumous (sic) Boy, [here describing a child with hydrocephalus – author’s note] I have see it (speaking of the pineal gland) swelled to a size of three times its ordinary magnitude, and by reason of the abundance of stagnate gelatinous Lympha contain’d in it, perfectly transparent. (Text and capitals as done by Ridley). ([26], pp 83–84)
Ridley is describing a gelatinous tumor of the pineal gland with a secondary obstructive hydrocephalus though he does not appear to recognize the association. Ridley goes on to note that the pineal gland is the region where Descartes has located the seat of the soul, a concept which he notes he agrees with (Figs. 1.19 and 1.20).
Fig. 1.19
(a) Title page from Ridley’s work on the brain [26]. (b) Ridley’s richly detailed anatomical illustration of the circle of Willis and the base of the brain [26]. (c) Ridley’s detailed anatomical drawing of the skull base outlining the posterior fossa with the trigeminal nerve illustrated at the lower left [26]
Fig. 1.20
(a) Ridley’s detailed anatomy of the cerebellum and brain stem is demonstrated here. The origins of the cranial nerves and each of the structures has been labeled in the text [26]. (b) Ridley provides here the earliest description of a pineal gland tumor which caused secondary obstructive hydrocephalus [26]
By the end of the seventeenth century, several key advances had occurred which laid a foundation that would eventually lead to an understanding of brain tumors and disorders of the posterior fossa. Neuroanatomy had developed to the point where identifiable structures were now consistently recognized in the brain. Brain function was now residing within the brain and not within the ventricles. Scientific societies were now providing public forums for disseminating scientific and medical information. For the surgeon, there still remain serious restrictions in surgical technique which would be the lack of antisepsis, anesthesia, and cerebral localization. The concept of a pathological basis to disease still had not yet been developed.
1.5 Eighteenth Century: Development of Brain Surgery Beyond Just Trauma
Judgment in distinguishing, and ability in treating diseases, are not to be attained by a transient cursory view of them; merely running round an Hospital for a few months, or reading a general system of surgery, will not form a compleat (sic) practitioner: the man, who aims at that character, must take notice of many little things, which the inattentive pass over, and which cannot be remarked by writers; he must accustom himself to see, and to think for himself; and must regard the rules laid down by authors, as the outlines only of a piece, which he is to fill up and finish: books may give general ideas, but practice, and medication, must make him adroit and discerning; without these, his reading may possibly keep him clear of very gross blunders, but he will still remain injudicious, and inexpert – Percival Pott – 1760. [27]
The foundations of investigative science and medicine were beginning to be established in the eighteenth century. Chemistry was now recognized as a science from the works of Priestley, Lavoisier, Volta, Watt, and others. The practice of “bedside medicine,” which had not been practiced since the Byzantine era, was now being brought back into medical practice in the teachings and writings of Thomas Sydenham, William Cullen, and Herman Boerhaave. A bedside examination of the patient continued to be advanced with Auenbrugger’s introduction of percussion of the chest. William Withering introduced the use of digitalis for cardiac failure. William Jenner helped eliminate a worldwide scourge with the introduction of cowpox inoculation for small pox. At the same time, surgeons were becoming better skilled at surgical technique and even more importantly were entering the ranks of the educated as many were now obtaining university educations. While the surgical apprenticeship system was still very much in existence, the more learned surgeon was advancing the art of surgery with a better understanding of anatomy and physiology of the human body. An individual who clearly demonstrated this new orientation in training and surgical skills was Percival Pott (1714–1788), a fashionable London surgeon who provided an early textbook devoted to the treatment of head injuries [27]. The treatment of “tumors” was very primitive with almost no understanding of tumor genesis or even the pathological basis of a neoplasm. The most common concept of a brain tumor was a “fungus” or unexplained growth of the brain or skull. The cellular origin of a tumor was not developed until the late nineteenth century.
Rather unique for an eighteenth-century surgeon, Pott was a strong proponent of surgical intervention whether for trauma or tumor. With improved surgical instrumentation, a better understanding of human anatomy, and improved necropsy techniques, Pott and others were achieving better surgical outcomes. In dealing with surgery of the head, Pott challenged the earlier Hippocratic doctrines on whether to trephine or not to trephine. Because of the high morbidity associated with opening the dura and skull, few surgeons of this period were willing to accept the morbidity of trephination. Clearly, a more aggressive Pott strongly favored the use of the trephine in brain injury and treatment of brain pathology [27, 28] (Fig. 1.21a, b).
Fig. 1.21
(a) Title page from Pott’s collected works on surgery [28]. (b) Pott’s surgical devices for operating on the skull and brain were mainly of his own design. Illustrated here are two elaborate devices for dealing with head trauma and depressed skull fractures. (The middle instrument was adapted from a device used to remove corks from a wine bottle [28])
In 1718, Lorenz Heister (1683–1758) published a surgical textbook [30–32] that rapidly became one of the most popular surgical textbooks of this century. Heister broke away from the prevalent model of the traveling itinerant barber surgeon and instead advanced a more scientific-based approach to surgery. Heister firmly believed that to be a skilled surgeon, one began with strong education in both anatomy and surgical technique. Heister’s 1718 textbook described a number of cases in which “tumors” were surgically treated though none involved the brain [29]. Heister refined his techniques for trephining the skull and provided illustrations showing the tools and techniques. With a broad and well-developed surgical practice, it is quite likely that Heister performed surgeries for tumors such as meningiomas, particularly those that eroded through the skull. In reviewing his surgical technique, Heister offered some interesting tips for the young surgeon. For control of scalp bleeding and hemorrhage, Heister developed a “crooked needle and thread” and then zigzagged the suture on each side of the skin flap. When this suture was drawn tightly, it sharply reduced bleeding from the wound edges. To further assist control of scalp bleeding, Heister had his surgical assistant apply pressure to the skin edges. Harvey Cushing (1869–1939) adopted a similar technique when opening a scalp flap in the early 1900s (Fig. 1.22a, b).
Fig. 1.22
(a) Title page from a later edition (1750) of Heister’s surgical textbook with his engraved portrait to the left [31]. (b) Heister’s surgical textbook illustrating some of his instruments for operating on the brain and skull along with an interesting technique for elevating a depressed skull fracture in a child –“Derby Hat fracture” elevation [30, 32]
In reviewing the eighteenth-century surgical literature on brain surgery, other than for trauma, surgery on the brain was quite rare. In 1743, a French surgeon by the name of Francois Quesnay (1694–1774) argued that brain surgery could be done safely based on his experience with brain abscesses and removal of foreign bodies [107]. In his surgical treatise, Quesnay was adventurous enough to argue that incisions in the brain cortex could also be safely made. If tumors (which he called “fungous growths,” i.e., meningiomas) were diagnosed, he argued they could be removed with minimal problems for the patient. Despite having made these statements, there is no evidence Quesnay actually ever removed a brain tumor.
In the year 1774, a treatise published by Antoine Louis (1723–1792) provides one of the earliest accounts of a successful brain tumor operation [33]. Antoine Louis was a French surgeon of considerable reputation having refined his surgical skills first as a military surgeon. Louis had an interesting personality and is remembered for a quarrelsome personality eager to come to physical blows with anyone who dare disagreed with him. In Louis’s book is described an early surgical attempt at removing a brain tumor. Louis described a case involving a large petrus ridge meningioma (?) that deformed the left temporal and mastoid region causing a downward deviation of the ear [94]. Louis operated and describes debulking the tumor and felt successful in reducing its mass effect on the brain. To deal with tumors, Louis developed a number of ingenious surgical techniques, including one that involved tying a silk ligature around the base of a tumor and then cinching it down slowly over the next several days, in effect amputating the tumor and its blood supply at its base.
One of the first “successful” attempts to deal with a surgical problem in the posterior temporal region and mastoid was published by Sauveur-Francois Morand (1697–1773) in 1768. In his surgical monograph [34], Morand describes a case of a monk, who had an otitis media and subsequently mastoiditis with temporal bone and posterior fossa abscess. Morand describes his technique of trephining over the carious bone removing the infected bone and pus. Morand placed a catgut wick within the cavity to allow the surgical wound to continue to drain. The monk’s clinical course continue to worsen so Morand reexplored the abscess site, but this time did something very aggressive in that he opened the dura through a cruciate incision. With this surgical maneuver, Morand was able to explore intracranially and describes how he drained a large brain abscess. Morand describes using his index finger as a probe and digitally explored the abscess removing as much as he could. Morand further treated the abscess by filling the cavity with balsam and turpentine – an early example of antisepsis treatment. A silver tube was placed into the abscess cavity to allow continuous drainage (Table 1.1). As the wound healed, the silver tube was slowly withdrawn. The abscess healed; the patient survived leading Morand to report one of the earliest successful surgically treated lesion of the skull base and posterior fossa (Fig. 1.23).
A French surgeon that provided some interesting insights on surgery of the brain and the posterior fossa was Louis Sebastian Saucerotte (1741–1814) (also listed as Nicolas). As a French military surgeon, he obtained extensive experience in dealing with injuries and pathology of the brain [35]. Saucerotte was the first to describe gait ataxia with opisthotonos and rolling of the eyes in a patient with a cerebellum lesion. Saucerotte came up with the concept that different areas of the brain tolerated trauma better. Saucerotte recognized that the region of the brain most susceptible to trauma with poorer outcomes where those occurred was at the base of the brain, i.e., the region of the brain stem and cerebellum. Trauma and injuries of the forebrain were, in his experience, the best tolerated.
Surgical treatment of tumors, in all parts of the body, developed quite late in surgical history. Key to the treatment of any tumor was to separate its pathology from other commonly confused lesions like inflammation, syphilis, tuberculosis, and other “swellings” or “fungus-like” lesions. The first monograph to begin the differentiation of these concepts and introducing the field of pathology was written by Giovanni Battista Morgagni (1682–1771), De sedibus, et causis morborum per anatomen… [36]. Morgagni’s work was to revolutionize the treatment of diseases by laying, for the first time, a pathological foundation to various medical disorders. Morgagni’s landmark work of 1761 was the first in a series of writings that categorized diseases into specific entities based on what he called “the seats and causes of disease” [37]. Morgagni studied under Valsalva and then at the unbelievably young age of 16, assumed the chair of anatomy at Padua in 1715. After a long and brilliant career, with a number of important publications already completed, he decided at the age of 79 to author his comprehensive work on the seat and causes of diseases which was based on over 700 autopsies that he had performed. From these pathological investigations, Morgagni offered a diagnosis, prognosis, and a specific treatment based on the pathological origin of a disease. In Morgagni’s work are presented a series of cases that deal with the pathological bases of diseases of the head and brain. Morgagni details some very interesting autopsy studies dealing with the brain and spine and at one point even comments on trephining on the brain. Morgagni’s investigations clearly set the standards for a landmark work in pathology, but this work is also not often recognized as also a landmark work in the history of neurology and neurosurgery (Fig. 1.24).
