Surgery of the Human Cerebrum Part I, Medycyna, Neurochirurgia - podręczniki
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EDITOR’S LETTER
T
HE
H
UMAN
C
EREBRUM
AND THE
R
EINVENTION OF
N
EUROSURGERY
he period of thirty years is generally
considered a generation, and likewise, the
period of an average professional career. For
neurosurgery, the past thirty years has been a time of
reinvention with the advent of concepts and
technical adjuvants creating advantages for the
practitioner in confronting the challenges of
neurological diseases. Imaging,
microscopy, endoscopy, stereotactic
guidance, navigation, radiosurgery,
endovascular techniques and molecular
adjuvants trend towards precision of
action through minimization and
refinement of comprehension in the
individual situation.
Surgery of the human cerebrum arguably
represents a consummate therapeutic technical and
strategic exercise. In many senses, the need and
quest for further sophistication in this endeavor has
both fueled the emergence and benefited from these
developments.
Surgery of the human cerebrum has enjoyed
revolutionary changes and enhanced capability
through a true reinvention during the past
generation.
This special supplement of
N
EUROSURGERY
,
celebrating a generation of its contributions to the
craft of neurosurgery, will focus on cerebral surgery
in the practical sense, examining its current status
and presenting contemporary methods in a
traditional topical fashion.
This comprehensive supplement will be
presented in three parts, each published at six-month
intervals with an expanded hardbound volume to
follow. As a unique component of this monumental
presentation, the supplement will also be published
digitally on the
N
EUROSURGERY
-Online website with
extensive video components. In addition, this
offering will be a “living” resource on the topic --
being updated regularly in perpetuity to maintain
the scope and currency of the subject. This approach
will represent the first of such an offering in the field
and will most likely be a template for future
activities related to other topics of importance.
It should be noted that in each of the three
supplements, both fresh and archival materials will
be presented. All new material will be the work of
high level authorities on each of the topics. Archival
materials and selected bibliographies will be
presented in support of these papers. Naturally, all
new materials will be subjected to the same rigorous
peer-review that is present throughout
all scientific material in
N
EUROSURGERY
and its supplemental publications.
In this initial offering (Anniversary
Supplement I), important grounding
papers from Michael Apuzzo (
History
),
Albert Rhoton (
Anatomy
), Chi-Shing
Zee (
Imaging
), Alex Valadka (
Trauma
),
Mitchel Berger (
Intrinsic Tumors
) and Nobuo
Hashimoto (
Vascular Malformations
) highlight the
twenty-two supporting papers selected from archival
materials dating back over the past decade.
Supporting bibliographic archival highlights will
close each topical section.
Supplement II will feature papers from Johannes
Schramm (
Epilepsy
), Walter Hall (
Infections
), Paolo
Cappabianca (
Endoscopy
), James Drake (
Pediatric
Hydrocephalus
), Marvin Bergsneider (
Adult
Hydrocephalus
), Ali Rezai (
Movement Disorders
),
Giovanni Broggi (
Psycho Affective Disorders and
Pain
), and Douglas Kondziolka (
Stereotactic
Radiosurgery
).
Supplement III will be highlighted by original
articles from M. Gazi Yasargil (
Intraventricular
Tumors
), Robert Spetzler (
Giant Aneurysms
),
Laligam Sekhar (
Revascularization
), Peter Black
(
Extra Axial Lesions
), Madjid Samii (
Basal Lesions
),
L. Nelson Hopkins (
Endovascular
), and Michael
Apuzzo (
Advanced Methodologies
).
As we generate this ambitious project, we will
make every effort to assure that
S
URGERY OF THE
H
UMAN
C
EREBRUM
will provide the most valuable
and comprehensive single source of information on
this formidable and challenging topic.
¸
Michael L.J. Apuzzo
Los Angeles, California
Neurosurgery 61:SHC1, 2007
DOI: 10.1227/01.NEU.0000277245.12159.85
N
EUROSURGERY
VOLUME 61 | NUMBER 1 | JULY 2007 SUPPLEMENT |
SHC-1
T
HISTORY
S
URGERY OF THE
H
UMAN
C
EREBRUM
—
A C
OLLECTIVE
M
ODERNITY
Michael L.J. Apuzzo, M.D.
Department of Neurological Surgery,
Keck School of Medicine,
University of Southern California,
Los Angeles, California
SAFE AND BENEFICIAL surgery of the human cerebrum is arguably one of mankind’s
most notable achievements and one of the great testimonials to human creativity, intel-
ligence, and character. In many ways, it is a testimony to the climates of civilization
that have marked human history. In historical terms, in the year 2007, cranial surgery
celebrated its 12,000th birthday, with cranial manipulation for various religious, mys-
tical, and therapeutic reasons being evident in Africa more than 10 millennia before
the birth of Christ. This article traces the major developments and attitudes that have
laid the foundations of modernity in what is currently surgery and medicine’s most
exciting and complex technical exercise. It is in fact a 12,000 year prelude to the moder-
nity that we currently enjoy. Before attempting to define our modernity and emerging
futurism with reinvention, examination of the prolonged and tedious invention is appro-
priate for perspective. The following examines and recounts the accrual of data and
changes in attitude over the stream of history that have allowed refined surgery of the
human cerebrum to become a reality.
Charles Y. Liu, M.D., Ph.D.
Department of Neurological Surgery,
Keck School of Medicine,
University of Southern California,
Los Angeles, California,
and Division of Chemistry and
Chemical Engineering,
California Institute of Technology,
Pasadena, California
Daniel Sullivan, M.Div.
Department of Plastic Surgery,
University of Texas,
Southwestern Medical Center,
Dallas, Texas
KEYWORDS:
Cerebral function, Cerebral surgery, Cerebrum, Medical history, Neurosurgery, Surgery
Neurosurgery 61[SHC Suppl 1]:SHC-5–SHC-31, 2007
DOI: 10.1227/01.NEU.0000255493.34063.7B
Rodrick A. Faccio, B.S.
Department of Neurological Surgery,
Keck School of Medicine,
University of Southern California,
Los Angeles, California
THE INVENTION
modern instrument (96). Although others may
have made earlier reference to trepanation,
Paul Broca (19) is generally credited as being
the catalyst for the widespread acknowledg-
ment of this practice in ancient cultures. He
was made aware of a skull discovered by E.G.
Squier, a French diplomat to Peru, and, after
careful examination of the specimen, sug-
gested that the procedure had been performed
on a living patient who subsequently survived.
Before Broca’s assertion, it had always been
thought that the bony defects found in French
skulls since the late 1600s had been the result
of postmortem rituals (10). At present, there is
almost universal acceptance of antemortem
cranial surgery in prehistory; archeological evi-
dence supports the theory that the practice was
indeed widespread, with skull specimens
found in Europe, Asia, Africa, North America,
Central America, South America, and Oceania
(10, 45, 69, 77, 89, 91, 96, 104, 110). In fact, the
practice survives to modern times in certain
East African and South American tribes (76).
To date, more than 1500 specimens have
been found and examined. The oldest exam-
ples of trepanation, dating back to 10,000 BC,
may be specimens found in North Africa.
Historical Foundations: The Evolution
of Cranial Surgery
For thousands of years, cranial surgery was
principally extradural. Historical evidence sug-
gests that perhaps man’s very first attempt at
surgical manipulation involved the removal of
pieces of the bony coverings of the brain (10, 23,
45, 69, 89, 91, 96, 108). Since these very early
attempts by Neolithic man, surgery of the brain
and its coverings has evolved slowly over some
12,000 years, with elements of refinement in
instrumentation but with similar end results.
In fact, the past few decades bear sole witness
to the rapid acceleration and expansion in the
scope and breadth of neurosurgery.
Reprint requests:
Michael L.J. Apuzzo, M.D.,
1420 San Pablo Street,
PMB A-106,
Los Angeles, CA 90033.
Email: neurosurgery-
journal@hsc.usc.edu
Received,
February 24, 2007.
Accepted,
March 22, 2007.
Prehistoric Cranial Surgery
The term
trepanation
describes the removal
of sections of bone from the cranium (69). The
instrument used to accomplish this procedure
is the
trepan
, which derives from the Greek
try-
panon
, or borer (
Fig. 1
). The term
trephination
,
on the other hand, refers to the specific cre-
ation of a circular saw, a
trephine
, or a more
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A
PUZZO ET AL
.
FIGURE 1.
Primitive trephination instruments made
of stone blades attached to wooden shafts. (
From
,
Laws ER Jr, Udvarhelyi GB: The Genesis of Neuro-
science by A. Earl Walker, M.D. Park Ridge, AANS,
1998, p 5 [64]).
blows by piercing weapons to
the chest or abdomen and
blunt instruments to the head.
For example, “death” by
piercing the chest or abdomen
was generally permanent,
whereas victims often recov-
ered from ostensibly fatal
blows to the head. Thus,
Neolithic man attempted to
revive the dead by surgically
manipulating the head.
However, this elegant theory
suffers from lack of concrete
evidence and has faced the
same criticism as earlier spec-
ulations.
However motivated, pre-
historic surgeons invoked
essentially four different
techniques to remove pieces
of cranial bone: 1) scraping,
2) grooving, 3) boring and
cutting, and 4) rectangular
intersecting incisions (
Fig. 3
)
(69, 91, 110). The earliest
instruments were made of
flaked stone, flint, obsidian,
and bone. Later, the ancient
Peruvians used curved
tumi
blades to incise soft tissue and
make rectangular cuts in the bony cranium (
Fig. 4
). Sharp
instruments were used to make grooves and drill holes that
could then be connected. Flat scrapers were also used with
Excavations in the Jericho area in the Near East and Asia have
produced specimens from approximately 8000 to 6000 BC. The
earliest European examples are more than 10,000 years old,
dating perhaps to the late Paleolithic period, but certainly to the
Neolithic age (69, 91). Early Danubians were performing cranial
surgery in 3000 BC, and ancients from the Seine-Oise-Marne
area of France were similarly active in 2000 BC. Based on the
number of skulls that have been found in France, it is probable
that a veritable “surgery center” existed there between 1900
and 1500 BC. Trepanation specimens have also been found in
other regions of Neolithic Europe, the Balkans, and Russia.
New World specimens of trepanation are much more recent,
with the oldest examples, dating to 400 BC, found on the south-
ern coast of Peru. Nevertheless, more trepanned skulls have
been found in this region than in the rest of the world com-
bined. It is possible that the practice spread from Peru to what
is now Mexico and North America. In the Far East and China,
however, no specimens have been found.
Despite the plethora of physical evidence of prehistoric trepa-
nation, insight into the motivation to the practice has been much
more problematic and controversial (69, 88, 91). In the absence
of written records, scholars are left to speculate, invoking a com-
bination of motives as varied as therapeutic, magicotherapeutic,
and magicoritual. For example, given the tendency of Peruvian
and Danish skulls to have openings in the left temperoparietal
region, it follows that trepanations had therapeutic intentions
for injuries from blows by a right-handed assailant. Ritual was
felt to be an important motivation for the development of the
trepanation “center” in Neolithic France. In postmortem opera-
tions,
roundelles
of cranial bone were presumably obtained for
use as charms, amulets, or talismans (
Fig. 2
). These speculations
are somewhat supported by observations of the practice of 20th
century East African tribes, in which the Kisii tribe performs
trepanations primarily to alleviate headache after a blow,
whereas the nearby Lugbara tribe desires to release evil spirits.
A novel speculation proposes that operations on the head were
aimed at resurrecting the dead (88). The author argues that
Neolithic man appreciated the contrasting outcomes of “fatal”
FIGURE 2.
Prehistoric amulets;
bone disks removed by trephina-
tion were polished into various
shapes and worn around the neck
as protection against disease.
(
From
, Leonardo RA: History of
Surgery. New York, Froben Press,
1943 [67]).
FIGURE 3.
Methods of trephination included scraping
(
1
), grooving (
2
), boring and cutting (
3
), and rectan-
gular intersecting incisions (
4
). (
From
, Lisowski FP:
Prehistoric and early historic trepanation, in Brothwell
D, Sandison AT (eds): Diseases in Antiquity:
A Survey of the Diseases, Injuries and Surgery of
Early Populations. Springfield, Charles C Thomas,
1967, pp 651–672 [69]).
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S
URGERY OF THE
H
UMAN
C
EREBRUM
men indicates that patients survived (
Fig. 5
). In some groups of
ancient skulls, as many as 80% of Neolithic and Melanesian
patients survived the operation. In present day Africa, opera-
tors claim mortality rates of less than 5%. The ancient Peruvian
faced upwards of 50% mortality. However, it is believed that
many of their patients were victims of trauma, and the con-
founding contribution of the traumatic injury could account
for their poorer results.
FIGURE 4.
Bronze instruments (champi) used by the
Incas in craniotomies, including a bone elevator, cres-
cent tumi knives, dissectors, and needles. (
From
,
Marino R Jr, Gonzales-Portillo M: Preconquest
Peruvian neurosurgeons: A study of Inca and pre-
Columbian trephination and the art of medicine in
ancient Peru.
Neurosurgery
47: 940–950, 2000 [77]).
Evolution of
Neurosurgery in Ancient
and Medieval History
The legacy of cranial sur-
gery by their prehistoric
ancestors was embraced as
humans began to record their
activities. In fact, the impor-
tance of operations on the
head and bony coverings of
the brain is recognized by the
prominent movements and
personalities that have
shaped the evolution of med-
icine through ancient and
medieval history (46, 69).
During this period, head
trauma seems to have been
the principle indication for
cranial manipulations.
FIGURE 5.
Skull showing evidence of bone healing
after trephination. Despite primitive instrumentation
and crude methodology, prehistoric surgeons were sur-
prisingly successful. Courtesy of Nationalmuseet,
Copenhagen, Denmark.
Egypt and China
The ancient Egyptians can
claim to have produced both
the earliest known practicing
physician, Imhotep (2600 BC)
(
Fig. 6
), and the earliest
known medical text, the
Ebers papyrus (46). This doc-
ument, along with the Hearst
and Edwin Smith papyri,
documented Egyptian aware-
ness of the importance of
neurosurgery. For example,
the Edwin Smith papyrus
(
Fig. 7
) dates to 1700 BC and
is thought to be the oldest
book on surgery. Included on
its 15
good effect, and in Mexico, a bow and obsidian drill may have
been used. Although the primitive surgical instruments have
survived to the present day, there is a lack of specific evidence
of the use of anesthetics. Scholars have speculated that alcohol,
narcotics, or coco products were administered to alleviate pain.
However, contemporary East African patients undergo trepa-
nation without anesthesia, and a survivor in Bolivia admitted
that, although the incision of the soft tissue is painful, analge-
sia is not an overriding issue once the bony cranium is
stripped of the pericranium (10).
Despite their primitive instruments and lack of fundamental
medical knowledge, prehistoric surgeons were surprisingly
successful (10). Evidence of healing in the archeological speci-
1 feet dimensions are
descriptions of 48 cases,
including those involving the
spine and cranium; this doc-
ument also recognized that
injuries resulting in exposed
brain often resulted in nuchal
rigidity (18, 34). Physical evi-
dence of their practice exists,
FIGURE 6.
Statute of Imhotep,
reputed father of Egyptian med-
icine, who served as physician to
King Zoser in the Third Dynasty,
c. 28th to late 26th centuries
B.C. In addition to being a med-
ical doctor, Imhotep served as a
royal architect, and designed the
step-pyramid of Sakkara.
Courtesy of the Egyptian
Museum, Cairo, Egypt.
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