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From Mystics to Modern Times: A History of Craniotomy & Religion
Abstract
Neurosurgical treatment of diseases dates back to prehistoric times and the trephination of skulls for various maladies. Throughout the evolution of trephination, surgery and religion have been intertwined to varying degrees, a relationship that has caused both stagnation and progress. From its mystical origins in prehistoric times to its scientific progress in ancient Egypt to its resurgence as a well-validated surgical technique in modern times, trephination has been a reflection of the cultural and religious times. Herein we present a brief history of trephination as it relates religion, culture, and the evolution of neurosurgery.
... [9] During the middle ages, the Arabic surgeon Abul-Qasim Al Zahrawi, known in Western literature as Abulcasis, wrote extensively on early depictions of neurosurgical diagnosis and treatments, including the treatment of head injuries, skull fractures, hydrocephalus, and subdural collections. [10] During the Renaissance, further progress was made in craniotomy techniques. Advances in firearms and grenades in the 16 th and 17 th centuries led to more cranial trauma. ...
... Military surgeons performed craniotomies to evacuate clots and pus. [10] During the second half of the 19 th century, after the advent of antisepsis and general anesthesia, the use and technique of craniotomies evolved. By the 20 th century, neurosurgery became an autonomous discipline and the modern era began. ...
... By the 20 th century, neurosurgery became an autonomous discipline and the modern era began. [10,11] At first, neurosurgical approaches were performed with extended craniotomies. Large cranial openings were necessary for several reasons. ...
Craniotomy, or a surgical opening into the skull, has been observed as early as Paleolithic and Neolithic periods. Early craniotomies carried great morbidity and mortality and standardized during the 20 th century, improving surgical outcomes. The simultaneous evolution of medical imaging and stereotactic navigation systems has allowed imaging to correlate findings with surgical approaches, further optimizing patient safety. We review the history of craniotomy and provide an imaging review of the most common craniotomy approaches.
... [2][3][4][5][6][7][8] The American continent, particularly the Mesoamerican region, is a vibrant area where evidence of neurosurgical interventions has been found. [11][12][13][14][15][16][17] Archeological pieces found in areas populated by ethnic groups such as the Aztecs, Mixtecs, Mesoamerica is culturally rich in diverse aspects, such as nature, sociology, and archeology. Several neurosurgical techniques were described during the Pre-Hispanic era. ...
Mesoamerica is culturally rich in diverse aspects, such as nature, sociology, and archeology. Several neurosurgical techniques were described during the Pre-Hispanic era. In Mexico, various cultures, such as the Aztec, Mixtec, Zapotec, Mayan, Tlatilcan, and Tarahumara, developed surgical procedures using different tools to perform cranial and probably brain interventions. Trepanations, trephines, and craniectomies are different concepts utilized to describe skull operations, which were conducted to treat traumatic, neurodegenerative, and neuropsychiatric diseases, and as a prominent form of ritual practice. More than 40 skulls have been rescued and studied in this region. In addition to written medical sources, archeological vestiges allow a more profound comprehension of Pre-Columbian brain surgery. The purpose of this study is to present the existing evidence of cranial surgery in Pre-Hispanic Mexican civilizations and their worldwide counterparts, procedures that have contributed to the global neurosurgical armamentarium and have significantly impacted the medical practice's evolution.
... Esta última fue un procedimiento en el que se realizaba una ventana en el cráneo por la que pudiese salir el espíritu maligno causante de la enfermedad. Se han encontrado cráneos trepanados en épocas prehistóricas en diferentes lugares del planeta (10,11). ...
Paul Broca (1824-188) fue un médico y antropólogo francés que hizo aportes en diferentes disciplinas, particularmente medicina y antropología. En el campo de la neurociencia su principal contribución fue la descripción de varios casos de pacientes con afasia motora. Realizó sus autopsias y describió que el área ubicada en la tercera circunvolución frontal izquierda es la responsable de la producción del lenguaje y que lesiones allí ubicadas producen afasia motora. En su honor dicha región del cerebro es denominada área de Broca y la afasia expresiva, afasia de Broca. Describió también un área del cerebro que denominó lóbulo límbico, y demostró que las trepanaciones llevadas a cabo durante la prehistoria en diversos lugares del mundo fueron realizadas en individuos vivos.
... Evidence of craniotomy and trephination goes back 8000-10,000 years in what is now Peru and has been found throughout the ancient world including Egypt, and Central and South America [75]. The first written document describing therapeutic trephination is Hippocrates' On Injuries of the Head, from approximately 400 BCE [76,77]. ...
Purpose of review
The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets.
Recent findings
Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1.
Summary
This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
... The process of creating window in the skull for intracranial condition can be dated as far back as the Neolithic era (8000-5000 B.C.). 8 The earliest description is documented in the Hippocratic treatise, in which for the first time a systematic account is provided complete with indications, timing and technical notes. The advent of antisepsis, improved anaesthesia and imaging technique, the craniotomy became cemented into modernity. ...
BACKGROUND
Chronic Subdural Haematomas (CSDH) is a frequently encountered condition in neurosurgical practice with increasing incidence
because of ageing population particularly in those who use anticoagulants and antiplatelet agents. These are treated with
evacuation of CSDH with burr holes, craniotomy and craniotomy after burr holes for recurrence or reaccumulation in few. The
surgical procedure, need for additional surgical procedure, complications and outcome are assessed.
MATERIALS AND METHODS
During the period of 4 years 6 months from September 2012 to March 2017, 225 patients who presented with chronic subdural
haematoma were treated. This is a retrospective study. These patients underwent non-contrast CT at the time of admission.
Surgical evacuation of CSDH was done and patient outcome in terms of reaccumulation, recurrence, complications and final
outcome are observed.
RESULTS
Out of total 225 cases, 183 are males and 42 are females, 81.33% and 18.66%, respectively. 167 cases are treated with burrhole
evacuation and 58 with craniotomy, 74.22% and 25.77%, respectively. 35 out of 167 patients treated with burr holes
needed re-exploration of previous burr holes and evacuation in 24 cases and conversion to craniotomy in 11 cases. 6 out of 58
patients treated with craniotomy needed exploration for reaccumulation of SDH. The death rate is 6.7% (11 patients) in burrhole
cases and 10.3% (6 cases) in craniotomy cases.
CONCLUSION
Management of CSDH either with burr holes or craniotomy should be selected on case-by-case basis depending on radiographic
findings like membrane thickness associated acute haemorrhage, multiple loculations, calcified membrane, underlying
intracranial complications and general condition of the patient.
... 7 The accuracy of medical information mentioned in this papyrus made some people think that the author had actually been a great physician, anatomist, army surgeon, and also an architect, Imhotep. 8,9 In Ancient Egypt, spinal fractures were quite common and occurred mainly after falls from heights of workers during the construction of Egyptian pyramids and temples. 10 Because during that time the information on the function and structure of the spinal cord was still primitive, in case of these accidents, Egyptian doctors made no difference between vertebral fractures and the presence of the underlying spinal cord injury, 11 preferring explanations shrouded in magic and superstition. ...
Since ancient times, the physicians of Antiquity noted the occurrence of priapism in some spinal cord injuries. Although priests saw it as a consequence of curses and witchcraft, after clinical observations of the Middle Ages and Renaissance, first medical hypotheses emerged in the 17(th)-19(th) centuries completed and argued by neuroscience and neurology developed in the European laboratories and hospitals. This study aims to present a short overview of the history of clinical observations of posttraumatic male priapism after spinal cord injuries since Antiquity until the beginning of the 20(th) century.
... Les origines de la médecine elle-même remontent à fort loin, trèsvraisemblablement à l'époque néolithique ou une fois dépassé les simples buts que sont la protection du groupe (abri), l'accès à la nourriture et la reproduction de l'espèce, il a été possible à l'humanité de concevoir d'autres champs d'abstraction que sont par exemple la religion ou une ébauche de science (astronomie, mathématiques, botanique). Cette médecine s'inscrivait sans doute dans des pratiques chamaniques et pouvait avoir une certaine dose de sophistication ;l ap reuvee ne st la découverte de crânes préhistoriques présentant des orifices de trépanation en voie de cicatrisation, ce qui laisse supposer une relatives urvie de leurs propriétaires [1,2]. Au 2 e millénaire avant notre ère, le code d'Hammourabi définit la rémunération des médecins et les peines applicables en cas de complications ou de faute professionnelle [3] tandis le papyrus Edwin Smith, du nom de son découvreur,m ontre la connaissance déjà approfondie des anciens Égyptiens en matière de traumatismes et d'anatomie humaine [4]. ...
It is common, in physical anthropology, to uncover human remains showing violence traces, trauma or discreet traits such as foramen and wormian bones and others. Such observations on recent human remains can be made both in forensic pathology and forensic anthropology. In this context of human remains discovery by the local police department, we proceeded to forensic anthropological examination of these bones which has showed several perforations, a sternal foramen, a sterno xiphoidal fusion and at last, a parietal perforation. This skeleton was found on the ground in procubitus position; no objects or weapons were found, which could have been directly related to the death of these discovered human remains. After differential diagnosis and radiological analysis, plausible causes of the parietal orifice presence, we conclude it is a surgical care such as trephination, a rarely mentioned case, to the best of our knowledge, in forensic literature.
This research article explores the ancient origins of trepanation, unravelling its early instances and the associated cultural beliefs that have shaped cranial surgery. It scrutinises the medieval and Renaissance periods, elucidating the evolution of trepanation techniques within the context of advancements in medical knowledge and societal changes. In addition, the research investigates the diverse practices of trepanation across cultures, offering insights into the unique approaches, beliefs and rituals associated with this ancient surgical procedure. Examining the decline of trepanation in mainstream medicine, the article assesses the factors contributing to its diminishing prevalence and the emergence of alternative surgical methods. The study also delves into sporadic resurgences of trepanation in unconventional contexts, providing a nuanced understanding of its enduring fascination. In exploring trepanation’s impact on modern medicine, the article sheds light on its contributions to the study of cranial anatomy, the evolution of surgical tools and the broader narrative of medical progress. Ultimately, this historical investigation contributes to a comprehensive understanding of trepanation, revealing the intricate interplay between medicine, culture and the human quest for knowledge and healing.
Craniosynostosis, the premature closure of cranial sutures, has been known to exist for centuries, but modern surgical management has only emerged and evolved over the past 100 years. Craniosynostosis can be non-syndromic or syndromic. The latter one is much more complex, and the disease involves the facial skeleton to a much greater extent. The evolution of craniosynostosis therapy is based on experiences and efforts in craniotomy and cranioplasty techniques, applied for various cranial diseases. The development of treatment tools for craniosynostosis patients in history spanned across a wide range of surgical approaches, beginning with craniotomies, craniectomies, strip craniectomies, and suturectomies and extended approaches up to extensive calvarial and facial remodeling. All developments have been driven by a growing understanding of how a prematurely fused cranial suture can affect the growth and shape of the entire skull. Craniofacial surgery developed as a new sub-specialty of plastic and cranio-maxillofacial surgery and owes its birth to the pioneering work of Paul Tessier in the late 1960s. Craniofacial surgery in the narrow sense means the simultaneous correction of cranial and facial structures. It includes and fuses together neurosurgical as well as maxillofacial/plastic surgical techniques. It has now become an established interdisciplinary discipline for the management of inborn anomalies of the craniofacial region.
Chronic subdural hematomas are one of the most common clinical entities encountered in today's neurosurgical practices owing to an aging population and continued increases in life expectancy. Although there is a role for conservative management, surgical drainage remains the mainstay of current therapy. Regardless of the technique used for hematoma drainage, there is level I evidence to suggest that use of closed-system drainage during the perioperative period significantly decreases the likelihood for hematoma recurrence, length of hospital stay, and mortality.
Job van Meekeren of Amsterdam was a surgeon, respected by outstanding contemporary medical doctors for his knowledge of medical literature and his skills, who made a definite link between anatomy and surgery. He showed a great interest in hand surgery, and interesting is a demonstration of flexor tendon repairs on corpses by one of his pupils. It is still a great joy to read his book today, which also gives a good representation of the state of the art of surgery in the seventeenth century in Amsterdam (Fig. 11). Names and addresses of patients are fully mentioned, so even today we know exactly where they lived and where the events took place. On the other hand, we also know quite well what the surgeons and doctors looked like through the efforts of many excellent painters who depicted anatomy lessons. In Amsterdam, barber-surgeons' guilds were very eager to sit for group paintings, centered around the teaching medical doctor (Table I). The painter Aert Pietersz in 1603 painted Dr. Sebastiaan Egberts surrounded by 29 surgeons, and in 1619, Dr. Egberts was painted once more, this time with five learning surgeons, by Thomas de Keyzer. Nicolaes Eliasz, named Pickenoy, painted Dr. Johan Fonteyn in 1625, and Rembrandt is well known for the Anatomy Lesson of Dr. Tulp (1632) and Dr. Deyman (1656). It is peculiar that a portrait of van Meekeren could not be traced.
Trephination is the oldest known surgical technique. Peru has been recognized as a major source of ancient trephined skulls, many of which date back 2300 years. This presentation reviews from a neurosurgical perspective many of the archaeological studies performed on these skulls. Comparative osteology has shown that almost 70% of patients survived the procedure. The various instruments, hemostatic agents, anesthetics, surgical techniques, and cranioplasties used are reconstructed from the anthropological literature. The possible reasons for the use of trephination are discussed. Analysis of the data leads to the conclusion that, despite their rudimentary knowledge of disease, the ancient Incas must have had some knowledge of anatomy and proper surgical procedure.
Cranioplasty is almost as ancient as trephination, yet its fascinating history has been neglected. There is strong evidence that Incan surgeons were performing cranioplasty using precious metals and gourds. Interestingly, early surgical authors, such as Hippocrates and Galen, do not discuss cranioplasty and it was not until the 16th century that cranioplasty in the form of a gold plate was mentioned by Fallopius. The first bone graft was recorded by Meekeren, who in 1668 noted that canine bone was used to repair a cranial defect in a Russian man. The next advance in cranioplasty was the experimental groundwork in bone grafting, performed in the late 19th century. The use of autografts for cranioplasty became popular in the early 20th century. The destructive nature of 20th century warfare provided an impetus to search for alternative metals and plastics to cover large cranial defects. The metallic bone substitutes have largely been replaced by modern plastics. Methyl methacrylate was introduced in 1940 and is currently the most common material used. Research in cranioplasty is now directed at improving the ability of the host to regenerate bone. As modern day trephiners, neurosurgeons should be cognizant of how the technique of repairing a hole in the head has evolved.