Fedor Krause: the First Systematic Use of X-Rays in Neurosurgery

Neurosurg Focus 33 (2):E4, 2012

Fedor Krause: the first systematic use of x-rays in neurosurgery

Ali M. Elhadi, M.D., Samuel Kalb, M.D., Nikolay L. Martirosyan, M.D., Abhishek Agrawal, M.D., and Mark C. Preul, M.D. Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Within a few months of Wilhelm Conrad Röntgen’s discovery of x-rays in 1895, Fedor Krause acquired an x-ray apparatus and began to use it in his daily interactions with patients and for diagnosis. He was the first neurosurgeon to use x-rays methodically and systematically. In 1908 Krause published the first volume of text on neurosurgery, Chirurgie des Gehirns und Rückenmarks (Surgery of the Brain and Spinal Cord), which was translated into English in 1909. The second volume followed in 1911. This was the first published multivolume text totally devoted to neurosurgery. Although Krause excelled in and promoted neurosurgery, he believed that surgeons should excel at general surgery. Importantly, Krause was inclined to adopt technology that he believed could be helpful in surgery. His 1908 text was the first neurosurgical text to contain a specific chapter on x-rays (“Radiographie”) that showed roentgenograms of neurosurgical procedures and pathology. After the revolutionary discovery of x-rays by Röntgen, many prominent neurosurgeons seemed pessimistic about the use of x-rays for anything more than trauma or fractures. Krause im- mediately seized on its use to guide and monitor ventricular drainage and especially for the diagnosis of tumors of the skull base. The x-ray images contained in Krause’s “Radiographie” chapter provide a seminal view into the adoption of new technology and the development of neurosurgical technique and are part of neurosurgery’s heritage. (http://thejns.org/doi/abs/10.3171/2012.6.FOCUS12135)

Key Words • Fedor Krause • radiology • x-ray • neurosurgery • history of neurosurgery

In discussing newer methods of examination, radiogra- Discovery of Röntgen or the X-Rays phy should be included. Above all other means of diagnosis it furnishes the most useful in tumors with calcareous or bony In November 1895, Wilhelm Conrad Röntgen discov- deposits as, for instance, in exostosis. ered the “X-rays.” On January 13, 1896, Röntgen person- 17 Fedor Krause ally demonstrated his new rays before Kaiser Wilhelm II, but he did not speak on his discovery elsewhere until a Among Harvey Cushing’s many accomplishments, memorable lecture before the Würzburg Physical Medi- he has been heralded as the first to use x-rays for neu- cal Society on January 23.6,8 The closing discussion of the rosurgical diagnosis.10 Upon closer inspection, the topic is more complicated, involving the seminal contribution lecture concerned whether Röntgen believed that it would of another, nearly unacknowledged for his earliest work be possible to make x-ray photographs of other human with x-rays in neurosurgery. This project traces the use of body parts beyond the bone, and whether surgery and x-rays by Fedor Krause (Fig. 1), who might be regarded as anatomy could benefit by the discovery. Röntgen believed more deserving of the accolade, and places his efforts in at the time that, because of the similar density of organs, the rays could not differentiate them. As mentioned by the context of contemporaneous events in the incorpora- 8 tion of a new technology. Indeed, 1908 was an auspicious Glasser, “Professor C. Schönborn [Karl Wilhelm Schön- year for neurosurgery, witnessing 2 major monographs born], a surgeon present, warned against too much opti- on neurosurgery by Cushing and Edward Archibald, as mism since the method scarcely promised to be of much, well as a textbook by Krause that heralded modern sur- if any value in the diagnosis of internal disturbances.” gical technique on neurological structures incorporating Glasser further wrote: x-rays. [Röntgen replied] that it was not difficult to photograph a

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cal diagnosis.” In another letter to his mother on May 10, 1896, he stated “We have at least succeeded in having an X-ray machine put in for which I have subscribed largely and hope the conservative staff will ultimately remuner- ate us for it.”7,10 The first clinical use of x-rays in North America was by Williams and Codman in 1896, which started shortly after its discovery in Röntgen’s laboratory. Cushing worked with Codman at the Massachusetts General Hos- pital with x-rays and then left for John Hopkins Hospital in 1896 with an x-ray tube. In Boston, attempts were made to demonstrate brain tumors by x-rays from 1896 through 1910. Williams,24 in the first text in North America on radiography, wrote of the technical problems with acquiring useful images: “Tumors in the brain with our present apparatus and inexperience must necessarily offer a great deal of difficulty to detection by the rays” (340). After his first use of x-rays on November 6, 1896, on a female patient who had sustained a gunshot injury Cushing wrote: It was in the fall of 1896 that I went to John Hopkins and made the first Roentgenograms that were taken there, with the aid of a decrepit and perverse static machine as big as a hurdy- gurdy and operated in the same way, by turning a crank. My first paper submitted for publication contained an account of a case of a gunshot wound of the spine showing a bullet which a Baltimorean had planted in the body of his wife’s sixth cervi- cal vertebra. I once showed these pictures to Dr. Cole and he expressed himself as astonished that such good plates could have been taken in 1896; but I do not know whether I told him, as I shall now confide to you, that the plates were the result of exposures averaging 35 minutes. And I may add that the pictures which were reproduced were not those of a single experience, for I think the patient was given as many as half a dozen sessions at least, before plates were secured which were sufficiently good for reproduction. Needless to say, she was a Fig. 1. Fedor Krause (1857–1937). Courtesy National Library of most cooperative patient. Subsequently a Will-young coil was Medicine, Bethesda, MD. purchased which I think had a spark gap of 2 or 3 inches. With this coil and many bottles of rodinol (I do not know if rodinol dog or cat according to his method and believed it would be is anything more than a memory for a few grey beards in this possible in the near future to make x-ray pictures of large parts audience), I spent many weary hours for the next year or two of the human body. He said that he, however, did not have in an improvised dark room off from the old amphitheatre at time to continue his experiments in that direction but that he the Johns Hopkins Hospital developing roentgen-ray plates in would be willing to lend the help of his experience for any such which no one at the time took any very great interest. Certainly experiments made in medical institutions. Thus this memorable no one of us could have had any possible conception of the lecture was ended. For every member of the large audience the increasingly important role of Roentgen-ray was to play in occasion was unforgettable. (51)8 clinical diagnosis and treatment.9 The world was promptly seized with what can only Cushing published on the use of x-ray applications in 2 be described as x-ray pandemonium; scientists, photog- spine cases in 1898. raphers, and hucksters quickly obtained x-ray apparatus. While Cushing was writing letters home, Krause’s Within a few weeks of Röntgen’s Würzburg meeting, work on his use of x-rays for surgery (The Importance Krause, working as a surgeon in the municipal hospital of of Röntgen’s Photogram’s for Surgery) had already been Altona, Germany, acquired an x-ray apparatus and began published twice in German scientific medical journals in exploring its potential applications for surgical diagnosis. March 1896 (in Deutsche medizinische Wochenschrift He began to use x-rays in his daily interactions with pa- and Münchener medizinische Wochenschrift). These tients and quickly amassed a huge experience.22 publications are recorded in the seminal book by Glasser8 on Röntgen. Concurrently in their 1900 text, An Ameri- X-ray Implementation in Neurosurgery can Text-Book of Surgery for Practitioners and Students, Keen and White stated that their use of x-rays was limited On February 15, 1896, shortly after Röntgen’s report, to localization of foreign bodies and fractures in difficult Cushing wrote enthusiastically in a letter to his mother, cases. In a chapter, “The Use of the X or Röntgen Rays in “Everyone is very excited over the new photographic dis- Surgery”, Keen commented: covery. Professor Röntgen may have discovered some- The Roentgen method is, of course in its infancy. It has, thing with his cathode rays that may revolutionize medi- however, reached already a degree of usefulness that makes it

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obvious that the necessary apparatus will be an essential part of the surgical outfit of all hospitals, and will be employed constantly in a variety of cases. Those to which the method can now be applied with advantage may be summarized as follows, emphasis being placed on the fact that what is written to-day may require revision or reversal tomorrow, so rapidly are improvements and discoveries taking place. (1191)15 With regard to intracranial tumors, Keen indicated that locating them still depended on “localizing symptoms…if they exist; for it must be remembered that in certain parts of the brain a tumor may exist without any localizing symptoms, but with only the general symptoms of headache, vomiting, choked disc, and convulsions” (547).13 Interestingly this was written in the section not titled with the term “tumor” but under the rubric “Fungus Cerebri, or Hernia Cerebri.” However, in the chapter on x-rays some pages later, Keen wrote presciently: Bony tumors can plainly be seen, and as the method improves it is to be expected that intracranial and intraspinal osteomata may be discovered and located, and possibly even Fig. 2. The title page of von Bergmann and colleagues’ 1904 mul- periosteal thickenings due to tubercular, syphilitic, or pyogenic tivolume text to which Krause was a contributor, but not on tumors or infection…. Penetration is not, however, of the greatest value; x-ray information. the property of differentiating between all ranges of densities is of greater value. Differentiation between the lesser as well portantly, the text contained a chapter devoted to x-rays as the greater densities is essential to the future development of for neurosurgery, titled “Radiographie,” subclassifying this method of diagnosis. In order, therefore, that a tube should indications for various tumors, hydrocephalus with shunt be most useful for diagnostic purposes, it should be capable of positions, and trauma to the brain. In this chapter, and producing and maintaining for any desired length of time any throughout the book, Krause described cases showing ra- of the various qualities of the Roentgen ray that the operator may desire to employ. (1192 and 1194)15 diographs and described diagnosis, surgery, and outcome with correlated masterful anatomico-surgical illustra- In 1901, Keen remarked, “At first it was thought im- tions by Max Landsberg. possible to discover anything inside of the bony skull, Krause must have obtained excellent apparatus as his but there are now on record nearly a score of instances radiographs are amazingly clear for the time. He routine- in which bullets have been detected within the skull….” 14 ly used x-rays to differentiate the origin and the direction (245). of growth of the tumor: In the 1904 multivolume surgical text (Fig. 2) by 23 In discussing newer methods of examination, radiography von Bergmann, von Bruns, and von Mikulicz, only one should be included. Above all other means of diagnosis it comment on x-rays as a diagnostic aid exists in the sec- furnishes the most useful in tumors with calcareous or bony tion on wounds of the head written by Krönlein. In the deposits as, for instance, in exostosis. If the neoplasm has its section on surgical treatment of brain tumors written by origin from the lamina vitra and grows toward the cranial cav- von Bergmann, there are no comments on x-rays. Inter- ity, its recognition by means of the X-ray is an easy matter. estingly, Krause was the contributor of the chapter on However, when exostoses originate at the base of the skull, neuralgias of the head. and reach a certain size, they, too, will throw a shadow on the plate which may permit of a diagnosis being made [278]… Neoplasmata of the base of the skull are closely allied to Krause’s Use of X-ray Apparatus tumors at the base of the brain. New formations originating in these cases from the outer (lower) surface of the dura or from By this time Krause had progressed well beyond the bone itself grow, as a rule, into the cranial cavity and may Keen’s and von Bergmann’s writings. It seems that Krause give rise to manifestations of cerebral compression as well as worked intimately with the neurologist Hermann Oppen- to morbid symptoms from involvement of the cerebral nerves. heim, who also readily accepted the acquisition of x-ray A differentiation as to the structures from which the tumor originated is, from the clinical manifestations alone, frequently information and who practiced in several Berlin hospi- 17 tals. Krause and Oppenheim were contemporaries (only 1 impossible. (821) year apart in age) and appear to have functioned smoothly Krause used the x-ray apparatus on every patient as a neurologist-surgeon team. Krause cites his frequent with epilepsy that he treated: association with Oppenheim for x-ray knowledge and ex- Any injury to the skull may bring on epileptic seizures…. perience. Acquiring x-rays on every case of epilepsy and Whenever possible x-ray examination should be made. It fre- all other cranial cases, Krause presented his expertise in quently is a great aid in clearing up the diagnosis. Even in other 17 his 1908 Chirurgie des Gehirns und Rückenmarks, which forms of epilepsy roentgenography is of urgent need. (479) was translated a year later into English (Surgery of the Krause stressed proper radiographic technique to Brain and Spinal Cord) (Fig. 3).16,17 It was the first neu- avoid artifacts and inaccurate results.3 The thought pro- rosurgical text with recognizable systematic, methodical cess behind Krause’s efforts to acquire useful images are case presentation, topic, diagnosis, surgical technique, apparent in comments in his chapter regarding the base of and teaching approach fully promoting neurosurgery. Im- the skull and the sella-sphenoid region:

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Fig. 3. Title pages of Krause’s textbooks. Note the signature of Krause on the German Volume II released in 1911. The title page of the “Radiography” chapter is shown in English (published in 1909), which was the last chapter of the German Volume I published in 1908.

Interpretation of the Roentgen plate must be carefully made. tumors section: “A radiograph may occasionally prove of The fact that the plate is of some distance from the Turkish value, though on the whole it is most disappointing as a saddle influences very largely the conformation of the shadow. diagnostic aid. It is of particular value in the recognition Each turn of the head on its vertical axis alters the picture of the cavity, and when to this is added the fact that in acromegaly of basilar tumors like those of the pituitary fossa, which have led to deformation of the sella turcica or absorption an enlargement and thickening of the skull is present, it is easy 5 to see that an accurate picture of the contour of the base of the of the bone” (230). skull is not easily obtained. The shadow should be compared Edward Archibald was somewhat more optimistic with that of the normal skull, and exposures should be made at and provided more commentary on the use of x-rays in stated intervals in order to observe the extension of the patho- his 1908 chapter on neurosurgery in Bryant and Buck’s logical process. The examination may be regarded as associated multivolume surgical textbook (as good as or better in with great difficulties. (279–280)17 quality than Cushing’s Keen neurosurgical monograph of By the time of publication of his text, Krause had been the same year) with regard to use for dermoid cysts, frac- using x-ray images for trauma and gunshot injuries, tumor tures, and penetrating trauma: diagnosis, shunt placements and other routine cases. These A good skiagram, in places where such is available, is natu- images were correlated with diagnosis, associated with rally the ultimate test. I speak here of vault fractures, not of specific signs, symptoms, and surgical indications. Com- basal, which will always remain difficult and often impossible pared with contemporary neurosurgical texts, his book of photographic proof. The fissures of bursting fractures of the was unique in having clear x-ray images. Krause made it vault can be traced for a variable distance in skiagrams where the frontal, temporal, or parietal bones are involved… (69–70) clear that by the time of his writing, his experience with Where possible skiagrams should be taken to locate the bullet. x-ray applied to injuries of the skull and brain was well (97)1 systematized: “As far as injuries to the skull and brain are With regard to tumors of the sella turcica, Archibald concerned bullets and metallic foreign bodies are easily thought x-rays were of good use, but he was pessimistic recognized on the Roentgen plate. Their location may be on the use of x-rays for tumors in other cranial locations: determined with considerable certainty by exposures made 17 “These tumors in their growth frequently enlarge the at various levels and in several directions” (282). sella turcica very materially, as Oppenheim first showed, so that a good skiagram may often be of decided help. Indeed, this is perhaps the only place in which the x-rays Cushing’s and Archibald’s 1908 1 Neurosurgery Monographs are of service in the diagnosis of cerebral tumors” (223). Cushing was later lured back in 1912 to be chief sur- Meanwhile, in his acclaimed 1908 neurosurgery geon at Peter Bent Brigham Hospital in Boston. Despite monograph in Keen’s multivolume surgical text (Fig. his initial enthusiasm for radiology, in his new proposal 4), Cushing appears pessimistic about the use of x-rays. for the hospital he mentioned, “In regard to a Roentgenol- There is only one minor mention of x-rays in the cerebral ogist... this department will probably involve the employ-

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scenarios Krause described and illustrated in his book, wherein he used x-rays for patient care.17 In these cases, not only did he reproduce the roentgenograms, he also had a clinico-anatomico-radiological correlation in all of his cases. He had illustrations of cadaver dissections included in his book for a clear understanding of the location of the pathology. Krause used these cadaveric speci- mens to devise surgical approaches without transgressing the critical structures. Gunshot Wound A 20-year-old man presented with a gunshot injury in his right temple. After stabilization of the patient, a roentgenogram was indicated. This clearly showed that the bullet was located in the anterior cranial fossa, rest- ing on the right orbital plate of the frontal bone (Fig. 5). Krause treated the patient conservatively, but after several Fig. 4. Title page of Keen’s 1908 text and first page from Cushing’s weeks, in January 1900, the patient presented with severe chapter within the volume. headaches and disturbed mental functions. A craniotomy was performed and the bullet was successfully recovered ment of one or more technical assistants not graduates from the inner side of the orbital plate. The patient was in medicine, with the probable supervision of a resident symptom free during the follow-up in 1907. or visiting graduate in medicine.”7 Not until Keen’s text revision in 1919 are there new, expanded comments on Skull Base Tumor 20 x-rays for neurosurgery by Lewis and Kanavel in what A 34-year-old woman who had been under observa- was Cushing’s monograph. In a supplement to Cushing’s tion for disturbed vision was diagnosed by Oppenheim chapter on surgery of the hypophysis in which they in- as harboring “a tumor at the base on the left side in the cluded x-ray examination of the sella turcica and commented on Oppenheim’s observations (really Krause’s experience working with Oppenheim), Lewis and Ka- navel wrote: “Since Oppenheim in 1899 demonstrated a widening of the sella turcica with a hypophyseal growth, numerous articles have been published upon the appearance of the base of the skull under normal and pathologic conditions” (300).20 In 1921 Neuhoff21 called x-rays “indispensable” in the “Surgery of the head” supplement to Cushing’s Keen chapter: “The best evidence that Cushing’s chapter on Surgery of the Head in Volume III of Keen’s Surgery, written eleven years ago, is a cornerstone in modern cerebral surgery is that almost everything there put down holds as well at the present time….However, definite progress has been made in a number of directions, particularly in the diagnosis and methods of treatment of…brain tumor” (134). Neuhoff cited the advent of the ventriculography and pneumoen- cephalography x-ray techniques as an “important and deci- sive step forward in the regional diagnosis of brain tumor [and] would appear to offer an early as well as an accurate localization of neoplasms and, accordingly, a much better outlook for radical cure by operation. Finally, the precision of the method would permit of exploratory craniotomy directly over the situation of the tumor and thus greatly simplify the operative technic” (185).21 It was not until the 1920s that a series of publications come from Cushing, Sosman, and colleagues that advocated serious, systematic incorporation of radiology in neurosurgery.

Case Illustrations from Krause’s Surgery of the Fig. 5. In this drawing produced from the roentgenogram from Brain and Spinal Cord Krause’s book, a revolver bullet can be seen at the posterior aspect of the orbital plate. From Krause F: Surgery of the Brain and Spinal Cord: Figures 5 through 9 are examples of the challenging Based on Personal Experiences. New York: Rebman Co., Vol 1, 1909.

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cephalus with open fontanels. On October 1, 1907, subcutaneous permanent drainage of the posterior horn was accomplished. Roentgenogram follow-up of the case in March 1908 (Fig. 6), revealed the shunt in situ, and the child improved symptomatically with a decrease in head circumference. Krause tried to distinguish cases of acute hydrocephalus from chronic hydrocephalus. Similarly, the separation of the cranial sutures was an important land- mark for him to know the progress of the hydrocephalus. He even observed the position and location of his bone flaps with x-rays. Permanent CSF Drainage With Ossified Sutures and Vent Formation On February 19, 1908, Krause performed a subcutaneous permanent drainage of the lateral ventricle with formation of a vent in a 16-year-old girl who presented with hydrocephalus. The formation of extra venting Fig. 6. Roentgenogram obtained in a 5-year-old boy, showing a through the cranium was, according to him, necessary permanent subcutaneous drainage cannula in place for 6 months after to rapidly reduce the intracranial pressure. The cannula treatment for hydrocephalus. From Krause F: Surgery of the Brain and was left in situ for 5 months without causing irritation. Spinal Cord: Based on Personal Experiences. New York: Rebman Co., Follow-up roentgenograms obtained 8 weeks after the 1909. operation on April 14, 1908, revealed the tube inside the ventricle, as well as the bone flap position (Fig. 7), with region of the chiasm in the middle portion of the middle the patient improved symptomatically. fossa of the skull. It is not possible to state whether the growth has its origin in the base of the skull or in the base Tumors Producing Secondary Changes in the Calvaria itself” (120).17 Krause noted that the roentgenogram, however, revealed an unusual shadow in the region of the sella Krause demonstrated a large tumor with “atrophy and turcica, which led him to a successful operation. pressure destruction with thinning of the bones and separation of the sutures” in a 16-year-old boy (Fig. 8). He found Hydrocephalus With Open Sutures a large sarcoma in the left posterior fossa. Max Landsberg drew the surgical illustration of the case. Krause wrote: A 5-year-old boy presenting with growth retardation In the past few years [Landsberg] has mastered a method of 3 years’ duration was diagnosed with marked hydro- of rapid sketching during the operations without in any manner interfering with my work. Only very few changes were made on the plates [for Krause’s textbook], and these in insignificant details, so that they truly portray the conditions as objectively presented to the eye of the observer. They are perfect. (iv)17 Krause’s “Radiographie” chapter was especially excellent for comparing the subtle and severe changes pathological processes could produce on the bone (Fig. 9). Tumors That Fare Poorly on Radiography Krause commented on tumor cases in which x-ray examination fails to provide excellent information: However, the Roentgen picture may, in certain cases, show a sufficient number of changes in the bone to lead to a correct diagnosis. Frequently [tumors at the cerebellopontine angle] that had destroyed the posterior surface of the petrous portion of the temporal bone [are difficult to diagnose using X-rays]. To discover such tumors, no method is at present at our com- mand other than intradural exploration through the posterior fossa of the skull. X-ray examinations have thus far invariably disappointed us; maybe because of the deep position of the tumor near the midline. It would be a great aid to the surgeon, if X-ray examinations threw more light upon the actual state of affairs in these cases, for we would then limit our surgical inter- ventions to simple decompression-trephining. (821)17 Fig. 7. Roentgenogram obtained in a 16-year-old girl, showing a permanent subcutaneous ventricular drain as well as the position of the bone flap, 2 months after the operation. From Krause F: Surgery of Krause’s Expanded Use of X-rays the Brain and Spinal Cord: Based on Personal Experiences. New York: Rebman Co., Vol 1, 1909. World War I broadened the adoption of x-rays in sur-

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Fig. 8. Roentgenogram (left) of a large sarcoma in the left posterior fossa with the medical illustration (right). Krause noted the opinion and care of Hermann Oppenheim: “In the latter respect I have had, together with H. Oppenheim, under observation, a boy of sixteen, and obtained a clear photograph…. The sutures behind the petrous bone appear separated several millimeters” (280). Images and quote from Krause F: Surgery of the Brain and Spinal Cord: Based on Personal Experiences. New York: Reb- man Co., Vol 1, 1909. gery. Marie Curie launched a project to make x-ray ma- chines mobile and trained soldiers to use them in battle- field hospitals. By the end of the war nearly 20 mobile radiographic units were established and had acquired about a million radiographs.12 On the 50th anniversary of his doctorate on June 22, 1919, the Prussian Academy of Sciences lauded Röntgen’s work: The eminent practical significance of the new rays which you recognized at once but which you, in your noble unselfish- ness, have left to others to develop practically, was revealed in a most striking manner during the world war. One can say with complete authority that the fruits of your scientific investiga- tions have spared life and limb to hundreds of thousands of poor wounded soldiers, both friend and foe. Thus you are not only esteemed by physical science as its immortal master but also by all humanity as its benefactor. (88)8 During the war Krause was a surgical consultant in the German Army and brought his surgical and radiographic expertise together in the treatment of traumatic injuries.11 Krause edited the 1914 text General Surgery of Brain Diseases, which included clear correlations between x-rays and cranial anatomy and pathology. In the post-war period, x-ray technology would become rapidly developed based on experience and use in the war.2 Krause continued to expand his use of x-rays as de- Fig. 9. A: Roentgenograms showing tumors producing calcareous or bony deposits. “If the neoplasm has its origin from the lamina vitra scribed in his later text of neurosurgery in 1933, pub- 18 and grows toward the cranial cavity, its recognition by means of the X- lished with his assistant Emil Heymann. Heymann, who ray is an easy matter. However, when exostoses originate at the base is regarded as one of the most eminent disciples and a of the skull, and reach a certain size, they, too, will throw a shadow good friend of Krause, succeeded him at the Augusta on the plate which may permit of a diagnosis being made” (278). B: Hospital in 1923. Their book Surgical Operations of the Roentgenograms showing alteration of the skull in infectious process. Head Illustrated by Clinical Observations for Physicians “The roentgen pictures give valuable information when the bones are and Surgeons published in 1933 (Fig. 10) quoted Krause: altered as the result of syphilitic or tuberculous process….In Syphilis, defects in various forms are found, at times appearing as holes or exca- “…an exposition of the operations of surgery from their vations of considerable magnitude, giving the picture of skull a peculiar clinical aspect….Each individual case…supplied with a hilly appearance” (281). Images and quotes from Krause F: Surgery of history, a short account of symptoms…the course and af- the Brain and Spinal Cord: Based on Personal Experiences. New York: ter-treatment, and in the cases which ended fatally… im- Rebman Co., Vol 1, 1909.

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Fig. 10. A: Title page from Krause and Heymann’s masterful 1933 text. B: Fedor Krause about the time of the publication of his book with Heymann. C: Emil Heymann succeeded Krause as Chief Surgeon at the Augusta Hospital in Berlin in 1921. Heymann was responsible for many new technical and surgical innovations and brought into full application the neuroradiological techniques begun by Krause. Because of his Jewish heritage, he was dismissed from the University of Berlin in 1935 and died shortly before he could take a position overseas. portant findings from the autopsy record” (v).18 The text introduction of x-rays became routine when others were contains 136 pages devoted to brain tumors and 54 pages still trying to identify a direction for the new technology to posterior fossa surgeries. X-rays, which had become and engaging in ambiguous discussion and fully mark routine in patient care, were used to guide such delicate him as neurosurgery’s leader. The neurosurgery textbook maneuvers as “opening of the antrum of Highmore” and he released from 1908 to 1911 is incomparable for its to visualize even mucous polyps as shadows. Posterior time and establishes him as one of the most influential fossa surgery sections contained detailed descriptions. early neurosurgeons. Krause’s advances in neurosurgical For example, with regard to “extirpation of an arachnoi- technique, especially at the skull base and for epilepsy dal sarcoma of the posterior fossa” and symptoms and (performing more than 400 operations for epilepsy), and signs description, Krause wrote, “The X-ray plate showed his early adoption and systematic use of x-rays yielded nothing pathological,” suggesting routine, second nature, profound change for neurosurgery. Ironically, however, and widespread use of the technology. In the forward viewing the rise of a separate neurosurgical specialty, to the book, Albert Ehrenfried from Boston mentioned Krause always believed that surgeons should excel in all with regard to the wide use of x-rays and neurosurgery in phases of surgical technique: “Since I hold to the point Krause’s book: “The presentation is by no means a nar- of view that specialization in surgery should be avoided, row one; various methods and modifications of technique if one desires not to become one-sided, I take particular are discussed, their advantages compared, and the reasons satisfaction in being able to devote my career to a hospital given why one should be preferred over another” (vii).19 [Augusta Hospital] in which…general surgery in the tru- Krause had found in Heymann “an experienced collabo- est sense of the term has been practiced” (v).19 rator” and masterful association; however, the intimate association of Krause and Heymann was not to last. Be- Disclosure ing Jewish, Heymann was persecuted by the Nazi regime Funding for this project was provided by the Newsome Chair and committed suicide in 1936. Krause, who had fully in Neurosurgery Research held by Dr. Preul. The authors report no supported Heymann, was deeply affected by this loss.4 conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Author contributions to the study and manuscript preparation include the following. Conception and design: Preul, Agrawal. Conclusions Acquisition of data: Elhadi, Kalb, Agrawal. Analysis and interpre- Described by his students as laconic, passive, detailed, tation of data: Preul, Elhadi, Kalb, Agrawal. Drafting the article: and dry, Krause was nevertheless known for his foresight Elhadi, Martirosyan, Kalb, Agrawal. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. and for his rapid adoption of the newest in technologies in Approved the final version of the manuscript on behalf of all authors: his surgical practice. Although students frequently slept Preul. Study supervision: Preul. through or avoided his lectures, they flocked to him for his lucid practical clinical and anatomical correlations, References and for his surgical teaching. Regarded as the most im- 1. Archibald E: Surgical affections and wounds of the head, in portant surgeon in Europe contemporary with Horsley, Bryant JD, Buck AH (eds): American Practice of Surgery: he is cited as a pioneer in early advances of 20th century A Complete System of the Science and Art of Surgery, by neurosurgery. Although considered as a “participant” in Representative Surgeons of the United States and Canada. the history of neuroradiology, his systematic, methodical New York: William Wood and Co., Vol 5, 1908, pp 3–378

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2. Assmus A: Early history of x rays. Beam Line 25:10–24, 1995 17. Krause F: Surgery of the Brain and Spinal Cord: Based on 3. Bull JWD: History of neuroradiology—The Presidential ad- Personal Experiences Vols I–III. New York: Rebman Co., dress, delivered at the British Institution of Radiology on Oc- 1909–1912 tober 20, 1960. Br J Radiol 34:69–84, 1961 18. Krause F, Heymann E: Surgical Operations of the Head: 4. Collmann H, Rosenow DE: [Pioneers of neurosurgery: Emil Illustrated by Clinical Observations, for Physicians and Heymann (4/15/1878-1/11/1936).] Zentralbl Neurochir 65:36– Surgeons. New York: Allied Book Co., 1933 39, 2004 (Ger) 19. Krause F, Heymann E: Text Book of Surgical Operations: 5. Cushing H: Surgery of the head, in Keen WW (ed): Surgery: Illustrated by Clinical Observations for Physicians and Its Principles and Practice. Philadelphia: WB Saunders, Students. New York: Rebman Co., 1915 1908, Vol 3, pp 17–276 20. Lewis DD, Kanavel AB: Surgery of the hypophysis (pituitary 6. Etter LE: Some historical data relating to the discovery of the gland), in Keen WW (ed): Surgery: Its Principles and Prac- roentgen rays. Am J Roentgenol Radium Ther 56:220–231, tice. Philadelphia: WB Saunders, Vol 6, 1919, pp 269–316 1946 21. Neuhoff H: Surgery of the head, in Keen WW (ed): Surgery: 7. Fulton JF: Harvey Cushing—A Biography. Oxford: Black- Its Principles and Practice. Philadelphia: WB Saunders, Vol well, 1946 8, 1921, pp 134–189 8. Glasser O: Wilhelm Conrad Röntgen and the Early His- 22. Preul MC: History of brain tumor surgery. Neurosurg Focus tory of the Roentgen Rays. San Francisco: Norman Publish- 18(4):Intro, 2005 ing, 1993 23. von Bergmann E, Kronlein RU: Injuries and disease of the 9. Gunderman RB, Seymour ZA: Harvey W. Cushing. AJR Am skull and its contents, in von Bergmann E, von Bruns P, von J Roentgenol 194:296–298, 2010 Mikulicz J, et al (eds): A System of Practical Surgery, Sur- 10. Gutiérrez C: The birth and growth of neuroradiology in the gery of the Head. USA. Neuroradiology 21:227–237, 1981 New York: Lea Brothers & Co., 1904, Vol 11. Horwitz NH: Fedor Krause (1857-1937). Neurosurgery 38: 1, pp 17–340 844–848, 1996 24. Williams FH: The Roentgen Rays in Medicine and Sur- 12. IEEE Global History Network: Field X-Rays. (http://www. gery: As an Aid in Diagnosis and as a Therapeutic Agent. ieeeghn.org/wiki/index.php/Field_X-Rays) [Accessed July 3, New York: MacMillan Co., 1903 2012] 13. Keen WW: Diseases and injuries of the head, in Keen WW, White WJ (eds): An American Text-Book of Surgery for Manuscript submitted April 15, 2012. Practitioners and Students, ed 3. Philadelphia: WB Saunders, Accepted June 27, 2012. 1899, pp 489–556 This work was presented in part at the 2010 Annual Meeting of 14. Keen WW: Surgery, in The Progress of the Century. New the American Association of Neurological Surgeons for which Dr. York: Harper and Brothers, 1901, pp 217–264 Agrawal was awarded the Vesalius Prize of the Section on History 15. Keen WW: The use of the x or röntgen rays in surgery, in Keen of Neurological Surgery. WW, White WJ (eds): An American Text-Book of Surgery Please include this information when citing this paper: DOI: for Practitioners and Student, ed 3. Philadelphia: WB Saun- 10.3171/2012.6.FOCUS12135. ders, 1899, pp 1191–1196 Address correspondence to: Mark C. Preul, M.D., c/o Neurosci- 16. Krause F: Chirurgie des Gehirns und Rückenmarks nach ence Publications, Barrow Neurological Institute, St. Joseph’s Hos- eigenen Erfahrungen Vols I and II. Berlin: Urban und pital and Medical Center, 350 West Thomas Road, Phoenix, Arizona Schwarzenburg, 1908 and 1911 85013. email: [email protected].

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