History of Traumatic Brain Injury (TBI) Gonzalo Bertullo 1*

American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409

Abstract

History is of one of the many disciplines that is considered as science, and which allows past events to be studied. This allows us to know about past facts, accompany their evolution, the origin of many concepts and terms, as well as errors and myths, allowing a comprehensive understanding of the present and learning to improve the future. The importance of history is such that it ends up determining the culture of many countries and also frames scientific disciplines. The great advances in knowledge of neurological function and its brain localization began in the nineteenth century. It is only recently that head injuries are classified by their neurological deficit rather than the type of skull fracture. This is not surprising, since most head injuries were treated by general surgeons who knew little about neurological examination. Although the illustrations in the early sixteenth century showed the anisocoria, this condition was not mentioned until three centuries later, when Jonathan Hutchinson first reported a dilated pupil on the same side as an intracranial clot, and pointed out that it was due to the compression of the third cranial nerve.

Keywords: Trauma; Brain injury; History; Skull fracture; Neurological deficit

*Corresponding Author: Gonzalo Bertullo: [email protected] 1Department of Neurosurgery, College of Medicine, Clinics Hospital Montevideo-Uruguay Received March 02, 2015; accepted June 27, 2015; published July 24, 2015 Copyright © 2015 GB et al. This is article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction comprehensive understanding of the History is of one of the many disciplines present and learning to improve the that is considered as science, and which future. The importance of history is such allows past events to be studied. This that it ends up determining the culture of allows us to know about past facts, many countries and also frames accompany their evolution, the origin of scientific disciplines. many concepts and terms, as well as In Medicine, and in particular, surgical errors and myths, allowing a discipline, these principles are

Copyright © 2015 AJBM 381 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 paramount in importance and application, as expressed by the first medical document known in the history of Medicine: the Edwin Smith Papyrus, a real treatise of trauma. In this regard, in this chapter we will travel throughout the history of traumatic brain injury Figure 1. Timeline of Universal History (TBI), its terms and evolution, following a timeline based on how the most TBI in pre-history significant historical events were During the Paleolithic period, developed. approximately 2.7 million years B. C., Pre-historic and historical periods the ancestors of man (Homo Habilis, If we draw a timeline following a Australopitecus, Homo erectus) [1, 2] traditional view, human evolution is appear. The man accepted as such divided into a period called Pre-History, (Homo sapiens) would have appeared in which runs from human origin to the the Middle Paleolithic period (100.000 appearance of written documents, and years B. C), and consolidated in 40.000 another known as History, beginning B. C. Attacks on human brain skull over with the appearance of written evidence this period are mainly due to injuries and it marks the certainty of knowledge caused by different animals, and not based on events determined by our man. ancestors [1]. Archeology, through the In this pre-historic period, the first study of material remains, was the only evidence of brain injury in human resource to reconstruct facts before the evolution appears (2.000.000-1.800.000 appearance of scripts. years B.C approximately). It was found Pre-History has three main stages: in Olduvai Gorge, Tanzania, apparently Paleolithic, Neolithic and Metal Age. due to a crocodile bite (1, 2). History is born with writing and includes Subsequently, other injuries appear, like four major stages: Ancient History, the one found in the ape-like man middle Ages, Modern Era and (Australopithecus Africanus) in South Contemporary History, each of them Africa. The Australian anatomist and limited by major events (Fig.1) [1]. anthropologist, Raymond Dart, argued

Copyright © 2015 AJBM 382 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 that such injuries were caused by an purposes due to the results of the study antelope humeral condyles found in the regarding trepanations characteristics immediate area and used as a tool to club and the precarious knowledge at the time its prey to death from behind [3]. Other in all aspects [5]. It is believed that anthropologists do not agree with this humans formed tribes giving origin to hypothesis and argue that these the “wizard” image and following the ancestors were not able to use “tools”, beliefs of the majority of primitive and that the fractures found, were the peoples; diseases were considered of result of attacks perpetrated by divine origin and therefore the “wizard”, mammalian predators known as “cats or who faced them, was a man with powers saber-toothed tigers” [4] (Fig. 2). Such to communicate with the gods [1]. fractures were found in later Hominids, Trauma did not escape reality and Homo erectus, Java Man (300.000 B.C) apparently it was another reason for the and Neanderthals (40.000 B.C.) [1, 4]. need of “wizards” who probably were those who trepanned, even in living Figure 2. people according to anthropological Developed results [1, 8, 27, 28]. upper fangs like BTI in ancient history a curved sable. Ancient history is the historical period where ancient civilizations arise and In contrast, the earliest evidence of develop, approximately 3,000 years trepanation performed by man himself B.C, and ends in 476 B.C with the fall of appears in the Neolithic period, and the the Western Roman Empire. During this interpretations of the earliest long period a large number of important trepanations discovered have been events in history of BTI took place, diverse. Domenec Campillo in the which will be detailed in chronological Paleoanthropology Laboratory of Spain, order. who studied more than 3,000 ancient The Egyptian Period-Edwin Smith skulls during 14 years, emphasizes that Papyrus it is unquestionable that trepanation The origin of writing gives way to began in the Neolithic period. Their History, the period in which events that reasons basically had to do with rituals occur start to be documented, and hence, and magic, and not for therapeutic gives veracity to knowledge.

The first written evidence of brain condition I can treat, a medical condition injuries is documented in Egypt in the I can contend with, and a medical Edwin Smith Papyrus, 3,000-2,500 condition you wilI not be able to treat [6, years B.C. when the pyramids were 7, 8, 10]. There were 27 head injury built, being the first medical document cases of which 13 were fractures with recognized in the history of medicine neurological involvement and the rest [6,7] (Fig. 3). only soft tissue injuries [6, 8, 10]. The fractures were classified as: 1) splits (fissures or linear fractures) 2) smashes (comminuted depressed fractures) 3) compound comminuted, 4) Conminuted and depressed [8, 10]. It is accepted that its author was the oldest Egyptian

Figure 3. physician, Imhotep [6, 8, 10]. These data Edwin Smith Papyrus show the “state of medical art” in ancient times and its great capacity of This is a real surgical trauma treatise, systematization. which reflects the high incidence of Observation and palpitation were traumatic injuries of that time. It transcendent and for first time the terms corresponds to a single scroll of 33cm fracture, brain, meninges, convulsion, high and 5m in length approximately, cerebrospinal fluid (CSF) and suture [6, and assembled from multiple sheets of 8, 10, 11] were introduced. Edwin Smith 40cm approximately It consists of 17 (1822-1906), an American Egyptologist, columns written on its front face and 5 is the person who obtains the papyrus on the back, all of them in horizontal that now bears his name. This is because lines (Fig.3). It describes 48 cases Smith was visionary about the hierarchy beginning with head injuries and moving of the document, and the important task down the body using a carefully of following the seller to buy his parts, prescribed formula: Title, Examination, put it together, identify and Diagnosis, Treatment and definitions of accommodate its elements, and missing terms used. spaces. He kept it until his death and his The procedure chosen in each case was daughter donated it to the Historical carried out in three Diagnoses: a medical Society of New York [6, 8, 9, 10]. In

1920, Breasted, Director of the Institute sleeping exhausted by fatigue, she kills of Oriental Studies in Chicago, was him instantly by hammering a stake in asked to translate and edit the whole text his “temple” till reaching the earth; the which was published ten years later [9]. opponent of the Israelites was put to The Bible death at that very moment (Fig. 4). Few are the biblical references regarding head trauma. Its origins are dated after the Edwin Smith papyrus between 1300 to 1000 years B.C., where initially injuries by crocodiles are mentioned in Psalms (74:13,4). All the injuries resulted in death without instance of Figure 4. recovery or reporting of treatment as Sisera’s death by a penetrating wound expressed in Isaiah (1:6), Genesis (50:2), The story of Abimelech is also described and Jeremiah (8:22). However, the Bible in the book of judges in the Old describes in detail three cranial injuries: Testament (9:50-54) [12,13]. Sisera’s death at the hands of Jael; skull Abimelech, a “self-proclaimed” King, fractures on Abimelec; and the most ruled Israel for three years, and famous death of Goliath by David [12, conquered and killed the rebels from 13]. Shechem and its inhabitants, the first The story of Sisera and Jael, the latter capital of the kingdom of Israel. being one of the strongest women in Subsequently, he sought to approach the biblical history, is narrated in the book Tebes tower (now known as Tubas in the of judges in the Old Testament (4:21-22; northeast of Cisjordania) as it was the 5:26). Sisera was the commander of the refuge of the all the people from the Jabin army, King of Canaan, whom town, and set it on fire. When Deborah and Barac defeated in a war approaching to the tower, a woman fought by the river Kishon. He survived, throws a millstone from the roof of the fled the battlefield and sought temporary tower which impacts his skull, and refuge in Heber’s tent, a Ceneo that until eventually culminated in his death. that moment lived in peace with the During a moment of lucidity, he asks Canaanites. Jael, Heber’s wife, offers one of his squires to kill him with his him a bed and milk. While he was

Copyright © 2015 AJBM 385 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 sword to simulate that a brave man like endocrine neoplasia type 1 (pituitary, himself was actually killed by a soldier parathyroid and pancreas tumor) that and not by “a stone” thrown by a ultimately caused his death indirectly woman. Finally the most famous biblical [12, 14, 15, 16]. The macroadenoma story and fight between David and determined acromegaly and visual field Goliath gives an account of another deficit, the latter allowing David to cranial injury (1st book of Samuel approach the giant unnoticed (biblical 17:49-51). Goliath was a leader of the witnesses said Goliath had to look Philistine soldiers from the city of Gath, around to find David). who wore strong armor, a helmet and Osteitis fibrosa as a result of carried a sword, and was about 2.9 hyperparathyroidism is determined the meters tall. For 40 days he defied the Goliath’s skull thinning, contributing to Israeli army in the Valley of Elah to the easy penetration of the stone in the choose a man who would fight against skull, and a pancreatic tumor that him and whoever lost would submit to secretes insulin or gastrin hormone (with slavery. subsequent of the hypoglycemia or David was a young shepherd that arrives hyperacidity) mean that morning was a at the scene to deliver food. When he bad time to fight [12, 14, 15, 16] (Fig. 5). hears the challenge, he immediately offers to fight Goliath without armor, and only holding a sling and stones. The giant falls literally from a “sling shot” by the stone that enters the basal front region. Like Abimelech, Goliath does not die immediately, so David ensures his death by beheading Goliath with his own sword. Literature indicates some doubt regarding the ease with which a Figure 5. young Hebrew defeats a heavily armed David and Goliath giant with only a sling. This was difficult to accept, so a medical explanation was Homeric Period -XI-VIII B. C. Century sought. The hypothesis accepted is that Homer was a Greek poet who was Goliath was a carrier of multiple believed to have lived in VIII B.C.

Copyright © 2015 AJBM 386 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 century. This period is also known as the the history of medicine and considered Greek Middle Ages or dark Ages. The by many as the “father of Medicine” [17, oldest source of Greek knowledge are 18, 19]. He was born on the Greek island Homer’s poems: Iliad and Odyssey. The of Kos and his contributions to BTI were Iliad tells the story of Achilles during the transcendental (Fig. 6). Trojan War, and the Odyssey, the return He was the first physician to perform a of Ulysses to Ithaca after the War. systematic approach to BTI in his work: In the Odyssey, Homer mentions “On injuries of the head”. It deeply injuries caused by skull indentation. In analyzes the cranial anatomy and the Iliad, there is mention of penetrating clinical observation that resulted in a wounds as a result of spears, swords, and variety of surgical procedures, each arrows. He describes a higher rate of applicable to different types of skull mortality due to wounds caused by fractures and brain injuries [8, 20]. spears and swords rather than arrows, Trepanation, but for therapeutic and explains that in the latter, if vital purposes, is widely specified with its structures are not injured it may heal clinical, technical indications and without infection after removing the results. While Edwin Smith Papyrus arrow [8]. classified fractures into linear and In this same work Homer also describes comminuted with or without depression, the “explosion of two” of a Greek Hippocrates proposed a new warrior during the siege of Troy when he classification of six categories [8, 20]: was hit in the head by a rock. 1) F issured fractures: he described that This data provides a “predictive” idea of all possible varieties could exist, from the situation experienced in the period non-visible to distinguishable fine and the predominance of penetrating fissure or extensive wide linear wounds in the skull as a cause of BTI. fractures; 2) Bone contusion: it Both epics are the culmination of a long corresponded to a bruised bone without tradition of oral poetry that emerged fracture and stressed that it was not between 1300 B.C - 1100 B.C and put visible to human eye; 3) Depressed skull into writing in VIII century B.C. fractures: it is when an area of the bone Hippocratic Period- V- IV B.C. Century is “depressed” and the rest remains Hippocrates of Kos (460 B.C- 370 B.C) normal; 4) “Haedrae”- dints or “marks” is one of the most outstanding figures in with or without fractures: he introduces

Copyright © 2015 AJBM 387 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 the term referring to bone “mark” that exploration, and those fractures that defines the shape of the object that required trepanation were included. He generated it; 5) Countercoup fracture: he showed trepanation in a very interesting also introduces this new concept of way in three types of fractures: fissured, fracture in a different place where the bruised and haedrae. He did not trauma was received. That is, 25 recommend the depressed ones as he centuries before an image could prove used the trauma itself and depression to its existence, Hippocrates described it remove it, yet he did recommend that for the first time and said, “there is no fractures on the sutures should be done possible way to examine … when this above them but adjacent to it if accident occurs, I cannot help” [8, 20]; necessary [20]. 6) Fractures on cranial sutures: he Although there is no direct reference to highlighted this separately because he the presence of dural sinuses just below maintained that they represented a the cranial sutures, their existence is naturally weak spot, and thus, more clearly involved in this message. easily damaged. Hippocrates warned to avoid making a For the first time, Hippocrates burr hole just above the cranial sutures, introduces the importance of a detailed if this principle represents a deeper “record” of patient with BTI, something understanding of the underlying brain already inherent in the rest of the structures or an unpleasant personal Hippocratic treatises. Through clinical experience, it remains a mystery. He observation he was also able to make an could not help with Countercoup extensive and detailed description of the fractures, as he described. cranial anatomy as the dissection of the Another interesting aspect is that he human body was not allowed in ancient gave a three-day deadline for trepanation Greece [20]. He describes the anatomy because otherwise the patient would die of the skull made of two layers and in the from suppuration [20]; this limit today is middle there is a “sponge” that contains known to be the turning point from "numerousa fleshy wet particles”, the which chances of infection increase diploe and a “membrane” that covered dramatically. It is assumed that he the brain, dura mater [20]. Treatment of advised trepanation to provide an exit to fractures was an important chapter pus rather than to evacuate blood clots where first aids and bandages, wound that build up underneath. There is no

Copyright © 2015 AJBM 388 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 mention of this, but perhaps it could be changed the principles of superstition due to loss of information of the and magic by a medicine based on manuscripts. The ultimate goal was to systematic observation. He encouraged trepanate and leave the wound open so and taught clinical evaluation of head the suppuration could flow out, and injuries, proposed a new classification of therefore, having more possibilities of a skull fractures, applied therapeutic cure. trepanation and presented prognostic factors. All these contributions Figure 6. combined with being the first treatise on Hippocrates of Kos medical history that deals with injuries exclusively on skulls, allow Hippocrates The Hippocratic to be a pioneer of BTI according to some concept that the authors [20]. formation of pus Trepanation is a prerequisite Human skull trepanation is the oldest for normal wound healing dominated the documented surgical procedure surgical practice until the Renaissance performed by man. Trepanned skulls and is clearly represented in the have been found from the Old World, Hippocratic aphorism, "You must make (Europe, Asia and Africa) to the New the wound fester as soon as possible " World of America (especially the Incas [20]. in Peru), and from the Neolithic to the Four surgical instruments were used by beginning of history [1, 5, 7, 20, 24, 26, Hippocrates: 1) a probe, that he use to 36, 37]. Trepanation methods were examine the surface of fractures and to basically 4 types: 1) rectangular determine the depth of trepanation; 2) intersecting incisions; 2) boring and rasp, to “iron out” and find remains of cutting (multiple small perforations); 3) bones in surface levels; 3) saw; 4) grooving (creation of a circular…oval trephine. The latter was used to open the dent); and 4) scraping (oval curettage) skull and produce a primitive bone flap, (Fig.7) [8, 37, 38, 39]. The instruments what is now known as craniectomy. used were originally made of sharp Hippocrates apparently had trephines of stones (Fig. 7). Over time they were different sizes especially for use in refined to give way to the era of metals. skulls of children [20]. Hippocrates

The term trepanation derives from the the description and invention of the Greek trypanon (bore or drill), a tool trephine in his teatrises of surgery used to make a hole. Although it had (Opéra chirurgica) in 1617, although it is been described in the Neolithic period, it accepted that it was already in use in the was not therapeutic agent in everyday times of Christ [8, 23]. When the ancient practice [21, 26, 36, 37]. The word Greeks performed a trepanation, they trephina, however, comes from a later used a tool called terebra (rotating drill period and is of French origin, used to thatoperated by means of a belt around indicate the instrument ends in a sort of its center), or the trypanon that was circular saw, which means that handled by an arc (Fig.7b). A third tool, trephination involves the use of a cutting terebra serrata or modiolus serratus (any instrument with a trephina [21, 26, 36, tool that makes a hole in the skull by 37]. rotation) consisted of a cone shaped metal, with a circular edge and with a lower toothed part, which was held in place by a central pin that could be rolled out quickly with the palm of the hand or a bow. The central pin is removed and the perforation is done. It is easy to understand that the terebra was the precursor of manual and electric craneotome trepanation used today for neurosurgical procedures [24] (Fig. 8). Figure 7. Kinds of trepanation and tools used

While both techniques determine a perforation of the skull as it involves the removal of a piece of bone with a tool, Figure 8. currently for these purposes, they are A tool similar to the terebra serrata. exchangeable term [21, 22, 36, 37]. The pieces make it burr or trephine according to the distal end. Hieronymus Fabricius, an Italian anatomist and surgeon, is attributed with

Trepanation in the Old World however, it is in the Museum of The trepanations found in Europe date Anthropology in Paris where the vast back to 10.000 years B.C (Neolithic) and majority of specimens are found (about there are who mention that they date 60) [21, 29, 31, 32]. Moreover, Paul back as far as 350.000-100.000 years Broca (1824-1880), a respected man in B.C (Paleolithic) [8]. The first skull was Europe for his knowledge and found in Cocherel- France in 1685 seriousness, and famous for his whose meaning was later recognized in discoveries about language brain 1865 when a second skull was found in location (1861) and hemispheric the same place [29, 32]. Barthélemy dominance (1865), had founded the Prunières, a French anthropologist, Society of Anthropology of Paris in studied more than 200 skulls found in a 1859 and was considered as the world’s prehistoric burial pit (Dolmen) in leading anthropologist by many Lozère- France, and published it in 1868 contemporaries. Broca had had contact under the title “Excavation of the Lozère for the first time, as we shall see later Dolmen”. It became the first publication with trepanation in America, with a on trepanation made by man [21, 32, 37, trepanned skull in Peru [40]. This fact 40]. It is one of the largest and oldest had aroused Broca’s interest in the study collections of Old World and it is of trepanation in France, hitherto little presumed it corresponds to Neolithic known. With the strength and times of approximately 5000 years ago encouragement that characterized him, [21, 29, 32, 40, 41]. he began to study some skulls he found This collection was studied by Prunières himself, but especially those found by immediately, who presumed some holes other anthropologists and from his friend were made post-mortem, probably for and partner Prunières [37, 38, 40]. making religious amulets and in other Broca categorically concluded that most cases for therapeutic purposes. The size of the procedures were performed was very variable, from millimeters to almost exclusively in children to treat real cranietomies with a maximum of benign childhood seizures. As a approximately 13 x 10 cm, mostly Neolothic man adjudged those “attacks” parietal but also frontal and occipital. on evil spirits, trepanation was a simple They were also found in other parts of way to “set them free”. Since the Europe with similar characteristics, isolated infantile convulsions were

Copyright © 2015 AJBM 391 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 solved alone, practice culminated being trepanation in Europe is clear, and these a successful “surgical cure” and thus no doubt, were performed by various spread in successive generations [8, 28, causes, whereby many of them were 29, 38, 39, 40, 41]. Broca agrees with unknown. In Asia, trepanation was not Prunières that most of the fragments universally popular and was performed removed, called “rondelles”, were used due to insanity, epilepsy and headaches, as religious amulets, a little “biased” by so that the “demons could come out .” the spiritual importance that reigned in In Africa, some people say that ancient France at the time [37, 38, 40]. Broca Egyptians did not perform trepanation. rejected the theory of trepanation by Some evidence suggests that in fact depressed fractures in France, as well as there was, and a trepanned skull was any other cause arguing lack of evidence found in Dynasty XII (2000-1788 B.C). in this regard. Nonetheless, many other [22, 29]. Towards the north of Africa authors discredited Broca’s idea stating trepanation was observed by Herodotus that Prunières collection did not have (484-425 B.C), and it also dates back to skulls of children and that they would the Neolithic period, especially in the have died immediately after carrying out Tuaregs villages, as such skulls were the procedure [8, 37, 38, 40]. found in the Canary Islands [22, 29]. Twelve years after Broca’s Trepanations in the new world investigations, Victor Horsley (1857- In South America, the trepanned skulls 1916), regarded by many as the “father dated from 5000 to 2000 B.C of neurological surgery”, studies the approximately. The first illustration of a skulls found by Prunières and concludes trepanned skull was depicted by Samuel that these trepanations were carried out Morton (1779-1851) in 1839 in his due to post traumatic epilectic seizures anthropological atlas Crania Americana, by depressed fractures [8, 28,29, 38,39, but it was not recognized as such. The 40, 41,42]. He was convinced that the author believed it had been caused by the procedure was carried out just where he back of a battleax [29, 30, 32]. believed the motor area was located [8, The first trepanned skull in a living 37, 38, 40, 41, 42]. Regardless of the real person and recognized as a therapeutic dilemmas posed by major historical case was found in 1865 by Ephraim figures mentioned, the enormous Squier (1821-1888), an archaelogist, contribution they made to the study of writer, and American diplomat sent to

Peru, who discovered a skull with a were performed as treatment for quadrangle left front bone defect of depressed fractures that generated 15x17mm in a tomb in the Valley of epilepsy as well as subdural hematomas Yucay [29, 31]. Squier considers it was [34]. important evidence that revealed the Figure 9. A Tumi surgical knowledge South American tribes had. He presented the case at a It is estimated that more meeting of the Academy of Medicine in than 5% of trepanned New York the same year, and where it skulls were found in was recognized that the surgery and Machu Pichu, the trepanation of the frontal had been multiple defects were of performed on a living individual [29, 3 to 5 with predominance of covexity 32]. Given the skepticism at the time, he and never encompassed sutures. They took it to Paris to obtain a second were carried out with a metal tool made opinion from Paul Broca, who presented of gold, bronze, silver, or copper known the case in the Society of Anthropology as Tumi, according to the Age of Metals and French Academy of Medicine in [29, 31, 32] (Fig. 9). 1867. The skull was studied and signs of Greco-Roman Period: V B.C – II A.C Century postoperatory inflammation was found In this period, the growth of Greek and which indicated an estimated survival of Roman civilizations in Ancient History about seven days. Broca concluded that is developed. However, with the procedure was carried out to Hippocrates’ death in 370 B.C, the rise “evacuate an epidural hematoma( ”[29, of Greek medicine begins to fall in 32]. contrast to the events occurring in other From the 400 Peruvian skulls studied by civilizations. From then and until the JulioTello (1880-1947), a Peruvian appearance of Galen of Pergamon (129- doctor and archaeologist (currently in 210 A.C), the school of Alexandria the Museum of the School of Medicine began to grow. The museum of from Harvard), 250 showed elements of Alexandria is created, where most of the healing and regeneration at the edges of information is collected and translated, the holes; findings that indicate the leading science for over 300 years. survival of many people [33, 34, 35, 37, Alexandrian physicians relied almost 38, 40]. Tello confirmed the surgeries

Copyright © 2015 AJBM 393 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 exclusively on the legacy of period it is recognized that lesions of the Hippocrates. left side of the head caused convulsions Aulus Cornelius Celsus appears on the on the right side and vice versa. scene (25 B.C-50 A.C), who is Respecting this principle, during the considered a physician for some Greco-Roman period motor paralysis historians, while others deny this and seizures determined, very often, condiction and consider him a very contralateral exploration of BTI. observant scientist who compiled Nevertheless, Celsus did not believe in information regarding medicine in Countercoup fractures as Hippocrates Alexandria. In one way or another he stated, and also unlike him, Celsus stood out for collecting and recording in advocated the realization of holes to lift his treatise “De Re Medicina”, the depressed fractures. medical knowledge of the time. He As the Roman Empire grew and decribes the symptoms and signs to be influenced Greece, physicians divided taken into account when a person suffers and formed different groups that a BTI, unconsciousness, vomiting, replaced the Hippocratic legacy by more bleeding from nose or ears, if he/she philosophical than scientific theories. communicates, motor condition, that is, The School of Alexandria greatly Celsus makes a breakthrough in the contributed to knowledge of cranial basic assessment that today constitutes injuries and established a “nexus” to the the Glasgow Coma Scale, and in the continuation of knowledge with the suspicion of fractures of the skull base. following figure: Galen of Pergamon . Celsus noted that serious head injuries Galen of Pergamon (129-210 A.C) was could increase intracranial pressure the first to strongly refute the (ICP) and argued that most severe brain Hippocratic concepts founded on his injuries associated brainstem lesions [8, great contributions to the anatomical and 26, 29, 33, 34, 35, 37]. In his treatise the physiological studies. extradural hematoma due to rupture of As a physician of gladiators and keen the middle meningeal artery and the observer in the Roman Coliseum, he diagnotic elements of a wound could see and treat all kind of traumas inflammation are described for the first and wounds, but wrote little about time (heat, redness, pain, and edema) [8, traumatic brain injury. These 28, 29, 33, 34]. From the Hippocratic observations stand out in his work

“Omnia Opera”, where he describes his of countercoup fractures, and warns of own classification of depressed fractures the danger when removing an arrow that and the importance of not damaging the penetrated the brain [28, 29, 33, 35, 8] dura mater during surgery [29, 33, 35]. BTI in the middle ages In contrast with Hippocrates, he Most historians agree that the Middle proposed to always rule out comminuted Ages begins with the fall of the Western fractures and supported Celsus in Roman Empire in 476 and ends with the making holes to lift depressed fractures. discovery of the new world in 1492. He provided a detailed description of the After the fall of the Roman Empire an different techniques of trepanation and intellectual “stagnation” followed in insisted on the importance of brain Greece and Rome, and the leaders protection during the procedure; he recognized the Arabs to preserve this invented a kind of “dural protector (a flat medical knowledge, thus, giving way to piece of metal)” to lift depressed the Arabic Medicine period [8, 26, 28, fractures and not injure the brain [8, 28, 29, 33, 35]. This fact, along with the 29, 33, 34]. Galen is recognized as the invasion of Europe by the Barbarians first to introduce the term “autopsy” and and the spread of Christianity, led differenciate dura mater from pia mater medicine to be concentrated in the [8, 29]. After Galen, Paulus Aeginata monasteries; monks became “healers” followed (625-690), a Byzantine Greek and performed medical procedures. physician, who moved to Rome and Arabic Medicine Period -VIII-X Century continued compiling and putting into Arab medicine placed the physician as writing the knowledge of the time in an illustrious figure that did not allow seven volumes. In the sixth volume, he contradiction and considered surgery as talks about surgery and describes a drill a despised and secondary discipline, for trepanation for the first time called hence, avoiding it. Knowledge of abaptista which stopped automatically Hippocrates and Galen was used by on impact with bone “protuberance”. most physicians in that period. The most The same was associated to another prominent characters of Arab medicine piece called meningophilax which were: Rhazés, Avisena and Albucasis. protected the dura mater. Aeginata Rhazés (852-932) was a physician that describes fractures and their treatment, lived in Baghdad, and his fundamental and like Celsus, he rejects the existence contribution to BTI was to introduce, for

Copyright © 2015 AJBM 395 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 the first time, the term concussion [8, 29, without preparation, but affordable”, 33, 34]. Avicenna (979-1037) was born and the surgeon, “skilled but expensive” in Afsana, in present-day Uzbekistan, (Fig. 10). and wrote one of the most famous Medical Encyclopaedias known as Avicenna’s Canon of Medicine, in 14 volumes by the year 1020. He translated the works of Hippocrates and Galen and introduced the treatment of epilepsy with medicinal plants among the most important contributions linked to BTI

[8, 29, 33, 34]. Albucasis (936-1013) was born in Al- Figure 10. A barber performing a craniotomy to “relieve Zahra and was the main reconciler of headache”. Arab medicine with surgery as a discipline. His book “Altacrif” is based The return of medical knowledge to on the writings of Paulus Aeginata, Europe was by means of Constantine the essentially, a surgical treatise where African (1015-1087), a monk born in Albucasis makes classifications of Carthage (city that was under Arab rule), cranial fractures, surgical instruments who given his command of Latin could and techniques of the time. Salerno’s translate the Arab writings. The greatest Medical School Period- X-XIII Century source of knowledge in Europe between The church, which maintained the the X-XII centuries, was the Salerno’s “monopoly” of medicine through monks Medical School. It was the first medieval who practiced it, demanded that the medical school located in Salerno, Italy. religious people of the time shave to be Constantine was invited to work at the differentiated from others. Many of Medical School by Alfano I (a monk them moved to convents and began to who practiced medicine). Thus, he learn the discipline taught by monks and helped to reintroduce the classical Greek to practice it. As a result, the figure of medicine into Europe. Hippocrates and “barbers-surgeons” appears. In the Galen’s translations were the first to middle ages, a dispute began between spread the Greek knowledge of medicine the barber-surgeon, “uneducated, to the west. He also wrote “Arab

Copyright © 2015 AJBM 396 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 manuals” for travelers. Roger of extended unless the bleeding or other Salerno, better known as Rogerius, was complication prevents it. The trephine one of the leading surgeons of Salerno´s should be used cautiously on each side Medical School and who wrote the first of the fracture and make the necessary medieval text, a real treatise on surgery perforations. Then with a chisel a cut is that dominated the field throughout made from one hole to another, so that Europe and was influential until the the opening extends from end to end of modern times (Fig. 11). the fracture and the exudation can exit. Later, it must be cleaned gently with linen strips placed by a feather between the brain and skull. After introducing a linen folding between the bone and the dura mater, the injured bone must be removed [8, 29].

In 1130, the Council of Clermot, and in Figure 11. Roger of Salerno removing an arrow. 1163 the Council of Tours prohibit

monks and religious people to practice His work “Practica chirurgiae” (The any kind of Medicine, and especially Practice of Surgery), had a therapeutic surgery to avoid “blaming” a religious recommendation for each disease. person of death. In 1215, this is ratified Among his recommendations was the by Pope Innocent III, and, therefore, use of egg shell for wounds, gave an surgery is placed in the hands of barber- account of the maneuver of pushing for surgeons and not of physicians, given diagnosis of CSF leak, and used wool the Arab teachings and their contempt and feathers for hemostasis [26, 28, 29]. for surgery had been successful [33, 38]. He postulated that traumatized nerves do XIII-XV Century not regenerate but still had to be Salerno’s tradition in the medieval anastomosed. The works of Roger of period was continued by Brunus Salerno on skull traumatic surgery were Longoburgi (Bruno of Calabria), Ugo important and considering he wrote his Borgognoni and Teodorico Borgognoni recommendations 800 years ago, they (Teodoro de Cervia). Bruno argued that are surprisingly modern. In the skull: “if penetrating injuries of the pia mater the wound is small, it should be were dangerous but those that entered in

Copyright © 2015 AJBM 397 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 the ventricles were fatal. In Bologna, he prognosis was dark and gloomy. made important progress showing his Nonetheless, if only one appeared, the surgical techniques both to prognosis was better. He realized that undergraduate and graduate students, the loss of brain substance was and he completed a study on surgery in compatible with survival and reported Verona in 1275. William of Saliceto about two soldiers who lost brain (1210-1277), a barber-surgeon, could substance from their frontal lobes and recognized a skull fracture by “the dull had good recovery but poor memory [8, sound made by an extended thread 26, 28, 29]. between the little finger of the barber- The terms "hemisphere" and "lobes" surgeon, and the patient’s teeth”. were introduced by Willis in 1561, but Another associate to Salerno’s Medical the four main lobes were not named until School was Walter de Agilon, a 1807 by Chaussier. Willis was the first Frenchman who also emphasized the to consider the existence of the cerebral importance of applying clean linen cortex and its importance in motor bandages to the meninges. function and also to think in the In the late XIII century, Lanfranco of existence of a blood – brain barrier. Milan (also known as Lanfrancus or Already in the early XIV century, Guido Lanfranchi) was the first to trepanation was continued by Guy de describe the concept of concussion as a Chauliac (1300-1368) another great brain lesion without fracture. He used a surgeon of that time and one of the first scalpel instead of a cautery. He to shave patients for brain surgery, and developed techniques to differentiate one of the first in successfully removing himself from barbers [26, 28, 29]. His part of the brain and clean. He hypothesis was that symptoms followed recommended removing “bridles” by by TBI could disappear quickly and this trepanation, but only with serious temporary paralysis of brain function fractures and avoiding sutures [8, 26, 28, was a consequence of brain “agitation”. 29]. As we can see, the medical writings He proposed an only indication of on BTI at that time came from Europe. trepanation, “dural irritation by In France, after the Council of Tours, depressed bone fragment “, and surgeons who had studied at University conceptualized that if fever and formed one of the first medical societies convulsions appeared together, in 1268. They were known as “Master

Surgeons” and were more important was born in Carpi, was the son of a than barber-surgeons, but less than barber - surgeon, and had medical and physicians. They were known as the engineering knowledge that enabled him long-robe surgeons, which differentiated to exploit the design of new instruments, them from the barbers who wore short drawing and writing [23, 43, 44]. robes [28, 33]. In 1540, Henry VIII, King of England, separated the role of barber and surgeon, whereby the barber was in charge of his specific duty, and the surgeon operated; each one had to fulfill his own role. The same was applied in France and in 1743 Louis XV decreed the definite separation. The same occurred in England two years Figure 12. Figure 13. later, in 1745 [33, 28, 1]. Berengario da Carpi Carpi Treatise BTI in the modern era Recognized as one the first to highlight The beginning of the Modern Era is the importance of anatomical marked by various historical events, like illustrations, these are embodied in the the consolidation of European states, the brain-encephalic surgery treatise of the discovery of America, among others, sixteenth century (1518): Tractatus de but, in turn, its development coincides Fractura calve sive cranei (Treatise of with the Renaissance. This era began in skull fractures) (Fig. 13). It was the first the XV and XVI century that marks a modern treatise on BTI, which reviewed cultural movement determining the the existing literature, made detailed growth of science and culminating in the anatomical drawings, and provided late eighteenth century with the explanations of instruments, surgical beginning of the Contemporary History. techniques, and “guidelines” for the This period is received with various conservative managing of some contributions to BTI with important and fractures. renowned personalities who advanced He is another renowned historical on the subject. Berengario da Carpi pioneer in Neuro-traumathology in the (1465-1527) (Fig. 12) was the noted Modern Era [43, 44]. He classified skull referent of the sixteenth century, who

Copyright © 2015 AJBM 399 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 lesions into lacerations, contusions, and speechless. And through experience this perforations, each of which might be year I saw a case of commotion resulting associated with a fracture [23, 43, 44]. from vein rupture in the membranes ... He described the concept post– [23, 29, 31]. It is very likely that concussion headache and made great Berengario was describing what is now emphasis on the high frequency of known as subdural hematoma, Countercoup fractures. In this era, the depending on the meaning that can be term concussion-commotion was given to those “membranes”. If he was referred to any head injury (regardless of the first or not, it is difficult to discern the severity) and its symptoms. Since the because Berengario also quoted words time of Hippocrates, commotion was of Celsus (25 B.C-50 A.C) as back up of associated with “loss of speech”, and his reasoning: "However, sometimes the Berengario shared this view stated bone remains fully intact as a result of almost 2000 years earlier. the blow, but inside, a broken vein inside Other authors of the time complemented the brain membrane releases little that "the loss of expression was due to a blood" . With this data we could attribute transient loss of consciousness typical of the first description of a possible commotion". His interest on Neuro- subdural hematoma to Celsus [23, 29, traumatology was clear and especially 31, 34]. As an interesting historical with the entity "Commotion", so much cultural phenomenon, Berengario so, that he wrote a monograph on the treated the Duke of Urbino, Lorenzo de subject. An interesting controversy Medici, who was shot in the back of the comes up in the monography regarding head during a battle. The injury did not the content: ... when the skull is not penetrate the skull but it left a “deep fractured, some nerves or veins are mark” on the left occipital region of the damaged within the membranes after a skull, which can be seen in Florence in sharp movement of the brain, either from the Anatomical Institute of the a fall or a sudden impact ... This is University. particularly the case in an excited body, Andrea della Croce was another where the skull is more prone to Renaissance figure who published a fractures because their brain dries and work on general surgery and shrinks ... if the head is shaken by some traumathology in 1557, one third of violent action, patients should be which was devoted to BTI. When there

Copyright © 2015 AJBM 400 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 was no skull fracture or brain advising surgeons on how to remove hemorrhage, he called it concussion and sharp “spikes” [46]. Paré had called developed the concept. Berengario’s “commotion” as Ambroise Paré (1510-1590) was another concussion or commotion indistinctly great contributor to BTI, the most and it was after that moment that the famous and prestigious French surgeon term concussion began to appear in of the time (Fig. 14). He determined the medical literature [23, 45, 46]. transition between the last barber- In 1556, King Henry II suffered a right surgeon and the first surgeon. At the age frontal wound with a wooden spear of 13 he became an apprentice barber- during a festive event, apparently it surgeon for Dieu Hotel in Paris and penetrated the helmet but without focused on performing autopsies to learn causing fracture in his skull. Paré anatomy. Ambroise Paré did not have indicated surgery but the queen university education and was famous for (Catherine of Medicis) did not allow it his dictum: “Guérir rarement, soulager and decided not to do anything as it was souvent, aider toujours”- Rarely heal, suggested by the great anatomist Andrea often relieve, and always help [45]. To Vesalio, who had little experience in become a surgeon of four successive surgeries. The king died 11 days later kings of France, he is admitted to the and the autopsy described by Paré, School of revealed a subdural hematoma in the Surgeons as occipital region opposite the front chief surgeon trauma he received [8, 23, 26, 43, 44, 45, [8, 23, 43, 44, 46]. In his book of Anatomy published 45]. in 1561, Paré emphasized the Figure 14. importance of Countercoup fractures Ambroise Paré and posited, quite accurately, that the

mechanism could be a subdural

hematoma due to a cortical vein tear and Paré considered concussion as a the blood accumulated would produce movement disorder of the brain headache, blurred vision, nauseas, and associated with brain edema and decreased consciousness. hemorrhage as an epiphenomenon. He Fallopius (1523-1562), as a professor of wrote many reports of head injury cases anatomy at the University of Padua,

Copyright © 2015 AJBM 401 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 wrote two books about head injuries and Jean Luis Petit (1674-1750) and Henri- supported the importance of François Le Dran (1685-1770) were Countercoup fractures and contusions. recognized surgeons of the French Whilelm Fabry von Hilden (1560-1624) School along with Percival Pott in was a barber-surgeon who treated cronic London (1714-1788), who described the headache by trepanation and lifted existence of an interval free of depressed fractures in emergencies. At symptoms, but only prior to the this time, Hildan designed an instrument development of a post-traumatic to avoid penetration of the brain with a infection [47, 48, 49]. trephine; progress on this technique In 1751, James Hill from Dumfries, followed by both Petit and Bell. Scotland, defined for the first time the Johann Schulthes, a physician born in lucid interval related with hematomas on Ulm-Germany in 1595, was Spigelous’s a patient with subdural hematoma. surgical assistant for 10 years and Finally, it is Jhon Abernethy who for the prosecutor from 1616-1623. This first time delineates the first case of lucid allowed him to gain the experience and interval in a patient with extradural enough knowledge to write his only hematoma (EDH). Later on, in the last book Armamentarium Chirurgicum half of the nineteenth century , Jonathan written, in Latin, and published ten years Hutchinson and Walter Jacobson’s after his death in 1645. This was the works provide the description and final surgical text used in the last half of the detail of the lucid interval as we know it seventeenth century which shows how to today [47, 48, 49]. perform craniotomy after the experience The importance of a dilated pupil by the gained in 30 years of war (1618-1648]. third cranial nerve was reported for the Andreas Vesalius (1514-1564) first time by Richard Bright (1831) after considered the founder of modern a confirmation through an autopsy of an anatomy, who published the historical EDH. Years later, this piece reaches text De Humanis Corporis Fabrica (on Jonathon Hutchinson who explained for the structure of human body) in 1543, the first time that this dilated pupil also performed craniotomies, but his should be caused by direct compression main contribution was of an anatomical of third cranial nerve [8, 47, 48, 49]. nature.

Contemporary age indication for surgery and not the This historical period begins in 1789 presence of fracture. Management of with the French Revolution and concussion in the eighteenth century was continues to this day. Humanity very controversial. Francois Quesnay in experimented a real growth and France (1694-1774), Louis XV’s economic, social and cultural change physician, and Pott in England, advocate with the development of more advanced prophylactic trepanning if there were societies, and others in the process of such “localizing signs”, such as pain, developing. while others treated conservatively, XVIII Century pointing out that compression can come We have seen that the terms commotion, on slowly and go without being invasive. concussion and compression in brain The radicals did not take into account the trauma have been used for centuries in entity “intracranial hypertension without different countries and times. The real fracture”, in fact, when there was a clinic pathological distinction of murder by BTI without fracture, the commotion, concussion and murderer was considered non- compression is introduced by Boviel in attributable. 1674 and continued by Jean Louis Petit . Jhon Hunter (1728-1793) also made Dupuytren (1777-1839) introduced the detailed observations on concussion, term concussion describing the three compression and brain laceration, terms but maintaining that they often correlating the level of awareness with occurred together. He explains for the variations in pulse, respiration and first time as a physiopathologic pupillary response. He did not trepan in mecanism that the vibration of the skull case of “isolated concussion states”; he caused by injury was transmitted to the did it in all cases of depressed fracture brain and thus generated a brief loss of and opened the dura mater if there was conciousness or amnesia [8, 23, 28, 29]. certainty about “fluids” below [8, 23, 26, He was also the first to describe the ICP 29]. Each of these phrases from different increase due to an EDH, so trepanation surgeons were included after years of was imperative. Percival Pott, experience, where observation and trial aforementioned, was among the were the fundamental scientific tools of pioneers to emphasize that patient’s the time along with the autopsy. neurological condition determined

19th Century on the same side as an intracranial clot, In this century the napoleonic wars and pointed out that it was due to the determined a breakthrough in the compression of the third cranial nerve experience of skull injuries. There were [8, 23, 29, 37]. The discovery of two surgeons, each on opposite sides, bacteria, the development of asepsis and Baron Larrey (1766-1842), a great antisepsis as well as anesthesia gave the favorite of Napoleon, who already held final momentum for further growth and that cerebellar lesions produced an study of head injury. ipsilateral disorder. On the British side, 20 th Century there was George Guthrie (1788-1856) The outstanding figure of Harvey that wrote on the need to evacuate the Cushing (1869-1939) not only perfected EDH and epidural abscess in his the techniques known in head injuries in monograph, which is mandatory today. the early twentieth century, but also He was the first neurosurgeon to write founded the specialty as surgical applications that had the neurophysical discipline in his work presented at the principles of Pierre Flourens and Robert Academy of Medicine, Cleveland on Whytt on the lesion localization [8, 23, November 18, 1904, which he called, 28, 29, 37]. “The special field of neurological The great advances in knowledge of surgery” [33, 50]. But the greatest neurological function and its brain contribution made in this century to the localization began in the nineteenth history of BTI corresponds to the century. It is only recently that head creation of the Glasgow Coma Scale. injuries are classified by their At the beginning of World War II, the neurological deficit rather than the type Medical Research Board in Great of skull fracture. This is not surprising, Britain, published a glossary of since most head injuries were treated by psychological terms commonly used in general surgeons who knew little about cases of skull injury: confusion, dazed, neurological examination. Although the semi-coma, mild coma, deep coma, illustrations in the early sixteenth stupor, among others [51]. After World century showed the anisocoria, this War II, neurosurgical practice focused condition was not mentioned until three more on treating tumors and aneurysms centuries later, when Jonathan of coordination as there was a fatalistic Hutchinson first reported a dilated pupil attitude in relation to BTI. Occasionally,

Copyright © 2015 AJBM 404 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 skull depression was treated and small when evaluating the state of intracranial hematomas were evacuated consciousness. The definitions used because it was thought that little could were inaccurate with much variability be done to change the prognosis and among examiners, which determined outcome. By any means, as the certain “subjectivity” and little resuscitation and intensive care started correlation of lesion, and worse still, to save lives of many seriously skull they were not measurable variables, injured patients, neurosurgeons of the complicating the possibility of statistical time in Glasgow were challenged to try data analysis. This led to creation and to reduce mortality, so as to avoid as subsequent publication of the Glasgow much collateral damage and improve the Coma Scale in 1974 by Graham survivors’ disability. In addition, Teasdale and Bryan Jennett [55] pathological studies showed that much (Fig.15-16). of the mortality and permanent disability Figure 15 Figure 16. after BTI were potentially preventable, as it is clearly stated in the work of Reilly, “BTI patients spoke and died” [52]. The reasoning they made was very smart: if they had spoken, then they had not suffered irreversible damage, and Bryan Jennett Graham Teasdale therefore, they should not have died. The key was that many of those deaths were Its original and clearly stated purpose by preventable, and were due to a lack of the authors in their original work and detection of complications in time and subsequent articles, was to clinically manner. assess, in practi cal and simple manner, These concerns led to perform a the alterations of consciousness and multicenter study on severe BTI in coma produced by any cause, both Glasgow in conjunction with the traumatic and non-traumatic [55, 56, 57, Netherlands and the USA [53]. But, 58, 59, 60]. In its original publication, consequently, this stimulus extended to the scale had ranks from 3 to 14 points proceed with a concomitant study, non- [55]. Two years later (1976) its creators traumatic causes of severe brain injury modified the flexor response [54]. The major problem was generated subdividing it as appropriate and

Copyright © 2015 AJBM 405 American Journal of BioMedicine AJBM 2015; 3(7): 381- 409 doi:10.18081/2333-5106/015-07/381-409 inappropriate from which is currently with scores of 14-15, 13-20% had an known [61]. In 1977, it was applied and abnormal tomography and only 5% validated to define the severity of BTI needed surgery. These results set limits [53], a fact that marked a world on a substantial change in the historical moment in the clinical classification of BTI: 14-15 was assessment of these patients and considered mild, 9-13 moderate, and 3-8 determined a great impact to the point severe [66]. that many experts thought that it was Glasgow Coma Scale is, undoubtedly, created exclusively for BTI. the most prominent contribution made in Nevertheless, the scale was validated the twentieth century to the history of also for non-traumatic coma in the same BTI. Through a universal, simple and year, thus eliminating any confusion in practical language, it allowed the this respect [54]. assessment of brain damage caused by The Glasgow Coma Scale becomes the any etiology (traumatic or non- most universally accepted classification traumatic), define coma, TBI severity, of BTI. The first severe BTI is defined and determine a prognosis in patients with a Glasgow score of 3-8 and it is with brain damage. All this is due to its published in 1977 [62]. This, in turn, creators, Bryan Jennett and Graham allowed Coma to be defined as that Teasdale, who have both left their mark patient with a score from 3 to 8 [62]. across the world. Four years later, Rebecca Rimel applied Competing interests the scale and defined mild BTI with scores from 13 to 15 [63], and in 1982 Authors declare that we have no the same author completes the clinical competing interests spectrum of classification defining References moderate BTI with scores from 9 to 12 [64]. This graduation was maintained 1. Roberts JM. Historia del Mundo. De la until 1990 when Stein and Ross [65] Prehistoria a nuestros días. Penguin Random House Grupo Editorial España: used skull tomography to show evidence DEBATE; 2010:1-18. that those patients with Glasgow 13, 2. Tagle Madrid P. Apuntes sobre la classified as “mild”, had an abnormal historia del traumatismo encéfalo- craneano en Chile. Ars Médica. Revista tomography in 40 % of the cases, and de estudios médicos humanísticos: 13% requiring surgery. While patients

Pontificia Universidad Católica de Chile; 14. Rabin D, Rabin PL: David, Goliath and 7(7). smiley’s people (letter). N Eng J Med 1983;309: 992. 3. Dart RA. The predatory incremental technique of Australopithecus. American 15. Spreacher S. David and Goliath (letter). Journal of Physical Anthropology Radiology 1990;176;288. 1949;7:1-38. 16. David and Goliath;Images. 4. Saber-toothed-tiger/Images/website http://www.shutterstock.com/s/%22sab 17. Marketos SG, Skiadas PK. Hippocrates: er+tooth+tiger%22/search.html. The father of spine surgery. Spine 1999;24:1381–1387. 5. Campillo D. Neurosurgical pathology in Prehistory. Acta Neurochirurgica 1984; 18. Poulakou-Rebelakou E, Marketos SG. 70:275-290. Renal terminology from the Corpus Hippocraticum. Am J Nephrol 6. Sanchez G, Burridge AL. Decision 2002;22:146–151. making in head injury management in the Edwin Smith Papyrus. Neurosurg Focus 19. Viale GL, Deseri SE, Gennaro S, 2007;23(1):E5. Sehrbundt E. A craniocerebral infectious disease: case report on the traces of 7. González FRF, Flores SPL. El Papiro de Hippocrates. Neurosurgery 2002; Edwin Smith. An Med (Mex) 2005;50 50:1376–1379. (1):43-48. 20. Panourias IG, Skiadas PK, Sakas DE, 8. Rose FC. The history of head injuries: An Marketos SG. Hippocrates: A Pioneer in Overview. Journal of the History of the the Treatment of Head Injuries. Neuroscience 1997;6(2):154-180. Neurosurgery 2005;57:(1):181-189.

9. Breasted JH. The Edwin Smith Surgical 21. Walker AE. The dawn of Neurosurgery. Papyrus. University of Chicago Press; Clinical Neurosurgery 1959;6:1-38. 1991. 22. Rawlings CE, Rossitch E. The history of 10. Atta HM. Edwin Smith surgical trephination in Africa with a discussion papyrus: The oldest known surgical of its current status and continuing treatise. Am Surg 1999; 65:1190–1192 practice. Surgical Neurology 1994;41: 507-513. 11. Helgason CM. Commentary on the significance for modern neurology of the 23. Bakay L. Francois Quesnay and the 17th century BC surgical papyrus. birth of brain surgery. Neurosurgery Canadian Journal of Neurological 1985;17:518-521. Sciences 1987;14:560-569. 24. Faria MA. Violence, mental illness, and 12. Feinsod M. Three head injuries: The the brain-A brief history of biblical account of the deaths of Sisera, psychosurgery: Part 1- From trephination Abimelech and Goliath. Journal of the to lobotomy. Surgical Neurology History of the Neurosciences 1997;6(3): International 2013;4:49. 320-324. 25. Jorgensen JB. Trepanation as a 13. Pérez Millos S. Curso de exégesis Therapeutic Measure in Ancient (pre- bíblica y bosquejos para predicadores: Inka) Peru. Acta Neurochir (Wien) Jueces 1998;3:150-151. 1988;93:3-5.

26. Apuzzo MLJ,Liu CY, Sullivan D, the United States. Neurosurgery Faccio RA. Surgery of the Human 1990;26:1015–1020. Cerebrum. A Collective Modernity. Clin Neurosurg 2002;49:27-89. 37. Kshettry V, Stefan BA, Batjer H. The management of cranial injuries in 27. Rifkinson-Mann S: Cranial Surgery in antiquity and beyond. Neurosurg Focus Ancient Peru. Neurosurgery 2007;23(1):E8, 1-8. 1988;23:411-416. 38. Liu CY, Apuzzo ML. The genesis of 28. Goodridge JT. Neurosurgery in the neurosurgery and the evolution of the Ancient and Medieval Words. En neurosurgical operative environment: Greenblat (E). A history of part I-prehistory to 2003. Neurosurgery Neurosurgery. The American 2003;52:3–19. Association of Neurological Surgeons: Park Ridge 1997; 37-64. 39. Kinds of trepanations/Images.

29. Finger S: Origins of neuroscience. A 40. Clower WT, Finger S. Discovering History of Explorations into Brain trepanation: the contribution of Paul Function. Oxford University Press: Broca. Neurosurgery 2001;49:1417- 1994;1:3-17. 1426.

30. Horsley V. Brain surgery in the Stone 41. Finger S, Clower WT. Victor Horsley Age. British Medical Journal 1887:582. on “Trephining in Prehistoric Times.” Neurosurgery 2001;48:911-918. 31. Bakay L. An early history of craniotomy: From antiquity to the 42. Tan TC, Black P. Sir Victor Horsley Napoleonic era. Springfield; 1985. (1857–1916): Pioneer of Neurological Surgery. Neurosurgery 2002; 50(3):607- 32. Carod-Artal FJ, Vázquez-Cabrera CB. 612. Paleopatología neurológica en las culturas precolombinas de la costa y el 43. Mazzola RF, Mazzola IC: Treatise on altiplano andino (II). Historia de las skull fractures by Berengario da Carpi trepanaciones craneales. Revista de (1460-1530). J Craniofac Surg 2009; Neurología 2004;38(9):886-894. 20:1981-1984.

33. Peña Quiñones G. Breve historia de la 44. Di Ieva A, Gaetani P, Matula C, et al. Neurocirugía. Historia de la Medicina. Berengario da Carpi: a pioneer in Revista de Medicina de Bogotá 2005;2 neurotraumatology. J Neurosurg 2011; (69):112-121. 114:1461-1470.

34. Peña Quiñones G. Aulus Aurelius 45. Peña G, Pubiano A. Reseña histórica del Cornelius Celsus. Su aporte a las ciencias trauma craneoencefálico. En Pubiano A. neurológicas. Historia de la Medicina. Pérez (Eds). Neurotrauma y Revista de Medicina de Bogotá 2010;32 Neurointensivismo. Editorial Médica, (89):166-170. Bogotá, 2007.

35. Wilkins RH. Neurosurgical Techniques: 46. West CG. A short history of the An overview. En Greenblatt (E) A management of penetrating missile history of Neurosurgery. The American injuries of the head. Surgical Neurology Association of Neurological Surgeons. 1981;16:145-149. Park Ridge; 1997:193-212. 47. Ganz JC. The lucid interval associated 36. Stone JL, Miles ML. Skull trepanation with epidural bleeding: evolving among the early Indians of Canada and

understanding Historical vignette. J 57. Jennett B.The Glasgow Coma Scale: Neurosurg 2013;118:739-745. history and current practice. Trauma 2002;4:91-103. 48. Flamm ES. From signs to symptoms: the neurosurgical management of head 58. Teasdale G, Laura EI, Pettigrew LEL, et trauma from 1517 to 1867, in Greenblatt al. Analyzing outcome of treatment of SH, Dagi TF, Epstein MH (eds): A severe head injury: a review and update History of Neurosurgery: In Its Scientific on advancing the use of the Glasgow and Professional Contexts. Park Ridge, Outcome Scale. J Neurotrauma 1998; IL: American Association of 15:587-597. Neurological Surgeons 1997:65–82. 59. Zuercher M, Ummenhoffer W, 49. Ford LE, McLaurin RL: Mechanisms of Baltussen A, Walder B. The use of epidural hematomas. J Neurosurg 1963; Glasgow Coma Scale in injury 20:760–769. assessment. A critical review Brain Injury 2009; 23(5): 371-384. 50. Bliss M. Harvey Cushing. A life in surgery. A window on the brain. Oxford 60. Teasdale G. The Glasgow coma and University Press: 2007;164-203. outcome scales: practical questions and answers. In Practical Handbook of 51. Marion DW, Carlier PM. Problems with Neurosurgery. Springer Wien NewYork: initial Glasgow Coma Scale assessment 2009;1:395-409. caused by prehospital treatment of patients with head injuries: results of a 61. Teasdale G, Jennett B. Assessment and national survey. J Trauma 1994;36:89- prognosis of coma after head injury. Acta 95. Neurochir (Wien) 1976;34:45-55.

52. Reilly PL, Adams JH, Graham DI, et al: 62. Jennett B, Teasdale B. Aspects of coma Patients with head injury who talk and after severe head injuries. Lancet 1977;4: die. Lancet 1975;2:375-377. 878-81.

53. Jennett B, Teasdale G, Galbraith S, et al: 63. Rimel R, Giordani B, Barth J, Boll T, Severe head injuries in three countries. J Jane J. Disability caused by minor head Neurol Neurosurg Psychiat 1977;40: injury. Neurosurgery 1981;9(3):221- 291-298. 228.

54. Bates D, Caronna JJ, Cartlidge NEF, et 64. Rimel R, Giordani B, Barth J, Boll T, al. A prospective study of non-traumatic Jane J. Completing the clinical spectrum coma: methods and results in 310 of brain trauma. Neurosurgery patients. Ann Neurol 1977;2:211-220. 1982;11(3):344-351

55. Teasdale G, Jennett B. Assessment of 65. Stein SC, Ross SE. The value of coma and impaired consciousness: a computed tomographic scans in patients practical scale. Lancet 1974;2:81-84. with low-risk head injuries. Neurosurgery 1990; 26:638-640. 56. Jennett B. Development of Glasgow Coma and Outcome Scales. Nepal 66. Stein S, Ross S. Moderate head injury: Journal of Neuroscience 2005;2:24-28. a guide to initial management. J Neurosurg 1992;77:562-564.