The History of Craniotomy

THE HISTORY OF CRANIOTOMY: AN ACCOUNT OF THE METHODS WHICH HAVE BEEN PRACTICED AND THE INSTRUMENTS USED FOR OPENING THE HUMAN SKULL DURING LIFE By LAMBERT ROGERS, M.Sc., F.R.C.S., Edin., F.A.C.S. CARDIFF, WALES

’Tis Man’s worst deed sequence, to get into the habit of thinking To let the things that have been, run to that most of the achievements of present waste day surgery are peculiar to this century, And in the unmeaning Present sink the or perhaps even to this last decade; that Past.—Lowell there was no such thing as surgery, in Ideas are born; they develop; they are the real sense, until almost within the transformed; they never die. The history memory of, say, our grandfathers. of ideas is the history of the race. They It is a very salutary corrective to this are the real events. Let them be never so impression or assumption to glance back new or strange, they have their roots in for a little upon the history of surgery in the far past with a continuity of growth. the past. Sir Andrew Macphail If any of us have acquired this Introduction impression or assumption, this paper Familiar though most of us may prove a salutary corrective such are with the modern methods as that to which Prof. Young refers, of performing craniotomy, not but it was not with this high object all of us are equally well that its preparation was undertaken acquainted with the way in which but because of a much more lowly the operations practiced today have one. At one stage in his ascent of evolved from the more primitive efforts the Mountain of Purgatory, Dante of our surgical forefathers. Nor do all of reached a high terrace from which, us realise how ancient an operation while resting for a moment, he turned craniotomy really is, how many and to the East and remarked to his varied have been the methods practiced conductor: “all men are delighted for its performance and how curious to look back,” and from the terrace and highly ingenious have been certain reached by the practice of cerebral of the implements used by its prac surgery today I am delighted to look titioners. back and report the retrospect. Prof. Archibald Young130 in his While the knowledge gained by presidential address for the year 1924 the toil of one generation soon be to the Royal Medico-Chirurgical So comes the commonplace of the next, ciety of Glasgow, used these words: it is equally true that the discoveries of our forefathers have a habit of Many addresses and lectures have been written in recent years, and many papers attaining a new importance many contributed to medical journals, whose decades later. This is well exemplified chief purpose has been to dilate upon the in the history of surgical craniotomy. great advances of modern surgery. The It will be seen that certain instruments lay Press has contributed its quota to used for performing the operation the same process of what one may almost in quite recent years and even some call self deception. We are too apt, in con of the most modern had their proto types which were used by our surgical formed even before this, namely in the forefathers many decades before and Campigny or Early Neolithic Period. were subsequently lost or forgotten. Many prehistoric human skulls In an introduction to an account of have been discovered and continue surgical instruments in Greek and to be unearthed with pieces of bone Roman times, published in 1907, the missing from them. The defects in the author, Mr. J. S. Milne, remarked bone are due to various causes. They that prior to the publication of his may have been produced by a deliber essay, no systematic attempt to re ate operation performed during the construct the surgical armamentarium life of the subject, and it is with holes of the ancients had been made, that so produced that this paper is con comparatively little attention had cerned; but on the other hand they been given to this department of may have been caused by commi archaeology, and that literature bear nution, the result of violence such as ing on it was scarce. If this applies to that from spears or clubs; they may surgical instruments generally, it does have been produced by disease during so with greater force as regards those life, by defective development in instruments appertaining to a par early life, by post-mortem decay or ticular operation such as opening the injury by the picks or shovels with skull. A research into the literature which the skulls were unearthed, or has failed to reveal any systematic they may have been the work of and comprehensive account of this necrophilous beetles, portions of the aspect of the history of surgery so elytra of which were identified in that the time seems opportune to connection with certain cranial open present this brief history of the meth ings around which a notable con ods which have been practiced and the troversy141 raged some years ago. instruments used for opening the From the types of opening known to human skull during life. result from each of these various processes, however, the nature of the Part i. Neolithic bone destruction, and the fact that signs of reparation around the bony L’origine de la chirurgie cranienne se edges of holes produced some time perd dans la nuit des temps.—Velpeau. before death are apparent after death, Sir William Osler78 described the it is possible to recognise attempts modern operation of cerebral decom made to remove bone discs from the pression as the oldest known surgical skulls of the living. There are numer procedure, and it is certain that the ous examples of successful attempts operation of opening the skull during so made upon neolithic skulls. life dates back to the very dawn of In the British Isles there are but civilisation. In all probability the few examples but France is rich in operation was performed as far back them,* many having been unearthed as the Carnac Epoch of the Neolithic * Some ideas of their frequency will be Period which is supposed to have gathered from the fact that at Vendrest, 60 ended in northwestern Europe about miles east of Paris, remains of over 120 indi viduals were found buried in a neolithic tomb the year 2000 b.c.123 That distin and no less than 8 of the skulls had been guished French neurologist and anthro opened during life and discs of bone removed pologist, Paul Broca,9-14 gave sound therefrom. Badouin, M. Societe Prehistorique reasons for thinking that it was per Franjaise. 1911. since 1865 when M. Prunieres,87-91 also, while more recently Dr. Wilson a medical practitioner of Marvejols Parry, 119.123.124 after investigating the in the department of La Lozere, first question very minutely and perform aroused interest in them by a dis ing much experimental work relating covery which he then made near to it, concluded that the openings Aiguieres. In a dolmen there he found were made with sharp flakes of either a human skull from which a large flint or obsidian used to scrape out portion of bone had been removed. a hole or to plough a groove in the Part of the edge of the hole in this bone until the gradually deepened skull was polished and Prunieres sur groove ultimately perforated the skull mised that the skull had been used by and released a bony rondelle. Dr. a neolithic savage as a drinking cup, Parry claims that boring a series of a custom not infrequent among sav small holes and connecting these by ages, and that the bone edge had been sawing, the method suggested by worn smooth by the lips of drinkers Lucas-Championniere as that used for from it. Broca12 however pointed out making the larger openings, is a very that the polishing was really due to arduous procedure taking considerably a healing process which during life longer to perform than what he calls had taken place in a wound made in “push ploughing” out a bone disc and the skull for removing a rondelle of that for this reason and also because of bone. Prior to this it had not been the absence, in his opinion, of any evi realised that in prehistoric times our dence of the bored holes in the great primitive ancestors used to remove majority of the French neolithic speci discs of bone from the living skulls of mens, he believes the usual method of their fellow tribesmen with imple performing the operation to have been ments made of stone. The effect of the simpler furrowing out of a circular this startling discovery on contempo or oval groove with a sharp stone. rary thought can well be imagined, What were the possible reasons for for it was not long before ample producing these openings in the skull? confirmation of Broca’s hypothesis In his treatise on Prehistoric Problems, was forthcoming. Dr. Robert Munro74 asks, “Were the Speculation next centered around motives that guided the hand of the the methods of making these openings neolithic operator inspired by thera in the skull and many and varied were peutic exigencies or by religious senti the suggestions put forward to account ments? Was the result of the operation for them. Lucas-Championniere61 gave to benefit the individual in this or it as his opinion that they were made in a future world?” Dr. Munro then either by scraping or else by first drill proceeds to discuss these questions at ing a series of small holes and then con length. It appears difficult to divorce necting these perforations by sawing or therapy from religion especially in the scraping. Sir Victor Horsley49 from an days of primitive man. Probably the inspection of the collection of skulls operation was most often performed as in the Broca Museum of Anthro a religious or thaumaturgic rite applied pology in the University of Paris, to cases of epilepsy with a view to thought the openings had in most releasing supposed imprisoned spirits. cases been made by sawing, possibly Prunieres believed that it was also supplemented in some by scraping performed for fracture, and from one specimen found by M. Gaillard38 at speculate upon the reasons why these Saint-Pierre de Quiberon, it appears operations were performed, the chief that the neolithic surgeon also oper object of this paper is to review the ated for the evacuation of abscesses methods which have been practiced following compound fractures of the and the instrument used to open the skull. From his examination of the living human skull and so these reasons Broca Museum specimens, Sir Victor cannot be considered at greater length. Horsley49 even went as far as to Today craniotomy is still performed suggest that the prehistoric surgeons in a most primitive manner in North had some idea of localisation of func ern Africa and among the Islanders of tion in the brain since a number of the the South Pacific. The Shawiya sur openings had been made over those geons of Algiers burn out a piece of areas of the brain which comprise the scalp with a red hot iron ring mounted motor cortex, irritation of which gives on a wooden handle, and then after rise to movements of the opposite side drilling a few holes through the bone of the body and to other syndromes gradually saw out a disc. The opera well known today.* Horsley’s opin tion may be completed at one sitting ion however was not at the time nor but is often performed in stages, a has it since been generally accepted. little sawing being done each day Support to the view that the cranial until the bone disc comes away. It openings were in most cases made for sometimes takes the surgeon fifteen religious reasons, is furnished by the to twenty days to remove a disc about discovery of numerous amulets made the size of a penny. Great care is taken from bone discs or taken from per to protect the brain and its membran forated skulls in relation to openings ous coverings, and to avoid the sutures in them, but although amulets occur since these are believed to be the in association with the neolithic skulls patient’s destiny written by the hand of France they have never been found of Allah.47-48 In the South Pacific also in Peru where openings in neolithic the skull is opened in an even more skulls also are quite frequently en primitive manner for such conditions countered.119 Since in the Peruvian as headache and giddiness, for frac skulls fractures are quite common it tures, and even to promote longev appears as if in that part of the world ity,23 the bone being scraped out with the operation had a basis more defi a piece of glass. Shark’s teeth were nitely surgical than religious.f at one time used as the cutting tool Although it is interesting to thus * In a visit paid to this museum in June able, and in several skulls two openings have 1929, I was unable to corroborate this. The been made. Several of the openings traverse openings appeared too irregularly placed in the midline but evidence of healing shows regard to the motor cortex and to be placed that the superior longitudinal sinus had not indiscriminately over the vault of the skull. been fatally damaged during the operation. t Owing to the courtesy of Sir Arthur There is no example of suboccipital cranio Keith and Mr. R. W. Burne of the Staff of the tomy, and as far as I am aware no neolithic Royal College of Surgeons Museum in Lon specimens from any part of the world afford don, I have recently examined 14 specimens of examples of trephining in this frequent site of primitive trephining from Peru. Two of the operation today. The Peruvian skulls have specimens show that the operation had been trephined in front, over the sides and apparently been performed for fracture. The at the back. One skull shows evidence of size of some of these openings is consider- infection and suppuration. but today these have been replaced by who had almost certainly obtained his glass.30 The Museum of the Royal knowledge from several sources, one of College of Surgeons of England con which was probably Egyptian,19 de

tains two Melanesian skulls with scribed this instrument and laid down defects in them due to operations rules for its use, but to what literature performed in this rude manner, and he may have had access, is not known from the fact that the bone edges show since pre-Hippoeratic Greek medical healing it is evident that these patients writings have perished. It must not both survived the operation and lived be thought that trephining was the for some time afterwards.* only method used by the Greeks for opening the skull because Percival Part ii. Trepans or Trephines Pott86 tells us that in some cases “the It is possible, I think, that the more piece of cranium intended to be taken perfect methods of trephining practised away was surrounded with perfo by the hippocratic surgeons had a direct rations made at small distances from and continuous descent from the primitive each other, and the interstices were operations of the stone age. cut through by chisel and mallet or —Sir Charles Ballance. by means of a scalper.” This oper ation recalls a form of craniotomy These are instruments which pro occasionally practiced by the neolithic duce a cutting action by rotation. surgeons and by primitive races today Examples are in use today, and al (vide Section 1). though from the etymological point Hippocrates described the crown of view they would perhaps be better trephine (modiolus) which in con called trepans they are more commonly sisting of a saw having a circular described as trephines, f motion parallel to the plane of the The trephine is a very ancient skull is similar in principle to instru instrument. Hippocrates (cu. 400 b.c.) ments in common use today. In * Specimens numbered 1172-11 (New referring to the method of using the Britain), and 1172-62 (New Ireland). The Trephining. (L. tres, three, and finis, end, museum also contains other specimens from a word introduced by Woodall early in the New Ireland 1172-63, 64, 65 and 66 and a seventeenth century when he gave the trepan “Trephined Anglo-Saxon skull,” specimen a handle.) 1 am much endebted to Dr. 373-1, the history of which is not related. Wilson Parry for calling my attention to the f Trepanning. (Gr. trypannon, an augur.) significance of these words. trephine he mentions the desirability these protected drills (abaptista) and of occasionally plunging it in water to then removing the bone not whole prevent the instrument becoming over but in pieces with chisels.

Over twelve hundred years after Galen, Guy deChauliac (1363), appar heated. Apparently several sizes of ently ignorant of the crown trephine, trephine were employed in his time was still using the guarded gimlet because he mentions a small instru type (abaptista)45 (Fig. 3). The crown ment for use in head injuries in young trephine appears to have been re people. discovered by Bertapaglia in the fif In Galen’s time (ca. 130 b.c.) the teenth century and it was in use by crown trephine appears to have been Jean de Vigo in 1517.19 It is interesting displaced by a gimlet type of instru to note the way in which the crown ment (terebra). This pointed trephine type of instrument was made to bite had a collar (abaptista) to prevent the skull to commence cutting the damage to the brain and its invest bone disc. Cclsus5 (ca. 30 b.c.) refers ing membranes by undue penetration to a removable center pin which is the through the bone. Apparently the device adopted in modern trephines distance of the collar from the point such as Horsley’s (Fig. 4), but in Jean varied in different instruments so de Vigo’s time male and female instru that a series of these trephines was ments were used, the male trephine kept in order to perforate thick or having a fixed center pin and being thin skulls.19 discarded for the female instrument as Evidently the Greek surgeons per soon as the saw had commenced to formed extensive craniotomies on cer cut into the bone. Although Horsley’s tain of their patients because Paulus trephine today is operated by hand of Aegina5 (early 7th century a.d.) with a screw motion, in the time of refers to perforating the bone with Celsus the trephine was driven by a throng, and following the re-intro eenth century the crown trephine duction of the crown instrument, was improved somewhat by making Berengar of Carpi in 1535 attached a the cutter slightly conical instead of

perfectly cylindrical, in this way con brace to it to quicken and facilitate tributing to the ease with which the its action.6 (Fig. 5). Recently (1928) a bone disc could be elevated after brace driven perforator with an adjust cutting through the skull, and while able collar to prevent undue penetra cutting the bone lessening the chances tion has been introduced into cerebral of damaging the underlying mem surgery by H. S. Souttar of London and branes covering the brain. This modi may be regarded as a return of the fication can be seen by comparing the terebra abaptista driven by a brace.104 trephine made by Savigny with that In the works of “that famous designed by Sir Victor Horsley. Sa- chirurgion, Ambrose Parey,”135 sev vigny’s instrument, introduced about eral trephines are depicted and de 1798,* had a barrel of cylindrical scribed, also a “gimlet or piercer to pattern (Fig.7) while that of Sir perforate the scull before the setting Victor Horsley which remains in use to of the Trepan: A crown trephine today resembles a truncated cone and brace are illustrated fitted to (Fig. 4)- gether and taken apart, and another Both crown and gimlet trephines instrument is shown with two tri have thus been in use with only minor angular bits and a pin to hold them modifications for over two thousand in the stocke.” Still another illustra years, but while the crown type of tion shows “a desquamatorie or scal ing trepan” which closely resembles * Three good specimens of this instrument can be seen in the Museum of the Royal the modern brace and center bit College of Surgeons of England. They arc (Fig- 6). catalogued as k 14, k 15, k 16 in the instru Towards the middle of the eight ment room. instrument was lost for some time, it Part hi. Saws eventually reappeared and today is The past is always with us, never to be in more common use than the gimlet escaped; it alone is enduring; but, amidst

the changes and chances which succeed one another so rapidly in this life, we are apt to live too much for the present and too much in the future. Aequanimitas—Osler The crown trephine may be re or center bit type of instrument. garded as a modified continuous hand From the time of Hippocrates trephin saw bent on its flat into the form of a ing appears to have been carried out circle. Saws of many varieties have for surgical rather than thaumaturgic been used in cranial surgery, the most reasons. Fracture of the skull however primitive being the serrated shark’s was not the only indication for the use teeth and jagged pieces of Hint and of the trephine. Hippocrates trephined obsidian referred to in Part 1 of this and decompressed to relieve failing paper. Following the introduction of vision, the result of rising intracranial metal saws, two kinds of saw were tension, in much the same way that a evolved. The first and simpler of these modern decompression is performed was the hand saw, the second the for the same purpose, and Cclsus5 circular or disc saw which, since it required some driving mechanism to (ca. 30 b.c.) recommended trephining for meningeal hemorrhage without frac operate it, may be called the mechan ture of the skull. But, as mentioned ical saw. in the previous section, the object The Hand Saw. The best known of this paper is rather to describe model of the hand skull saw is that the methods and instruments used for widely called Hey’s saw (Fig. 8) and opening the skull than to discuss in used about 1780 by Mr. William Hey, detail the reasons for operating. Tre f.r.s. of Leeds, He, however was not phining was very readily resorted the originator, for in his “Practical to in the sixteenth and seventeenth Observations in Surgery”46 published centuries for we read that as a result in 1803, and in a chapter dealing with of a fall from his horse Philip of fracture of the skull he thus writes of Nassau was subsequently trepanned this saw: by “Henry Chadborn, Surgeon in It was first shewn to me by Mr. (now Nymegan,” no less than twenty-seven Dr.) Cockell, an ingenious practitioner, times.136 at Pontefract, to whom the public is indebted for the discovery, or revival, of There is a footnote stating that this excellent instrument. A saw, formed the saws represented in this Plate on the same principle, is represented in (vide Fig. 9) were made by Mr.

Savigny in London. But long before the time of cither William Hey of Leeds or Mr. Cockell of Pontefract, saws of this type had been used for opening the skull. Ambroise Pare135 depicts several which he describes as “saws fit to divide the scull”* and these closely resemble Hey’s saw, and An drea a Cruce24 has a picture of a saw which is also very similar to that of Cockell and Hey (Fig. 10). Although Hey was not therefore the inventor of the saw named after him he did draw attention to this Scultetus’s armamentarium chirurgicum; type of saw and emphasized its ad but I understood Dr. Cockell to say, that vantages in cranial surgery, and as the instrument which he shewed me was of his own invention, and that he had used Sydney Smith says, it is not the man it with great advantage in extensive who first says a thing, but it is he who fractures of the skull. Dr. Cockell’s saw says it so long, so loudly and so had a semicircular edge, as represented in clearly, that he compels men to hear the annexed Plate, where the size of the him: it is to him that the credit figure is two-thirds of the real dimensions belongs. So far as his own country is of the instrument. But the edge may be concerned, then, the credit of thus made straight (as is shewn in the Plate) * Vide reference to Ambroise Pare on p. or of any degree of convexity which may 509. The illustration occurs on p. 345 of be thought most useful. Pare’s works. emphatically demonstrating the value instance by ivory turners for cutting of hand skull saws belongs to William round corners and so on.”162 Hey of Leeds. It seems highly probable that small saws mounted on handles were in use for many purposes long before Bigger, Hey, Cockell or even Ambroise Pare drew attention to them. Mechanical or Rotation Saws. Early in the nineteenth century a number of circular saws variously mounted and driven came into use for cutting bone, and some of these were applied to cerebral surgery. The sim plest of these instruments was that of Prof. Thai,137 first surgeon to the Copenhagen Hospital for the Poor (Aemindelig). A description of Thai’s saw with a plate (Fig. n) appeared On March i, 1878 at a meeting of in the Edinburgh Medical and Surgical the Surgical Society of Ireland, Dr. Journal for January 1, 1823. From L. Bigger showed a saw like Hey’s but the plate it can be readily seen how with teeth also on the concave side the instrument worked: blades either so that both the convex and concave completely circular or sections of sides of the cutting blade could be circles and of various sizes could used. In claiming advantages for hand be fitted to a shaft which was rotated saws such as Hey’s and his modifica by one hand of the surgeon, while tion of it, Bigger said: his other hand supported the whole in strument by a handle upon which was . . . various attempts are to be found in mounted the main bearing through the records of ancient armamentaria, of which the shaft passed. Apparently very near approaches to the short saws Thai was both ingenious and versatile brought into use by that excellent sur because in 1823 Prof. Howitz com geon, Mr. Hey of Leeds. He, practising menting upon this saw observed, “In in a district where powerful machinery its present form, the whole instrument was continually causing fearful fractures has also been executed by the inven and injuries, felt that the trephine was not always competent to fulfil the inten tor, who is almost as skilful in such tions of the surgeon and he designed the workmanship as his countrymen ac saws known by his name. knowledge him to be in the principal object of his studies.”137 During the discussion which fol Numerous other disc saws, all how lowed the presentation of Dr. Bigger’s ever more complicated than that of paper, the President of the Society, Prof. Thai, appeared at this time but Robert McDonnell, f.r.s., agreed of these not one has survived to be with Mr. Richardson, one of the used in cranial surgery today, that is speakers, that “there had been a good to say they have all been complete deal of claim for novelty for surgical failures. Some proved little more than saws which had long been in use for inventor’s toys and never came into use at all, others had an ephemeral have added two small points, which existence; all proved either too cum are found very useful in applying the bersome or too complicated or danger sawr to the cranium.”63 ous and inefficient for general usage. Some very ingenious mechanical saws were produced, however, and an ex amination of some of these in the instrument collection in the museum of the Royal College of Surgeons in Lincoln’s Inn Fields proves a fascinat ing occupation. In May 1808 Mr. Machell,63 a surgeon of Wolsingham, communi cated to the Edinburgh Medical and Surgical Journal a description and a drawing of a circular bone cutting saw.63 An editorial note commenting on the saw reads as follows: “We have examined it, and we think it remark ably ingenious. It is so far as we know the first contrivance whereby a circu lar saw is enabled to cut deeper than its semi-diameter, an advantage of incalculable importance in the oper In 1815 Charles Griffith, Surgeon to ations for which it is intended.” the Forces, produced a circular sawr Figure 12 is taken from the plate of which in conjunction with “a new Machell’s saw, and an example of the form of bone nippers” wras communi instrument can be seen among the col cated to the Edinburgh Medical and lection previously referred to, in the Surgical Journal by Dr. R. Hall138 Museum of the College of Surgeons.* of the Detached Military Hospital at Machell considered his saw specially ' Chelsea with the following rather suitable for clearing the ends of old ponderous introduction: ununited fractured bones, but it is The military practice of surgery, em conceivable also that attempts to use bracing a greater variety of casualty than the instrument for cranial surgery any other, owing to the fortuitous passage may have been made, because he of balls through, or their lodgement in, refers to the value of a joint “which every part of the body, urging military will allow of the conveyance being surgeons occasionally to the exertion of formed into different angles, which is their inventive faculties, for the purpose frequently particularly necessary in of preserving life, relieving pain, or applying the annular saw to the con avoiding as much as possible, a too san vexity of a patient’s head, as in cases guinary use of the knife, it becomes, I of fractures of the cranium,”63 and think, a duty which they owe to their again, “at the end of the forceps I profession in general, to make public such matters as they have reason to * Specimens, k 53, k 54, and also k 55 which believe may prove of public utility. is a modification of a Machelfs saw by the addition of forceps to hold the bone. Mr. Griffith refers to the possible use of his saw in cranial surgery but ... So early as 1887 he added, to the there is no record that the instrument use of the trephine and the bone cutting “proved of public utility.” (Fig. 13.)* forceps, the use of a minature circular saw

driven by a Bonwill’s surgical engine [Fig. 14]. This was apparently the first mechanical saw designed for the special purpose of opening the skull but apparently About the time of the appearance Horsley did not find the instrument very of the saws of Machell and Griffith, successful, and it was not very long before a number of mechanically operated he abandoned it. Sir William Macewen in disc saws were produced in France Glasgow was using a circular saw for per but none seems to have become forming craniotomy about the same time established as a practical instrument as Horsley was using his in London, but Macewen was not pleased with this for use in cranial surgery. method of opening the skull and cau The mechanical saws that have been tioned against the use of circular saws referred to were devised for cutting for the purpose. bone generally, and although it was thought by the designers of certain Doyen in Paris introduced a circular of them that they might be used for saw for cranial surgery in 1897* (Fig. opening the skull not one of these 15) and in the same year William saws was especially designed for this Waldo Van Arsdale, adjunct pro purpose nor did any come into use in fessor of surgery at the New York this way. Polyclinic, published a paper entitled, The great pioneer of cerebral sur “Remarks on Temporary Resection gery, the late Sir Victor Horsley, of the Skull by a New Method with a realised the desirability of having a Report on Three Successful Cases.”111 rapid mechanical method of cutting This new method consisted of the use through the cranial bones, and his * I am indebted to Messrs. Meyer and biographer, Stephen Paget, writes:143 Phelps for kindly lending me the saws from which figures 14, 15 and 16 are made and for * The museum of the Royal College of kindly writing to Messrs. Collin of Paris for Surgeons of England contains 3 examples of me about Doyen’s saw. The following reply Machell’s saw, specimens k 53, k 54, k 55, and was received. “Nous avows Pavantage de vous examples, specimens k 51, k 52, of formidable faire connaitre que la scie du Dr. Doyen a etc clockwork driven instruments, the diameter of construite par nous et presentee a la Societe de the saw of one of these being 4^ inches. Chirurgie vers I’annee 1897.” of a specially constructed disc saw a laboring man aged twenty-seven, which Van Arsdalc had presented (Fig. who was unconscious following a blow 16) to the New York Surgical Society on the side of the head, and who two the year previously when he also pub days after the accident developed lished an account of the instrument.110 signs and symptoms pointing to intra Horsley’s, Doyen’s and Van Ars- cranial hemorrhage from the left mid dale’s saws were all driven by surgical dle meningeal artery. Wagner, who engines connected to the driving spin had previously experimented upon dles of the saws by flexible cables. cadavers with the object of producing It is interesting to note that of all a bone flap attached at its base to the these varieties of skull saws, the only soft parts so that the flap could be one to remain in use today is the simple turned down, a reasonably large area hand instrument known as Hey’s saw. of the brain exposed and the flap subsequently replaced, now performed Part iv. Further Advances in Technic: his operation for the first time on a the Formation of Bone Flaps. living subject. A large bone flap was I feel the great thing in this world is chiselled out and turned down with its not so much where we stand, as in what base attached to the scalp, the bleed direction we are moving. ing meningeal artery secured and the —Oliver Wendell Holmes flap replaced. Wagner’s patient died By the historical method alone can twenty-four hours later, but the oper many problems in medicine be ap ation had introduced a new technic in proached profitably. For example the the surgical exposure of the brain, and student who dates his knowledge of it was not long before other and more tuberculosis from Koch may have a very successful attempts were carried out. correct, but he has a very incomplete Osteoplastic craniotomy has now come appreciation of the subject. to be known as Wagner’s operation.139 —Sir William Osler At the time of his original descrip One of the greatest advances in the tion Wagner stated, “I only use small method of opening the skull for surgical strong chisels and elevators. Perhaps exploration of the brain and its invest some form of circular saw could be ing membranes was that made in 1889 constructed which could be set in by Wilhelm Wagner of Konigshiitte. motion after the manner of a dentist’s In 1864 Ollier had suggested an drill with which it would be possible osteoplastic resection of the skull, his to work more quickly and accurately.” idea being to lift up a piece of the He added a word of warning against skull adherent to a flap of soft parts,22 the hammering necessary for chisel but it was not until 1889 that Wagner ling, and the liability to cerebral first adopted this principle when oper concussion from hammering the skull ating upon the living subject. is of course obvious.* On November 23 of that year, Wagner was apparently unaware \\ agner reported the case of a patient of Horsley’s circular saw because he upon whom he had performed osteo concluded his suggestion to use such plastic craniotomy, and entitled his paper “On temporary resection of the * Gorodiski, Ein Vorschlag zur Trepana tion, Erlangen, 1893, commenting upon this vault of the cranium in place of trepa states that for this reason the use of hammer nation.”115 The operation had been and chisel for opening the skull was depreca performed on October 3, 1889 upon ted by Galen about 200 a.d. an instrument by stating that he did ments for the purpose have been in not know of such a saw, and then the direction of improving the technic when his paper was in print added a of performing this operation. Many footnote, that Richter had told him craniotomes have been invented to of a circular saw constructed by facilitate the Wagnerian operation, Collin of Paris and used by Pean and but none so far has been sufficiently Ollier.115 This was apparently Doyen’s successful to supplant Gigli’s saw saw to which reference has been made completely and relegate it to places in the previous section. similar to those held today by the saws Circular saws as constructed to of Thai, Machell, Griffith and others wards the end of the nineteenth to whom reference has been made. century, however, did not prove very At the seventh Congress of the helpful in performing osteoplastic re International Society of Surgery held sections of the skull, and the most in Rome in April 1926, Dr. A. Jcntzer useful instrument introduced for this of Geneva, suggested cutting bone purpose was the wire saw of Leonardo discs completely from the skull and Gigli of Florence. This instrument, replacing these later. He showed and now universally known as the Gigli demonstrated the action of an elab saw, was first described in 189439 and orate instrument which he had de rapidly came into general use. It signed for this purpose, and which consists of a flexible roughened wire consisted of a central trephine around operated by detachable handles at which other trephines fitted concen either extremity, and serves to cut trically so that a series of cuts could be through bone in much the same way made through the skull, and discs of that a plain wire cuts through cheese. various sizes removed and preserved The saw is used to divide the inter until the completion of the operation vening bridges of bone separating when they could be replaced in the gap trephine or other openings made into in the bone. the skull, and is similar in action to Most surgeons however still prefer certain old chain saws which were to perform the Wagner operation of introduced in the eighteenth and turning down a bone flap attached to nineteenth centuries for cutting long the soft parts, and the problem which bones. this type of operation presents is Gigli saws are in use today not how best to make the linear cuts only for performing osteoplastic cra through the bone. Forceps such as niotomy but also for cutting through those of De Vilbiss have been used, bony bridges, the situation of which electrically driven instruments which renders the application of other saws punch out a groove through the bone hazardous or difficult. Cutting bone in much the same way that a pneu flaps from the skull by means of these matic drill cuts a groove through a saws is tedious and the wires may jam hard road, have been introduced by or break, but the procedure is a safe Dr. De Martel* of Paris and others, one. and an ingenious instrument has quite The production of osteoplastic flaps is an essential part of cerebral surgery * The instrument which I have seen used by Dr. De Martel in Paris appears to have today, and since Wagner’s time the had a precursor manufactured by De Vilbiss chief advances in the methods of of New York and pictured by Terrier, opening the skull and in the instru Gaz. bebdom. de med. et cbir., 31: 573, 1894. recently been designed and used by gouge to the surgery of the skull,” Mr. H. S. Souttar of London. This and for opening the skull advocated instrument is operated by hand and the use of two carpenter’s parting

tools of different gauges and so ground that one was more suited to the thicker dense skull of the adult, and the other to the less resistant skull of the child.53 In the following year J. S. Pyle published a paper “On opening the cranial cavity with a new by swinging round an expanding man set of instruments.”96 The instruments dril fitted through an opening in the were hand operated cutting tools and a center of the proposed bone flap cuts a report of a case was included in his flap which is part of a circle.104 Mr. paper, but today these hand operated Souttar’s craniotome is particularly tools have, except in the case of interesting inasmuch as it is a modern Souttar’s mechanical craniotome, al counterpart of a similar type of instru most completely disappeared from ment described by Ambroise Pare in cranial surgery. 1634 as “a paire of cutting compasses Doyen’s, Van Arsdale’s and other to cut forth the scull”* (Fig. 17), and circular saws have not been successful well illustrates the tendency for certain for performing osteoplastic resection discoveries of our forefathers to be of the skull, and an examination of lost for a time and rediscovered many these instruments shows that the decades later. reason for their failure appears to be Mr. Souttar’s instrument consists the difficulty of engaging a power essentially of a hand driven cutting driven saw with the skull while at tool acting from a center pin. In the same time adequately protecting 1893, Sir William Arbuthnot Lane, the brain and its membranes from then assistant surgeon to Guy’s Hos injury. An attempt has been made to pital, read a paper on “The applica get over this difficulty in a recent bility of the parting tool or angular instrument by the introduction of * I am much indebted to Prof. R. Dobbin of a cutting action capable of accurately Cairo, for drawing my attention to this controlled biplanar movement in re ingenious instrument and for very kindly lation to a guard for the brain and its sending me drawings of it. I have since com pared them with the original and written to membranes (Fig. 18).* It remains for Mr. Souttar pointing out to him the similarity * The Skull Plough, a new instrument for between his and Pare’s instrument. cutting cranial bone flaps (Fig. 18). Reported time to classify this instrument either generation may become the common with those of Thai, Machell, Griffith, place of the next, sometimes abruptly Horsley, Doyen and Van Arsdale, or sometimes so insidiously as frequently with the more successful saws of almost to escape observation. William Hey and Leonardo Gigli. The distribution of the operation of craniotomy with respect to time, Conclusion territory and the stage of development In this account of craniotomy and of races shows that the operation is the instruments used to perform it, common to many countries and to an attempt has been made to show how different stages in the development from the very earliest times man has of mankind, from the unwritten past operated upon the skulls of his fellows, to the present and from savagery to using at first sharp stones or shark’s civilization, and that the methods of, teeth* to cut an opening through and probably the motives for, its the bone, then various metal instru performance have varied widely with ments in the form of trephines and cultural progress. saws; how with progress through the The story of the methods which man ages these became elaborated so as has practiced and of the tools, which, to facilitate the cutting process throughout the ages, he has used for and make it more rapid; how certain opening the skulls of his fellow men, not of the elaborations failed while only throws odd shafts of light on the others evolved, and how with the condition of races at various stages in wide application of mechanical power, their evolutionary progress, but also power driven instruments in certain affords fleeting glimpses of progressive cases supplanted those operated by stages in the social development of hand. Certain of these instruments had civilized man, “a tool using animal,” as an ephemeral existence almost as tran exemplified by the nature of his tools. sient as Jonah’s gourd, which “came In glancing back at these stages, up in a night, and perished in a night,” however, it must not be forgotten others remained for relatively long that progress is only rarely made by periods ultimately to pass away or sudden steps; more often it is along become so modified as to be no longer a gradient so gentle as to be almost recognisable, while still others have imperceptible and between the stages persisted and are in use today. there are many intermediate ones Throughout this, as in most stories that tend to be overlooked. We may of development, two tendencies are do well to remember what Carlyle has apparent, first that certain ideas and said about history in general: methods may recur over long inter vals, so that the discoveries of our The most important part is lost with out recovery, and, as thanksgivings were forefathers become lost for a time and once wont to be offered for unrecognised reappear long years afterwards, and mercies, look with reverence into the dark secondly that the toil and trials of one untenanted places of the past, where in by Lambert Rogers on July 24, 1929 to the formless oblivion many of our chief Surgical Section of the British Medical benefactors, with all their strenuous Association at its annual meeting in Man endeavours, lie entombed. chester. *A.s is well known, sharks’ teeth are and in this spirit I conclude this brief serrated. account of the history of craniotomy. References

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