Neurosurg Focus 36 (4):E12, 2014 ©AANS, 2014 The history of neurosurgery and its relation to the development and refinement of the frontotemporal craniotomy D. RYAN ORMOND, M.D.,1 AND COSTAS G. HADJIPANAYIS, M.D., PH.D.2 1Department of Neurosurgery, University of Bonn, Germany; and 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia The history of neurosurgery is filled with descriptions of brave surgeons performing surgery against great odds in an attempt to improve outcomes in their patients. In the distant past, most neurosurgical procedures were limited to trephination, and this was sometimes performed for unclear reasons. Beginning in the Renaissance and accelerating through the middle and late 19th century, a greater understanding of cerebral localization, antisepsis, anesthesia, and hemostasis led to an era of great expansion in neurosurgical approaches and techniques. During this process, fronto- temporal approaches were also developed and refined over time. Progress often depended on the technical advances of scientists coupled with the innovative ideas and courage of pioneering surgeons. A better understanding of this history provides insight into where we originated as a specialty and in what directions we may go in the future. This review considers the historical events enabling the development of neurosurgery as a specialty, and how this relates to the development of frontotemporal approaches. (http://thejns.org/doi/abs/10.3171/2014.2.FOCUS13548) KEY WORDS • frontotemporal craniotomy • history • pterional • keyhole approach HE history of neurosurgery is filled with courageous ries witnessed great advances in anatomical knowledge, individuals who worked against great odds in an but until further developments in the areas of cerebral attempt to improve the lives of their patients. For localization, anesthesia, hemostasis, and antisepsis oc- Tcenturies, the realm of neurosurgery was considered an curred, neurosurgery remained in its infancy. arena mostly of observation and “primum non nocere,” as surgical outcomes were often worse than disease progres- sion. The Hippocratic School was the first to codify treat- Anesthesia, Antisepsis, and Hemostasis ment for head injury in De capitis vulneribus, with skull Major advances in three areas of science and medi- fractures being classified by type and the severity of in- cine—anesthesia, antisepsis, and hemostasis—dramati- jury determining the need for trephination (the worse the cally improved the safety and efficacy of surgery. One of injury, the less the need for trephination).43 Furthermore, the evolutionary changes in Western medicine occurred this work did not provide any clues that the neurological under the hands of Ambrose Paré (1510–1590) in the mid- condition of the patient made any difference in the surgi- 16th century. A Huguenot and military surgeon, Paré re- cal decision-making process.35 jected the long-held practice of boiling oil and hot cautery The Renaissance in Europe saw a dramatic improve- for hemostasis and instead found that ligatures offered su- ment in the understanding of anatomy and the develop- perior hemostasis and wound healing.75 He popularized ment of surgical techniques. Jacopo Berengario da Carpi his findings by writing in French instead of Latin and (1460–1530) was an Italian physician, surgeon, and anat- was surgeon to the European royal courts.16,35 Cautery re- omist, who was the first to publish an anatomical text sup- turned later as electrocautery devices were improved and plemented with illustrations.76 He also published a mono- popularized by William T. Bovie (1881–1958) and Harvey graph dedicated to head injury, De fractura Cranii, the Cushing (1869–1939).66 Cushing used Bovie’s device for second after Hippocrates’ work.5–8 Carpi was motivated the first time on October 1, 1926, to successfully remove to write this text shortly after treating a serious head in- a skull myeloma from the head of a 64-year-old patient, jury in Lorenzo dé Medici. He had a dream in which a which he had failed to remove previously because of its capped man with golden-winged sandals encouraged him vascularity. 66 Improved methods of hemostasis coincided to write a treatise on head injuries.35 The next few centu- with the development of safe blood transfusion. William Neurosurg Focus / Volume 36 / April 2014 1 Unauthenticated | Downloaded 10/07/21 04:12 AM UTC D. R. Ormond and C. G. Hadjipanayis Harvey (1578–1657) had discovered the circulation of helped bring us into the modern surgical era, providing blood in 1628,39 and the first successful animal transfu- patients with the analgesia and anesthesia necessary to sion between two dogs had been performed by Richard increase surgical time and complexity. Lower (1631–1691) in 1665.61 A few years later Lower Beginning in the Middle Ages, various discoveries also performed the first blood transfusion from a sheep over several centuries eventually led to the rejection of to a human (xenotransfusion) for the treatment of mental old dogma and to the development of asepsis and anti- illness in a clergyman.61 Unfortunately, difficulties with septic technique. Early on, antiseptic technique was transfusion reactions, clotting, and incompatibility were not well understood. For example, Roger of Salerno (d. not resolved until blood groups were discovered by Karl 1119), a 12th-century surgeon, promoted suppuration in Landsteiner (1868–1943) much later, in 1900.86 With the open wounds. He believed it was helpful in the healing development of better hemostasis and successful blood process.35,82 Air was later understood as the harbinger of transfusions, the stage was set for more complex surgery. the putrefactive process. As early as 1516, Magnatus de- However, surgeons needed to overcome the other major scribed “miasms” that infected everything that was open limitations to successful surgery: pain and infection. and exposed to the air.16 Surgeons then made painstaking While wine and opium have been used for their seda- efforts to prevent air from getting into wounds. Antonie tive and analgesic effects for millennia, a dramatic change van Leeuwenhoek (1632–1723) later discovered microor- in the understanding and use of anesthetic agents in the ganisms after developing his microscope and described 18th and 19th centuries enabled the surgeon to operate in his work in numerous letters to the Royal Society.16,28 patients while they remained pain free for extended peri- Unfortunately, the connection between microorganisms ods of time.7,50,79,82 Generations of physicians in the East and human disease did not truly develop until well into and the West used various herbal concoctions with some the 19th century. In the mid-19th century, surgical mor- success. Ultimately, the consistent use of anesthetic agents tality due to postoperative sepsis remained nearly 50%. in surgery occurred following the discovery of nitrous ox- While a number of individuals were involved in discov- ide, diethyl ether, and other agents during the 19th centu- eries resulting in the reduction of postoperative sepsis, a ry. The Pneumatic Institution for Inhalation Gas Therapy few key individuals stand out as pivotal in the develop- was founded in 1798 at Dowry Square in Clifton, Bristol, ment of aseptic and antiseptic surgery. In the 1840s, Ignaz England. Here, Humphry Davy (1778–1829) discovered Semmelweis (1818–1865) was working in the maternity nitrous oxide and coined the term “laughing gas.”20 Davy department of the Vienna Lying-in Hospital. After noting documented its analgesic effects and potential benefits in the difference in mortality from puerperal fever in doc- relieving pain during surgery.20 By the 1830s, “ether frol- tor’s wards versus midwives’ wards, he hypothesized that ics” were held in the northeastern United States, where this occurred because of a contagion transferred by the participants inhaled either diethyl ether or nitrous oxide interns performing autopsies around the time that they to demonstrate their mind-altering properties as a form performed deliveries. He required interns to wash their of entertainment.22 Four men participating in these events hands with a chlorinated lime solution and successfully later became instrumental in the use of these agents in decreased the mortality rate from over 10% to less than surgery: William Edward Clark (1819–1898), Crawford 1%. 84,86,92 Unfortunately, his remarkable findings went W. Long (1815–1878), Horace Wells (1815–1848), and against conventional medical “knowledge” of the day, and William T. G. Morton (1819–1868).22 As a medical stu- it would be decades before his findings would be widely dent at Berkshire Medical College in 1842, Clark gave accepted.40 In the 1860s, Louis Pasteur demonstrated diethyl ether to a Miss Hobbie while Elijah Pope per- that microorganisms cause spoilage, not “spontaneous formed a dental extraction, completing the first surgical generation” (the hypothesis that putrefaction occurred ex procedure under general anesthesia in the modern era.62 nihilo from bad air), and that microorganisms can travel That same year in the state of Georgia, Crawford Long through the air and be killed by heat.29 During this same removed a tumor from the neck of a man who was un- time, Robert Koch (1843–1910) proved the germ theory der ether anesthesia.60 Long went on to utilize ether an- of disease by describing Bacillus anthracis as the caus- esthesia as a general anesthetic for limb amputations and ative agent of anthrax.57 Building on