Neurosurg Focus 33 (2):E4, 2012 Fedor Krause: the first systematic use of x-rays in neurosurgery ALI M. ELHADI, M.D., SamUEL KALB, M.D., NIKOLAY L. MARTIROSYan, M.D., ABHISHek AGRAWAL, M.D., anD MARK C. PREUL, M.D. Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona Within a few months of Wilhelm Conrad Röntgen’s discovery of x-rays in 1895, Fedor Krause acquired an x-ray apparatus and began to use it in his daily interactions with patients and for diagnosis. He was the first neurosurgeon to use x-rays methodically and systematically. In 1908 Krause published the first volume of text on neurosurgery, Chirurgie des Gehirns und Rückenmarks (Surgery of the Brain and Spinal Cord), which was translated into English in 1909. The second volume followed in 1911. This was the first published multivolume text totally devoted to neurosur- gery. Although Krause excelled in and promoted neurosurgery, he believed that surgeons should excel at general sur- gery. Importantly, Krause was inclined to adopt technology that he believed could be helpful in surgery. His 1908 text was the first neurosurgical text to contain a specific chapter on x-rays (“Radiographie”) that showed roentgenograms of neurosurgical procedures and pathology. After the revolutionary discovery of x-rays by Röntgen, many prominent neurosurgeons seemed pessimistic about the use of x-rays for anything more than trauma or fractures. Krause im- mediately seized on its use to guide and monitor ventricular drainage and especially for the diagnosis of tumors of the skull base. The x-ray images contained in Krause’s “Radiographie” chapter provide a seminal view into the adoption of new technology and the development of neurosurgical technique and are part of neurosurgery’s heritage. (http://thejns.org/doi/abs/10.3171/2012.6.FOCUS12135) KEY WORDS • Fedor Krause • radiology • x-ray • neurosurgery • history of neurosurgery In discussing newer methods of examination, radiogra- Discovery of Röntgen or the X-Rays phy should be included. Above all other means of diagnosis it furnishes the most useful in tumors with calcareous or bony In November 1895, Wilhelm Conrad Röntgen discov- deposits as, for instance, in exostosis. ered the “X-rays.” On January 13, 1896, Röntgen person- 17 FEDOR KRAUSE ally demonstrated his new rays before Kaiser Wilhelm II, but he did not speak on his discovery elsewhere until a Among Harvey Cushing’s many accomplishments, memorable lecture before the Würzburg Physical Medi- he has been heralded as the first to use x-rays for neu- cal Society on January 23.6,8 The closing discussion of the rosurgical diagnosis.10 Upon closer inspection, the topic is more complicated, involving the seminal contribution lecture concerned whether Röntgen believed that it would of another, nearly unacknowledged for his earliest work be possible to make x-ray photographs of other human with x-rays in neurosurgery. This project traces the use of body parts beyond the bone, and whether surgery and x-rays by Fedor Krause (Fig. 1), who might be regarded as anatomy could benefit by the discovery. Röntgen believed more deserving of the accolade, and places his efforts in at the time that, because of the similar density of organs, the rays could not differentiate them. As mentioned by the context of contemporaneous events in the incorpora- 8 tion of a new technology. Indeed, 1908 was an auspicious Glasser, “Professor C. Schönborn [Karl Wilhelm Schön- year for neurosurgery, witnessing 2 major monographs born], a surgeon present, warned against too much opti- on neurosurgery by Cushing and Edward Archibald, as mism since the method scarcely promised to be of much, well as a textbook by Krause that heralded modern sur- if any value in the diagnosis of internal disturbances.” gical technique on neurological structures incorporating Glasser further wrote: x-rays. [Röntgen replied] that it was not difficult to photograph a Neurosurg Focus / Volume 33 / August 2012 1 Unauthenticated | Downloaded 10/10/21 12:39 AM UTC A. M. Elhadi et al. cal diagnosis.” In another letter to his mother on May 10, 1896, he stated “We have at least succeeded in having an X-ray machine put in for which I have subscribed largely and hope the conservative staff will ultimately remuner- ate us for it.”7,10 The first clinical use of x-rays in North America was by Williams and Codman in 1896, which started short- ly after its discovery in Röntgen’s laboratory. Cushing worked with Codman at the Massachusetts General Hos- pital with x-rays and then left for John Hopkins Hospital in 1896 with an x-ray tube. In Boston, attempts were made to demonstrate brain tumors by x-rays from 1896 through 1910. Williams,24 in the first text in North America on radiography, wrote of the technical problems with acquir- ing useful images: “Tumors in the brain with our present apparatus and inexperience must necessarily offer a great deal of difficulty to detection by the rays” (340). After his first use of x-rays on November 6, 1896, on a female patient who had sustained a gunshot injury Cushing wrote: It was in the fall of 1896 that I went to John Hopkins and made the first Roentgenograms that were taken there, with the aid of a decrepit and perverse static machine as big as a hurdy- gurdy and operated in the same way, by turning a crank. My first paper submitted for publication contained an account of a case of a gunshot wound of the spine showing a bullet which a Baltimorean had planted in the body of his wife’s sixth cervi- cal vertebra. I once showed these pictures to Dr. Cole and he expressed himself as astonished that such good plates could have been taken in 1896; but I do not know whether I told him, as I shall now confide to you, that the plates were the result of exposures averaging 35 minutes. And I may add that the pictures which were reproduced were not those of a single experience, for I think the patient was given as many as half a dozen sessions at least, before plates were secured which were sufficiently good for reproduction. Needless to say, she was a FIG. 1. Fedor Krause (1857–1937). Courtesy National Library of most cooperative patient. Subsequently a Will-young coil was Medicine, Bethesda, MD. purchased which I think had a spark gap of 2 or 3 inches. With this coil and many bottles of rodinol (I do not know if rodinol dog or cat according to his method and believed it would be is anything more than a memory for a few grey beards in this possible in the near future to make x-ray pictures of large parts audience), I spent many weary hours for the next year or two of the human body. He said that he, however, did not have in an improvised dark room off from the old amphitheatre at time to continue his experiments in that direction but that he the Johns Hopkins Hospital developing roentgen-ray plates in would be willing to lend the help of his experience for any such which no one at the time took any very great interest. Certainly experiments made in medical institutions. Thus this memorable no one of us could have had any possible conception of the lecture was ended. For every member of the large audience the increasingly important role of Roentgen-ray was to play in occasion was unforgettable. (51)8 clinical diagnosis and treatment.9 The world was promptly seized with what can only Cushing published on the use of x-ray applications in 2 be described as x-ray pandemonium; scientists, photog- spine cases in 1898. raphers, and hucksters quickly obtained x-ray apparatus. While Cushing was writing letters home, Krause’s Within a few weeks of Röntgen’s Würzburg meeting, work on his use of x-rays for surgery (The Importance Krause, working as a surgeon in the municipal hospital of of Röntgen’s Photogram’s for Surgery) had already been Altona, Germany, acquired an x-ray apparatus and began published twice in German scientific medical journals in exploring its potential applications for surgical diagnosis. March 1896 (in Deutsche medizinische Wochenschrift He began to use x-rays in his daily interactions with pa- and Münchener medizinische Wochenschrift). These tients and quickly amassed a huge experience.22 publications are recorded in the seminal book by Glasser8 on Röntgen. Concurrently in their 1900 text, An Ameri- X-ray Implementation in Neurosurgery can Text-Book of Surgery for Practitioners and Students, Keen and White stated that their use of x-rays was limited On February 15, 1896, shortly after Röntgen’s report, to localization of foreign bodies and fractures in difficult Cushing wrote enthusiastically in a letter to his mother, cases. In a chapter, “The Use of the X or Röntgen Rays in “Everyone is very excited over the new photographic dis- Surgery”, Keen commented: covery. Professor Röntgen may have discovered some- The Roentgen method is, of course in its infancy. It has, thing with his cathode rays that may revolutionize medi- however, reached already a degree of usefulness that makes it 2 Neurosurg Focus / Volume 33 / August 2012 Unauthenticated | Downloaded 10/10/21 12:39 AM UTC Krause and x-rays in neurosurgery obvious that the necessary apparatus will be an essential part of the surgical outfit of all hospitals, and will be employed constantly in a variety of cases. Those to which the method can now be applied with advantage may be summarized as follows, emphasis being placed on the fact that what is written to-day may require revision or reversal tomorrow, so rapidly are improvements and discoveries taking place.