[HMD Lecture, LHC Auditorium, July 27, 2010]
[Dr. Elizabeth Fee:] This special lecture in
honor of James Cassidy,
I'd like to welcome Carol Clausen,
who has returned here and has been
responsible for the publication of Jim's book, "John Shaw Billings,
science and medicine in the Gilded Age."
So this is quite an accomplishment, Carol.
Now, before I introduce today's speaker,
I want to just make an announcement about the next.
We're calling it "A Summer of Seminars." Which is a series of talks by graduate
students in history of medicine. The first program is going to
be on August the 12th again, 2:00 to 3:30.
It'll be in the [NLM] visitor center. And Jameson Bell of the Pennsylvania
State University will speak on something relevant to today's,
“The Emblematic Brain in 16th Century Strasburg."
So everyone is welcome to come to that. Now.
Today's speaker is Doctor Eugene S. Flamm.
He's coming to us today in a dual capacity
as both a neurosurgeon and a bibliophile.
He received his undergraduate degree from Princeton University and his
MD from the University of Buffalo,
and one of his college mates is
right here to listen to his speech.
Doctor Flamm is now the Jeffrey P. Bergstein
Professor and Chairman of the Department of
Neurological Surgery at the Albert Einstein
College of Medicine in New York City. Now, in addition to his clinical work,
he has long been interested in the history and bibliography of medicine.
He has been a long time and distinguished book collector,
and he is currently the president of the
very prestigious Grolier Club in New York. And those of you who might not know about it,
it's a club for people interested in everything to do with the history
of the book and rare books. And it has a magnificent library
and they put on exhibitions, lectures and other activities. And a distinguished member
of that club is also with us. Bill Helfand,
who has been a great friend of the History of Medicine division
and a very generous donor. Thanks Bill.
So, Dr. Flamm is the current president of the Grolier Club.
He has published very widely in on early
classics in neurology and neurosurgery, as well of course as many scientific papers.
I think something over 200 publications. So with that,
please help me welcome Dr. Flamm.
[Applause]
[Dr. Flamm:] Thank you very much.
It's really a pleasure and a nostalgic thing to come back here.
Many years ago I was at NIH and when I wasn't experimenting with various
creatures, I would sneak over to the NLM and and actually wrote one of my
very first papers and certainly the first one on history of related to
the history of medicine. Right in the rare book section of the NLM.
In those days I would sign my name in a ledger and come back a week
later and sign my name under my name. That's how heavily used the place was.
No one had come in the interval. In any way, it was really a treat to spend the morning there,
and I get a chance to reacquaint myself with some of the treasures. I'm glad to see everyone here.
Particularly glad to see Dr. [Howard] Silby, my medical school roommate, so that at least someone will
appreciate the unkind words I have to say about neurology. Being a neurosurgeon, he's a neurologist,
so I'll say them specially for him.
The-- I have one disclaimer to make. I have no conflicts of interest here.
The disclaimers after hearing this lecture, you will not be qualified to
carry out neurosurgical procedures that you may learn about here. So don't run home and try them.
For many years I've been interested in the history of my specialty and have
coupled that with a active campaign to collect books in the same area.
So some of the books are from my own collection, others are images
I've borrowed from various places.
[Turns towards video screen]
[Changing slide]
I will explain as we go along the what the the dates or the significance of
those dates, and as a subtitle, the
period that I'll cover it between 1517 and 1857.
That 350 year period will try to demonstrate that there was a transition
from simply looking at signs to paying attention to symptoms of
patients would manifest particularly in the case of head injuries and
that would become the indication for neurosurgical intervention.
Well, everybody has seen these. I do not consider them neurosurgery, even though a couple of them
patients may have survived because there's evidence of new bone growth
around the these trephine skulls. The reasons for doing this is quite
speculative and I don't think anyone could really come up with
any other better explanation of it, but it's always a sort of an iconic
beginning for a talk on early neurosurgery. Certainly the Smith Papyrus,
which is at the New York Academy of Medicine is about the oldest known scientific document.
It's from 1700 BC and it's a fragment or a
large fragment of a compilation of cases. The part that remains deals
with injuries to the brain. And in this day and age where we're
particularly interested in outcome analysis and evidence based medicine, each case is described.
And then the recommendation to the surgeon at the time was to decide whether
this would be an ailment to treat, one with which he will contend and an ailment not to be treated.
I suspect they had the same malpractice issues that we have.
Neurosurgery got done in various positions. We've seen people kneeling down, people see that seated.
I've never tried doing it in the standing position, but going back into medieval manuscripts,
you do find a lot of representations. Whether this is an autopsy or someone actually doing surgery
isn't altogether clear, but we'll move on. For most people
somewhat familiar with neurosurgery. Harvey Cushing, of course, is the name that immediately
comes to mind. And I suspect that even many of my neurosurgical colleagues think that
he sort of invented neurosurgery, that it began with him. Well, he graduated from Yale in
1891 and from Hopkins and with his medical degree in 1895. And by the time he while he
was still in medical school, these advances in medicine
had all taken place. Anesthesia, asepsis, and cerebral localization.
Without which there wouldn't be such a thing as as neurosurgery as we understand it.
Furthermore, while he was still a student, or even before,
a number of publications highlighting what clearly is neurosurgical
activities had already been published to demonstrate that there really was a
field developing long before Cushing. This is an interesting book by Roberts,
published in Philadelphia in 1885, before Cushing was even an undergraduate on the
"Operative Surgery of the Human Brain." So that certainly qualifies by anyone's definition.
[Sir William] Macewen's famous monograph on brain abscess was published in 1893.
This is an earlier 1854 work on
diseases of the of the brain, and Paul Brokaw's son Auguste
Brokaw published an atlas and book on brain surgery
in 1896, just after Cushing graduated. [Antony] Chipault was another very
prolific French writer, published the first edited the first journal on neurosurgery.
Again, long before Cushing even knew anything about what his career would be.
He published a work on spinal cord surgery as well.
I'd like to move back a bit and now take you through what has interested
me in terms of the change in cerebral localization and the recognition
of the activity of the brain. And not just the ventricles, which is
where most activity seems to have started. There are any number of manuscripts
that have various types of drawings. This is one at the University of Pennsylvania
in [?Laurence Schaumburg's?] collection that
assigns various functions to the ventricles, and in all of them we find that
memory is in the posterior part of the head in the 4th ventricle,
and I suspect either it's the cause of or the derivation of our expression.
I have something in the back of my mind.
The first printed illustration of this ventricular system,
or cells as they were called. Again with assignation of function to these places
is in a work by Albertus Magnus. It's a work on Aristotle, his commentaries on it,
and the Aristotelian idea that that the intellectual capacities existed in the ventricles,
in the spinal fluid itself and not in the brain substance. It took about 150 years
to get rid of that idea, to start recognizing the importance of the brain issue itself.
And even we see this repeated in several editions here. Other people got into the act.
I mean, here's a drawing by Leonardo
and a woodcut by [?Aldrich Dura?]. Leonardo's work, of course,
didn't get published till the 18th century. Dura's was published again in A Tract on the Soul.
And here he's done a portrait of hisfriend [?Villabald Perkaima?] and
superimpose the ventricles on him. Sali, sorry--
Leonardo went on to develop a method rather than just drawing circles.
He poured molten wax into the ventricular system and made a cast of them,
and actually came up with a fairly good representation of what the ventricles
actually are shaped like. Here, still, almost contemporaneous with this,
we still have these cells in a later edition of Albertus Magnus,
even with a more humanistic face to go
with it rather than the early sketches. Other works [?Magnus Hunt?] the same sort of thing.
Gets a little monotonous, but we begin to see connections from the brain stem to the
various special of functions, special senses here, taste, hearing, sight, etcetera.
This is from an encyclopedia by Gregor Reisch
called Margarita philosophica. This is a curious work.
It's the first vernacular translation
of the 14th century anatomist Mondino [?de Luzzi?], and this is in French,
and it's one of the very few illustrations of the same brain system
with the mannequin or the cartoon with the face facing to the to the left.
Now, I don't know if that's has something to do with handedness of the artist or just what,
but most of them are always facing to the right. They're one or two that come up this way.
All of this came to a pretty good conclusion with a work by a man
named Eichmann known as Dreander, and this is published both in
1536 and again complete complete version of it in 1537. And what he did was this is the
first book on devoted solely to the anatomy of the brain,
and he followed the typical the description of how to dissect the brain,
starting at the top and making horizontal slices down.
His drawing for the ventricles is about the same, except it's quite an elegant
Renaissance portrait by now, rather than just a cartoon. Nevertheless,
here are the horizontal slices for the brain and we begin to see distinct
distinguishing between gray and white matter and the ventricular system.
Just to close this section, here is a very early drawing
from a manuscript of Avicenna, again showing connections and ventricles in the special senses.
And this is a drawing that I lifted from a recent paper
on speech and writing and cerebral localization. So I don't know how far we've
come in 700 years, but the the background for this is a
probably a little more sophisticated. Leonardo published, as you know many,
many drawings of the brain and other parts of the anatomy.
And this is one done about 1503 1504 with
showing planes with which to regard the
three-dimensional concept of the brain. And I thought, I couldn't resist the
similarity between one of our most contemporary functional MRI scans
here depicting the motor pathways displaced by this meningioma here.
This is a very recent MRI that we did
and again with these planar lines to
indicate the different planes of viewing it. Leonardo had it right,
he just didn't get it published in time. All right.
I mentioned that these two years, and I've picked them sort of arbitrarily,
but 350 seemed like a round number to compress the history of early neurosurgery into.
1515 is famous to a lot of people because Luther posts his 95 theses on the on the
Cathedral in in Wittenberg and Gersdorff publishes the first illustrated work
that shows actual surgical procedures. Now come back to him in a shortly,
those of you saw the poster. That illustration is from Gersdorff.
And the closing of this period that we're
covering in 1867 is the year that Lister published
his first papers on antisepsis. And I will conclude at the end of
the talk with the other event of neurosurgical interest in 1867. And it's Sir Jonathan Hutchinson's
description of compression of the third nerve in the dilatation of the pupil
that it resulted from that. Well, here's Luther and that's a copy of his 95 theses.
If I had more time, I'd read them to you, but we'll skip them for now.
This is a title page of the Gersdorff. It's got a number of surgical
misadventures and and procedures in it.
First illustration of an amputation with the patient actually getting some sort of an anaesthetic,
almost an inhalational and oral anaesthetic.
Treatment on the field here. Another type of treatment
taking a brain stone out. These are the figures that I'd like to deal with in the 16th century,
and I'll pause as we go along with each each one of them.
But just to give you an overview of it. Again, this is the title page of the Gersdorff.
In the second edition, he clearly switches to a neurosurgical theme.
In the second edition, 1526, it's a surgeon attending a man with a head injury here.
The printing in red and black accentuates the violence of the scene
and the blood coming out of the wound. This is the poster,
and that's the companion plate for it.
And it shows a neurosurgical procedure elevating this piece of depressed
fracture bone with this corkscrew device, which couldn't really work because it
would probably drive the bone into the brain. But anyway, we see that in many figures
over the over the next few centuries. The text simply describes how to put this on.
The significance for me has been that this portrait here has real neurological significance.
Not only does it show this instrument, but I showed this to a group of first
year residents last week and I said all you need to do is look at the patient
and you can make the diagnosis. The surge-- Gersdorff did not comment on it,
but the artist obviously saw that this patient had a facial palsy on this side,
a third nerve palsy here causing the eye to become disconjugant and move out.
And that would clearly make the diagnosis of a depressed fracture probably with
a hematoma here compressing the brain and causing herniation and brain stem
and 3rd nerve compression, a syndrome that we still see today and
most medical students would recognize it. But it took number of hundreds of
years before someone saw that the artist had clearly seen it in this case.
This is a copy of that and then the first English work on surgery,
the English translation of Brunschwig. Nevertheless, I use the Gersdorff plates and again
we we very faithfully reproduce the third nerve palsy in the contralateral facial weakness here,
but no comment about it.
A significant portion of this early history of neurosurgery involves the Medici,
and I thought I'd just take a little
diversion there and show you what has interested me.
This is Lorenzo de Medici, Duke of Urbino, who be, who was the head of the Medici
family for a brief period of time. And this is a portrait of the anatomist
and surgeon Berengario da Carpi. They came together, well,
Lorenzo ruled for a very short period of time.
He died at less than 30 years of age. He's buried in in the
Michelangelo's Medici Chapel. And we will hear a little bit more later
about his daughter Catherine de Medici. Although he seemed to have a very short period of time and
didn't really accomplish much as a leader of the Medici's
El Principe by Machiavelli is dedicated to him and Berengario da Carpi.
More to our interest today, wrote the book about his head injury.
His skull is still preserved and it shows an occipital fracture,
for which he underwent treatment and Berengario was called in as a consult.
And got into an argument with his then physicians and and tried to point out the way to manage this.
This is a portrait picture of the Michelangelo's sculpture for the tomb of Lorenzo.
So we've already heard from Leonardo, Durer, Michelangelo.
They never knew they were going to
figure into the history of neurosurgery. Berengario's work on head injury,
the 1st edition of it incorporates those same three circles for the cells and the second,
the later edition shows a composite trauma patient that some of us
have seen in the emergency room.
The instruments that he shows are really not so terribly different from what we
still have in an operating room today. A brace and a burr.
Of course we have a lot of power equipment now and digital images and things.
But basically when when all of that breaks down in the middle of the case,
you you ask for the brace in the burr and you make a burr-hole and get on with the case.
But this is sort of the first time that this kind of equipment was was illustrated.
Berengario also did another very interesting
thing in one of his anatomical texts. The other was on on head injury.
This is the abbreviated version of his commentary on Mondino.
This is the putatively the first illustrate-- printed illustration of
the brain from an actual dissection. The others were all schematic drawings
and this is pretty - pretty good considering this is 1523.
We certainly see the cerebral cortex. The ventricles are shown. Vermis here is not the cerebellum,
but refers to the to the corin plexus. We see the the shape of the ventricle
as Leonardo had demonstrated. With an occipital horn, temporal horn in the body here.
So for, --for what it is, I mean that's the earliest
brain illustration.
I said that we'd come back to the Medicis. This is Catherine de Medici and
this is the deathbed scene of [Henrici der?][King Henry II of France], the king of France.
He was in-- he sustained a head injury and it was a lance--
He was in a a joust in the last run of the day. The lance broke and a piece of it,
perforated his orbit and went into his brain, so they put him in bed.
He was conscious at this time and called in various consultations from
people they could get a hold of. Not only is his soon to be widow standing his bedside,
but his soon to be former mistress
Diane de Poitiers is also in attendance. Very forgiving environment there.
Called in consultation though, and this is of more interest to me
anyhow, are these two surgeons.
Andreas Vesalius and Ambrose Pare? Even though the French and
the Holy Roman Empire were not getting along so well,
when the news of Henry's injury came,
Vesalius was sent from the from that court to join Paris there.
Those are the two of them. This, of course, is the title
page of Vesalius's Fabrica. And this is the title page that the in
the case of [?ordinaire du?] generated for Paris
and became really the first modern or early modern book on head injuries,
a method of of treating curing wounds of the head.
Prior to this we only had commentaries on Hippocrates works, usually in Latin.
This is written in vernacular to be a benefit to surgeons who might need it.
And these two works really take us away from the medieval concepts of the brain
into the real stuff.
Here are the portraits that appear in these books of the Vesalius and
and Pare and his 45th year.
And here is one of the great illustrations
of the fabrica of the brain. And really this is as good if if you
take a photo, if you do this section and took a photograph of the brain, the head of the caudate,
the caudate plexus. I mean, it's really a wonderful accurate drawing of that. More famous
of course of the large full figure figures of muscle what are referred
to as "muscle men" in this work. So now we add to this illustrious group of artists,
we can add either Titian or someone from his school to Leonardo,
Durer and others.
This is a later work of Pare again showing that same version of that corkscrew
device so that he didn't get it all right. But he did recognize in the death of Henry the second,
the mechanism by which he died. And that was a subdural collection--
hematoma-- that occurred from the tearing of a vein going from the brain to the dura,
what we call a bridging vein. And that he describes that very accurately.
And that is still the understood mechanism of how one develops an acute subdural hematoma today.
And that was in 1559.
Just a little aside for my collecting interest here. This is a copy of the first vernacular
first French translation of Hippocrates work on the on head injuries.
And it's in a binding which has this motif on it and this is usually associated with the Diane de Poitiers.
These three interlocking crescents. Whether this was her book I don't know,
but it's a-- I think it's a good story. That she might have said to Pare.
This came out in 1555. Henry was not injured till 1559 and
Pare's book did not appear till 1561. So at the death of her lover, she
might have said to [?Cher en Boaz?], could you suggest something that I could read about [?Paul Veroni?] in
French and this was available so it is a plausible reason why she might
have had a medical book of this type. It was before Pare's book was published.
There are other things that developed in the in the latter part of the
16th century that are of interest. This is a flap book. It's a book on ophthalmology, but it has
this this illustration of the brain. And I've lifted up a couple of
the flaps here and you go through the dissection that I showed you in the [?] in a flat book.
Each one of these lifts up and you get a deeper layer of the brain.
This on a book in a book on ophthalmology, again in the vernacular in German.
So, we're beginning to see not only neurosurgical interest, but there's a book on plastic surgery
by [Gaspare] Tagliacozzi, and this book by[?Bartish?] on ophthalmology. Surgical
sub-specialties were beginning to emerge in the 16th century.
Coming back again to the Medicis,
a work by [Giovanni Andrea] Dalla Croce who was actually
the surgeon to Catherine de Medici. She of course was Italian but had
moved to France and Dalla Croce came from Venice and became her surgeon in residence.
And he published a work that shows all the surgical instruments. Again our friends,
the corkscrews here again with no comment. Hand drills that are still used.
What stands out for me in dalla Croce's books are these genre scenes
of neurosurgical activity. There's always someone boiling water just
like in the western go boil the water. Someone's boiling water here and someone who's busily drilling
[?] here at at somebody's home. This one of course has been used by
a lot of people for illustrations. Again, it shows the surgeon and unusual scrub suits here,
working way and the infectious disease committee busily taking
care of things down here. [cat captures a rat, faint laughter]
Such is life in the 16th century. These genre scenes appear more frequently.
This is a work by Pare's son-in-law,[?Guillemeau?]. And on this wonderful
engraved title page of 1594, one of these vignettes shows a
surgeon at work again in a--
a typical 16th century setting.
And in view of the fact that we heard about
the new book by [James] Cassedy on John Shaw Billings, I thought I would include this.
This is the English edition of Lanfranco [or Alanfrancus],
well known early 14th century French surgeon whose work finally got translated into English in 1565.
It's the first work that discusses, discusses and recognizes concussion
as a particular syndrome. And this copy, which I have, was given to Charles McBurney,
the McBurney's point, McBurney's incision for appendicitis-- surgeon
in New York by John Shaw Billings. Michael North asked me do you think he took it from the from the
New York public and gave it to to him? I said I don't want to go there. I don't want to give up the book.
We're going to move on to the 17th century here and I promise
I will stop at 1857.
And these are some of the figures that I would like to comment on.
I thought, this is telling. I had the privilege of being
at the Folger Library yesterday. In Lear, he calls out,
"Let me have a surgeon; I am cut to the brains," and for my neurology colleague and friend.
I would point out that even then Shakespeare had enough sense to call for a surgeon and not a neurologist
if he had a brain injury.
This was the old Hippocratic way of dealing with head injuries, That is.
One looked at the skull and decided, based on how the fracture appeared,
whether intervention was needed. Where there's a contusion of the bone, a linear fracture,
depressed fracture and and various other things had nothing to do with how the patient was doing.
And that's what I meant from signs, simply a surgeon looking at the head
would decide whether to operate or not, rather than paying any attention to symptoms
that the patient might be experiencing.
What led to this transition was a much greater understanding of how the brain
functioned, how it misfunctioned, or, or what what happened when it was injured.
Thomas Willis went a long way to ensuring this by in his work,
Cerebri Anatome made it very clear that function was no longer to be thought
of in the ventricles in that fluid. Others had suggested that, but Willis was unequivocal about
the fact that the brain function was in the brain substance itself.
The mechanism wasn't exactly what we would accept today,
but in any event he shifted the attention to the brain and was ably,
ably assisted by Christopher Wren, in this very famous illustration [Cerebri anatome']
of the base of the brain showing the [?] circle of Willis, the anastomosis of vessels at
the base of the brain. Around this same period. A couple of years later,
we have the first work devoted to the anatomy of the spinal cord
by Blasius in Amsterdam, and pretty good rendering of gray and white
matter and long tracks in the spinal cord. The relationship of the dura and the
nerve roots and the ganglia there. So this idea of an anatomy and
eventually a physiology underlying the brain function got it out of the
hands of the philosophers and into the natural scientist of that period.
Wonderful work in the latter part of the
17th century by Vieussens, improved on Willis. He's not as well known,
but they're these wonderful illustrations, and he developed a technique of
scraping through the white matter to delineate the pathways in the white matter and therefore could
trace them and begin to make some anatomical sense to the function.
Contralateral injury because of the decasation. This flying brain I like very much.
A little extra [?] here.
Relatively obscure surgical work by Dutch--
[Audio drop-out]
It's the first illustration of showing why we see one with two eyes, the decussation of the
fibers in the optic chiasm, crossing and giving a single image, or what the brain interprets as
a single image. This in 1685.
In the 17th century as well, we begin to see description of specific
diseases that again carried with it the idea of getting away from just looking
at the head injury or looking at the at the patient and interpreting
the symptoms that they might have.
Of course, everything was influenced
by [William] Harvey and the idea of circulation.
And that became the most outstanding
event of developing a concept of physiology. First in the heart and then eventually in the brain.
Descartes tried it in the brain and likened it to a much more mechanical, a [yatromechanical] concept
of how the brain function. But it was still be the beginning
of thinking about these things. This is a the famous Rembrandt
of Dr. [Nicolaes] Tulp. Dr. Tulp is famous for to many people because he featured in this portrait.
To some of us he's famous because he published this illustration of spina bifida
in an infant and actually discusses the the consequences of such a
birth defect in one of his works.
A Swiss physician in Schaffhausen
named [Johann Jakob] Wepfer [?],
change the idea of what we know about hemorrhage in the brain.
When someone would fall down unconscious, they would refer to as apoplexy,
and no one had a good idea of that. But in the mid 17th century, he recognized the association.
This is the carotid artery as it enters the head and goes through the cavernous sinus.
He recognized that disease in those arteries was associated with a hemorrhage and the apoplexy,
and that this was the cause. The hemorrhage in the brain was what caused people to fall
unconscious and having a stroke. So it begins here in the 17th century.
Oh, our recurrent theme of this man. You could argue this pupils a little larger than that,
but I won't stress the point. This is another anatomy work. Again, a commentary on Hippocrates in
the 17th century and using this famous illustration for it.
A lot of advances in all surgery and particularly in neurosurgery were
as a result of military activity. I just want to mention a few
things about several naval surgeons in this case in England. This is a man named [John] Woodall who was
the surgeon to the East India Company and required was required that all
surgeons on his on the ships of the East India Trading Company have a copy
of his surgical manual. On how to ensure the need for multiple additions.
In any event, he developed this and comments on this single trephine that could be used
with one hand and he describes the importance of this on a rolling ship.
It enabled the surgeon to hold the patient's head with one hand and drill with the other.
All the other drills required two hands.
Of interest to me as a someone who
runs a training program in neurosurgery, this was the advice that he gave.
"I therefore would advise a young Artist" - meaning a surgeon, "to make some
experience first upon a calves head, or a sheep's head till he can well
and easily take out a piece of bone; so shall he the more safely
do it to a man without error, when occasion is."
Clearly he was not an English major, but he I think this is the beginning
of training programs in neurosurgery. Practice before you go in the lab, go in the laboratory,
and practice how to do this before you do it.
Other elaborate instruments became more elaborate, but the principles really was still lacking.
That is, Hippocrates still reigned, and the idea of when to
operate was not at all clear. This is the first English depiction
of what one of these surgical genre scenes. The instrument is bigger than the patient's head.
I don't quite know the scale of that, but it's an interesting work.
Another instrument maker man named Zolingen designed his own instruments.
These are some of them-- a little ahead of myself. I'll come back to him.
Another navel surgeon, James Yonge,
begins to get it right. All the books I've shown you thus far talk
about head injuries or injuries to the skull,
to the to the calvarium, to the head. This is the first time we
see wounds of the brain. And that's a big distinction that gets us beyond the signs,
just simply looking at the skull and deciding it to begin to talk about the brain.
Now he brags that he cured this kid who was injured by a swinging gait that hit him in the head,
and he took care of him and the child survived and recovered. Oddly and if I'd show you the picture,
but the picture in the book is that of the gate, not of the patient. I don't quite? [Gasps]
I never understood that. All right, in the 18th century, then, this idea of more attention to
the brain and the idea of the development of symptoms on the part
of the patient comes to fruition.
Purmann, this is [Cornelis] Solingen, a Dutch surgeon who developed a
whole line of instruments published in latter part of the 17th century. These instruments,
his actual instruments, are on on display at the at the
Boerhaave Museum in Leiden, and they were used in the English translation of a German surgeon's work.
[Matthaus Gottfried] Purmann's work here, in in 1706.
And I would like to quote a relatively long
passage to you from this very work in 1706. Purmann describes taking care
of a man who was injured by a sword that had struck him in the head and cut through the brain,
cut through the skull and into the brain. "In the first ten days everything
seemed very forward, towards a safe and sudden cure.
The pulsation of the Dura [Mater]"
because the bone was exposed, "was a very regular and the wound was quite closed.
All the ill symptoms except head-ach vanished. And yet on the 11th day violent
pulsation of the dura returned, and the patient became senseless and speechless." And low and behold,
he's paying attention to the patient. "Upon which I concluded there was some matter." Which means pus.
"Gathering under the membrane the dura which caused this relapse. Whereupon I made a new incision
with good success. For it let out an abundance of corruption. And in less than an hour's time,
all of the ill symptoms vanished again." -- I mean, this is heroic.
I mean at this time when everyone had no idea of what one operated on for
and would drill a hole in the head, whether it be based on the injury.
This surgeon recognized the change in the patient's condition as an
indication for surgical intervention. And that's sort of the theme I'm
trying to demonstrate here today because for me that is a very critical step in the development
of the ideas of neurosurgery. That's what it's based on today, and it certainly took place
long before our most recent advances
by Cushing and his followers.
It's a manuscript of the lecture notes of lectures given by the
the very prominent French surgeon in the 17th in the 18th century, Jean-Louis Petit. And in it,
he points out that there was a difference between someone losing consciousness when
hit on the head and someone who might have regained consciousness and then lost
consciousness a second time, later on. And that today is still taught to our
medical students as a 'lucid interval', and it's the time that it takes for a clot to form.
The first blow to the head renders a patient unconscious. That's a concussion.
If a blood clot then forms over the next hour or many hours,
the patient may regain consciousness from the concussion, only to lose it again as the
blood clot presses on the brain. And that theme was picked up by a number
of surgeons in France at the time.
Garengeot again in these elegant clothing,
here drilling, drilling away.
And most especially by Le Dran, who was a student of Petit and published
long before Petit's works actually went into print. This idea
of the lucid interval. And he says-- "that the the first symptoms which
appear after a violent blow to the head, are the effects of the concussion
of the brain and do not proceed from a fracture of the skull. Whereas those which do not appear
till some hours or days after the accident are produced by the extravasation between the dura matter
and the fractured cranium, or by an extravasation in the brain." --Now this is 1731.
One could stop here and say we had it all correct and needn't go on,
but it takes a couple of odd turns.
His works were widely disseminated. It was translated into English.
It appears in these English editions demonstrating a woodpecker procedure here.
Multiple holes trying to find where to go and finally, the great
English surgeon of that period, Percivall Pott gets involved
in managing of head injuries. He was the leading surgeon in London
for about 50 years at Bart's [St Bartholomew's Hospital] and picked up on head injury.
He's remembered today for Pott's puffy tumor of the skull, Pott's fracture, Pott's disease,
tuberculosis of the spine. These are the two editions of his work on head injury. The same work,
but they changed the title page and then the title.
And again he 250 years after, Gersdorff picked up on the same illustration
again without commenting on the findings in that early illustration.
But what Pott did was he outlined
3 reasons why a surgeon should intercede after head injury. "The immediate relief of symptoms
present arising from the pressure of extravasated fluid." No argument with that's a good idea.
"The discharge of matter" --pus "formed between the skull and dura matter in
consequence of inflammation." Concept predates infectious disease and bacteria.
Inflammation was the cause of infection. And this is where he really went
astray and led a lot of people astray. He argued that since this worked,
if you did it ahead of time, you could prevent it from happening. And what happened,
what ended up happening was that they would, they would operate, the wound would get infected,
and then they really had problems that might not have needed surgery to begin with.
And this is where it took another 50 years to get away from that.
This is Pott's tuberculus, lesion of the of the spine.
That's known as Pott's disease. In the early part of the 19th century
Potts wrote that in 1768.
By the first part of the 19th century,
Benjamin Bell, a very respected Scottish surgeon working both in
Edinburgh and sometimes in London, published a huge work multi-volume work on surgery,
but talks about here of affections of the brain from external violence.
So the idea that the brain had something to do with all of this was catching on.
And he describes the usual symptoms here, most frequent after head injury.
Giddiness, dimness of sight, a loss of voluntary motion, vomiting, etcetera,
and a dilated pupils state of the pupils. So maybe someone's beginning to
pay attention to examining the patient and seeing that the pupils change when there's a head injury.
But he goes on. "For although I am clearly of the opinion that the trepan should
be applied with freedom, whenever there it is indicated by symptoms of a compressed brain,
and where these symptoms must in all probability prove fatal, if the cause which produce them
is not soon removed. Yet I'm equally satisfied that it is the presence of such symptoms only."
--remember symptoms, not signs. "Which can warrant this operation,
and that it should never be employed, as it too frequently has been
merely with a view to prevent them." So this is a complete turn around
a refutation of Pott as to what surgical indications for this are.
It persisted though John Jones, who was a an American surgeon
trained with Pott and came back and published a work that became the
handbook for the surgeons in the revolutionary in the Continental Army. It was the surgical handbook.
Every surgeon in the in the in Washington's Army had a copy of it and he subscribe to Potts idea
that you should trephin to prevent this from happening. I guess trephining had a long tradition.
This is a portrait of a physician named [John] Clarke. It hangs in the Countway Library
and Dick Wolf once told me that it's the first portrait of an American-- North American physician.
And it's a 17th century portrait. And lo and behold, what is he doing?
He's drilling a hole in the skull. So this is the first American neurosurgeon
I guess. My patients look better than that though. In any event, this is the two editions,
one in New York and one in Philadelphia, came out the same year of Jones's book. And I mean,
it's a real landmark of American surgery and it, it covers all sorts of surgical things,
but there's a section on the management of head injury and that's why I included it here.
And finally the, most one of the most famous early 19th century London surgeons,
Sir Charles Bell. Fortunately, he didn't operate a lot himself, but he wrote a lot.
But this sort of summarizes, "the injury to the bone is of itself nothing.
Therefore all the threatening symptoms are derived from the brain
and the constitution of the brain, as explaining these symptoms,
must be the first study of," [Dr. Silby] the surgeon,
not the neurologist. I'm glad you came. I wouldn't have known how to get through that slide.
It leads up to this whiskered man,
Sir Jonathan Hutchinson.
In a series of papers, 4 Lectures
'On the Compression of the Brain.' He takes us that one step farther
to explaining that illustration I showed you from 1517.
He autopsied several patients who
succumbed to a head injury in 1867,
350 years later, and they had a blood clot-- "from the position of the clot
there can be no little doubt that the third nerve is compressed, and thus the dilatation of
the pupil is explained. These two cases,
so exactly parallel, seem to supply us with a new and very valuable symptom indicative of a
fusion of the blood in this situation." So it took 350 years from the artists
seeing [?Hans Wechlin?] was the artist seeing a third nerve
from compression of the brain to Jonathan Hutchinson describing the pathophysiology of it.
And it remains a very important diagnostic sign in the management of patients with neurosurgical
and neurological disorders today. Modestly he goes on.
"Nor can we boast of having learnt much which may aid us in the
diagnosis of future cases with the one exception of having discovered the meaning of the one dilated pupil.
This point we will store up carefully for future use." And I think that, that I particularly
like the wording of that. I think it it represents the continuum
of surgical history that goes on today and the idea of recording your cases,
reporting it and who knows when someone might actually read it. In closing,
I would just leave you with these advice of Percivall Pott,
one of my surgical historical heroes. "Many and great are the improvements
which the chirurgic art has received within these last 50 years; and much thanks are due to those
who have contributed to them; but when we reflect on how much still remains to be done,
it should excite our industry rather than inflame our vanity." --Thank you very much.
[Applause]
[Wide shot of audience]
[Dr. Elizabeth Fee:] Thank you for a very fascinating presentation. I'd like to welcome
those of you who would like to ask
Dr. Flamm a question, make a comment. Yes, if you can exactly use your
mic so that we can all hear. Thank you.
[Audience:] Thank you. Well, I certainly enjoyed this presentation.
It was phenomenal. Thanks so much for doing so. I'm honored to be here.
I want to comment on your very first slide which was trephining operations
on old skulls probably from the 15th century or before. In the Museum
of Comparative Anatomy at Harvard there are skulls like that with as many as nine such trephinings.
Eight of which are recovered or healed. And the Inca used to fight
with hammers that would pierce the skull very sharp pointed hammers. And the Inca surgeons,
learned to use these very, very very sharp copper knives to do
beautiful trephining operations that often help the patient many times.
So I wouldn't dismiss it so quickly. [Laughter]
[Dr. Flamm:] I mean I-- I'm aware that patients survived this.
What I don't know, and I don't think anyone knows why they underwent these procedures?
Whether it was for medical reasons, religious reasons or? [Audience:] Well, the way it's explained to me
is that it actually released the, the blood that was, you know, forming under there because
of the hammer blow. Perhaps these weren't just regular hammers, these are sharp,
pointed hammers that just pierced the skull.
[Dr. Elizabeth Fee:] I was wondering
if we have any sense of how often these kinds of surgeries were
done and if it varied over time? You have such a wealth of sources
that one gets the impression that this sort of thing happened frequently. [Dr. Flamm:] Well, I think it did.
I mean between the many, many hand to hand battles that were going
on in warfare was really 'mano a mano' and I think there were a lot of injuries then.
Then nobleman did not go off to fight without
having their own personal surgeon with them. And I think even in street warfare,
I mean people carried swords, carried weapons and I think it was quite, quite common.
I mean if you read through in any country, France, Germany, England, everybody always,
even if it's a general work, there's always a section on managing this.
So it occupied people's, it captured people's attention I think. Howard.
[Muffled speech]
[Turning microphone on]
[Howard:] That work? I'm a neurologist. [Dr. Flamm:] This technical stuff is tough for a neurologist. Yeah.
[Microphone turned off again]
[Howard:] Oh, OK. I'm a really dumb neurologist. All of this is obviously based
on public published data. Is there any pre written published data,
cave drawings whatever, going way back that shows any history of neurology or neurosurgery?
[Dr. Flamm:] Well, I mean we were just talking about these skulls. I mean those are those are you know very,
very early, second millennium. There are there are some examples of that. Again what they were done
for isn't always clear. There's manuscript material long before
printing to describe surgical procedures. But that I guess the earliest of
that is probably 14th century. Mondino's Anatomy is 1315 when it first appears and so before that
I-- it isn't clear you do have Hippocrates writing [?]
[?] capitis on wounds of the head. So in the Hippocratic writing, which is 400 BC,
there there's a specific work devoted to head injuries. There's also one on epilepsy as well.
Bill.
[Bill:] You said that Pott made this
discovery after seeing two patients. Is this a common thing for neurosurgeons to make a judgement
of what happens when seeing so few?[Dr. Flamm:] Jonathan Hutchinson's.
[Bill:] Excuse me,
[Dr. Flamm:] Well, today, no, because you have to have a randomized clinical trial.
Just remember that penicillin was accepted after 9 cases because
of its its incredible efficacy. No one no one no one put it through a
multi centered randomized clinical trial
and we all subscribe to penicillin very well. So evidence based medicine has its
place but sometimes a good idea doesn't hurt. This were-- these were
four lectures he gave and he you know came to the conclusion based on autopsy.
This was a surgical experience. These were patients who died. He autopsied them and said, this is
why they died and and then wrote the paper and it seems to have been
substantiated over the years for many, many other people. But no, I mean most people don't go off and
start operating based on an experience of one. An N of one is kind of small.
[Dr. Elizabeth Fee:] Comments? Yes. [Audience:] Well, I'm I'm curious about the
fact that you have 3 1/2 centuries of a picture of this corkscrew that you think wouldn't work.
How in the world could they continue to show that as an operative device if it didn't work?
Isn't it possible to consider that it may have? [Dr. Flamm:] Oh it could pull the bone out,
but it the point I was making that no one ever commented on the fact that the third nerve palsy,
the dilated pupil in the paralyzed eye and face, was there. You could conceive of using it.
It just it. It's not a great design for an instrument but it if you attached it to the
bone and then use it like a corkscrew it it a screw pull it it would work
I guess. It's they're just better ways of doing it than that. I skipped over a slide that
showed an instrument that was better suited for doing that.
[off mic audio] [Dr. Elizabeth Fee:] I had a question about some of the earlier scenes in the operating
room or the bedroom wherever. And there seems to be a a crowd of
people around and there's cats or dogs or various animals and even small children.
And I'm sort of wondering about the sort of the socialization in the middle
of surgery that seems to be going on and what did do we know anything about why the kids were there?
[Dr. Flamm:] Well, I sometimes refer to my residence as my kids. So there they are.
We we've limit we we do draw the line with cats and dogs and rats and things in the O R.
There's always a there's still a crowd in there. I think because it was done in a
domestic setting. You know, met probably there weren't 20 other rooms to send anyone to.
There was a one room dwelling or it was just where the activity was. And I don't think it it didn't
have the kind of cachet that it was something very special that had to be done in a theater.
It was done at home, wherever the patient was. I-- I don't really know the answer to that.
[Dr. Elizabeth Fee:] But weren't these brain surgeries incredibly painful? I mean.
[Dr. Flamm:] no, no, no, no, no, not at all.
No, no, no, you wouldn't. If you were still screaming, you wouldn't need it. I mean,
these people were unconscious. That's how we got away with it. Furthermore, furthermore, I mean,
I don't know how many people here have any background in the brain, but it's the brain itself
is insensitive to pain. That is, we can operate if we anesthetize the skin with a local injection,
we can actually do procedures and stimulation of the brain without any pain
from the from the brain substance itself. So I get asked that question very often,
but I think the real answer is that yeah, they're in coma if they're unconscious
and you can drill away. --Yes, Milton...
[Dr. Milton Corn:] Two questions that possibly related. One of them was the the account of releasing the corruption and
I wondered if that they had that same attitude that about corruption in the brain as elsewhere.
I mean was it laudable pus and so on and-- and the related question
is why was somebody boiling water? [Laughter]
Boiling water? I mean what what?
[Dr. Flamm:] I'll go back to the first question. It's easier.
I don't know. The pus became less
laudable by the 18th century. It was not looked at as a complication and
that the wound had gotten infected. It was just, I mean, that really persisted until Pasteur and
then Lister in the 19th century began to pay attention to what to bacteriology.
I've mean prior to that it was part of the inflammatory process and was part of the healing process.
But I don't think anyone, I think, gradually said, well, it isn't so laudable. I don't.
I don't know why there's a brazier there with coals and somebody's fanning it,
but there it is. It was a cheap stunt on my part. I thought I could get away with it.
[Faint audio]
[Dr. Elizabeth Fee:] Are there other questions, comments? No. In that case, thank you so much.
--Thank you very much. Great pleasure. Great pleasure. Thank you!
[Applause]
[The End]