Heraclitus

pro-vides the first evidence of brain injury. At that time, the human’s predecessor was a semierect hominid now named Australopithecus africanus. A damaged skull from this species found in South Africa revealed two posterior fractures close together that fit the condyles of an antelope humerus discovered nearby, which was therefore presumed to be the instrument used for the clubbing to death from behind.¹⁰

Such fractured skulls have been found in later hominids who walked more erectly (Homo erectus), such as Java man (more than 300,000 years ago), Peking man (more than 100,000 years ago), and Neanderthal man (more than 40,000 years ago).

“The literature of trepanation is large, well over 1000 references.”²⁴ “Not all holes in skulls were made by human hands and these have been grouped as pseudo-trephination. The earliest known trephined skulls date from 10,000 bc and were found in North Africa. A distinction is made between the trephined skulls found in Europe which date from about 3000 bc, and those found in South America which are from the two millennia between 500 bc and 1500 ad.”^24a

Brain injuries had a reputation for being fatal, and Younge²⁷ in 1682 “reviewed the entire medi-cal literature back to Galen—more than 1,500 years—and was able to find reports of only a hun-dred individuals who survived a brain wound.” In the nineteenth century, this view was challenged because of the findings of skulls on which surgery had been performed.^24b

Trepanation

There is often confusion between trepanation and trephination, as the two terms have been used in-terchangeably. The word trepanation is derived from the Greek trypanon, meaning a borer, and this is the operation done in neolithic times, where the head was kept still by “a frame or brace similar to, and used in the manner of, the car-penter’s wimple” (p. 11).²⁵ Trephination “implies using a cutting instrument rotating around a cen-tre.”²⁵ The term is of more recent French origin, but both terms imply more than making a depres-sion or perforation of the calvarium since they

entail removing a piece of bone with a saw-like instrument.²²

When the ancient Greeks performed trepana-tion, they used either an instrument called a terebra, a drill that was rotated using a strap around its center, or a trepanon, which was operated by a bow. A third instrument was a serrata terebra, a cone-shaped piece of metal with a circular edge at the bottom that was serrated and kept in place by a central pin. That pin was removed after the drill, rotated by rolling its large handle by hand or with a bow, had made an initial hole. Hippocrates de-scribed the trepan, which was used for contusions, fissure fractures, and indentations of the skull, but rarely for depressed fractures.²⁶ Celsus disagreed, advising trepanation for depressed fractures.

Heliodorus (c. 100 a.d.), in recommending trepa-nation near a fracture site, advised cooling the in-strument by dropping water onto the wound.

The New World

The first illustration of a trepanned skull was in 1839 in an anthropological atlas by S.G. Morton of the United States. However, he did not recognize the results of trepanation, thinking that the hole in the skull was due to an injury from a blunt instru-ment, probably the back of a war axe. The first per-forated skull to be recognized as the result of surgery was revealed by Ephraim George Squires, who was the U.S. Commissioner to Peru and, according to Broca, the “foremost archaeologist in American In-dian matters.”⁶ Squires left Peru in 1865, and in the following year this skull was demonstrated to the New York Academy of Medicine, where it can now be found, as a “supposed case of trephining [sic] of the calvarium of one of the tribes of South America.”

Squires noted that the skull had a quadrilateral trepa-nation: “the most notable proof of surgical knowledge among the natives that has been discovered in this context, as trepanation is one of the most difficult of surgical procedures. . . .” He took the skull to Paris for a second opinion, and Broca showed it to both the Société d’Anthropologie and the Académie de Médicine in 1867.⁶

Broca was confident that since the outline of the hole was regular, it was not due to trauma but was surgical in origin. Furthermore, there were signs of postoperative inflammation indicating survival (he estimated from 7 to 8 days). A square of bone

15 × 17 mm had been removed, and the outline differed from the oval and serrated one of later Greek times. Since there was no evidence of trauma he concluded that trepanation had been performed

“to evacuate an epidural hematoma.”

Broca became fascinated by this procedure and, using pieces of cut silex, made a perforation in the skull of a dog in just over 8 minutes. Using a piece of glass, he did the same in an adult human in about 1 hour, but took only 4 minutes using the skull of a 2-year-old child. In 1888 Broca discussed a dozen skulls with man-made perforations that were oval in shape, the long axis being in the anteroposterior plane and mostly in the parietal area and found twice as often on the left as on the right.

Since the 1860s, many such skulls have been dis-covered, particularly in Peru, where they range in date from 3000 years ago to the immediate pre-Columbian Inca civilization based in Cuzco less than 1000 years ago. At this site, nearly half of the skulls found have man-made openings, whereas in other areas of Peru, such as south of Lima among the Paracas Indians, the frequency is just over 5%.

These latter skulls were found in burial caverns of sandy beaches and were excavated in the 1920s. The perforations were made using metallic instruments of bronze or copper called tumi, and since the vast majority of patients survived, it is likely that the operation was stopped when the dura was reached.

The indications for the operation are uncertain, but initially Broca thought it was performed for ritualistic rather than therapeutic purposes. Al-though the skulls came from humans of all ages, there were four times as many men as women, so that it is likely that the operation was performed in cases of depressed fracture due to trauma.

Albucasis (936–1013 a.d.) copied the trepanation techniques of Paulus Aeginata by using a drill that would not penetrate the brain. He described the operation as follows: “you cut through the bone in the confident knowledge that nothing inward can happen to the membrane even though the opera-tor be the most ignorant and cowardly of men; yes even if he be sleepy,” but if the dura turned black,

“you may know that he is doomed” (p. 420).¹⁴ It is unknown whether patients were anesthetized or comatose at the time of the operation or, more remotely possible, conditioned to withstand great pain. Possible anesthetics would have been cocoa leaves and alcohol, prepared as chicha (fermented maize). In addition, such locally acting drugs from

The History of Cerebral Trauma 21 the belladonna family as scopolamine, hyoscyamic

acid, and atropine were probably applied to the head.

Infection may have been prevented by the use of mercury salts, arsenic, copper sulfate, or cinnamic-acid-rich substances, whereas bleeding was stopped by tannic acid found in Pumaca, a common plant in the Peruvian Andes. Scalp wounds were approxi-mated by tying groups of hair or cotton sutures, and examples have been found of the head bandaged with cloth.

Europe

Although trepanned skulls in South America date back to 5000 years ago, in Europe they are at least 10,000 years old, from the Paleolithic period, as dated by the objects found with them. The first such skull was discovered in France as early as 1685 a.d., but its significance was not appreci-ated until 1816 a.d., when the next such skull was found in the same country; however, its advanced age was not recognized.¹⁴

On May 21, 1868, Louis Lartet read a paper to the Societe d’Anthropologie on Troglodytes in the Perigord (“Skulls of Les Eyzies”). The skulls were found at Cro-Magnon, near the railroad station of the borough of Les Eyzies, where widening of the railway tracks revealed the caves containing the skulls. One of the most complete skeletons was that of a woman, aged about 35 years, whose skull had a left frontal perforation measuring 33 × 12 mm. She survived the injury, which was thought to have been due to a blow with a flint axe, since there were signs of formation of new bone. These Cro-Magnon finds were the first and best-described prototype of Homo sapiens from the Paleolithic period (from about 350,000 to 100,000 years ago).

Five years later, Prunières, a consultant physi-cian, was the first to suggest that the holes in the skulls found in a prehistoric burial grave near Lazère were man-made,²⁵ and in the following years, skulls with scalloped edges were excavated in central France. These skulls were from the Neo-lithic period; some were healed and others un-healed. Some of the holes were made postmortem, presumably for the making of religious amulets.

Since then, such skulls have been found in many European countries and share common character-istics. Varying in size from a few centimeters to 13 × 10 cm (i.e., half of the skull), the holes are

mostly located in the parietal region; although oc-cipital and frontal holes are also seen, they are rare in the temporal region. These operations were done with polished stones and were grouped “over the motor and epileptogenic region of the surface of the brain.”¹⁸ Horsley argued that trephination would have been performed over the motor cor-tex, but probably not for Jacksonian epilepsy, and that it could cure convulsions and perhaps some other conditions, such as a depressed fracture.

The Broca Museum of Anthropology in Paris contains 60 specimens of perforated skulls, 10 of which are fairly complete, yet the number in the rest of Europe “could be counted on the fingers.”^24a

Asia

Victor Horsley¹⁸ raised the question of whether trepanation originated in Asia. Certainly, the opera-tion was not universally popular. For example, a Chinese surgeon, Hua To (190–265 a.d.), recom-mended trepanation for the headaches of his prince, who rewarded his medical advisor by executing him.

In the twentieth century, primitive societies performed the operation for insanity, epilepsy, and headaches and to “let the devils out.” South Sea islanders have treated headaches and dizzy spells by scraping the cranium down to the dura.

Ancient Egypt

In the Edwin Smith Papyrus,* there is no mention of the trepan. Although it has been claimed that the ancient Egyptians did not perform trepanation,¹¹

*Edwin Smith (1822–1906) was an American Egyptologist who settled in Luxor in 1858. Four years later, he was ap-proached by an Egyptian merchant who had a papyrus that he had found in a tomb and wished to sell. Although Edwin Smith recognized its medical content, he noted that the out-side of the roll was tattered, as if some layers had been stripped off. He declared his interest, and a few months later the same vendor came with another roll, the outside layers of which had come from the first roll and had been pasted around a dummy;

these fragments contained a discussion of the heart and its vessels. Edwin Smith eventually obtained eight fragments, which are now known by his name. Although he put five to-gether approximately, Breasted was asked in 1920 to translate the whole text, which he published 10 years later.

The Edwin Smith Papyrus dates from the time when the pyramids “were being built—3000–2500 b.c.—and could even

recent evidence suggests that they did.²¹ The first written evidence of brain injuries about 5000 years ago is to be found in the Egyptian papyri.

Of all the Egyptian papyri, seven are of medical interest—those of Edwin Smith, Ebers, Hearst, Berlin 3038, London, Carlsberg VIII, and Chester Beatty VI. Only the Edwin Smith Surgical Papy-rus, which antedates by several centuries the Ebers Papyrus, makes a significant contribution to the history of treatment of brain injuries. Because the causes of injuries are self-evident, the descriptions are accurate, in contrast to those of the later Ebers Papyrus, which was concerned mainly with medi-cal disorders for which the causes were unknown and were considered to be due to visitations from the gods and treated irrationally. It is to Breasted⁵ that we owe a debt for his decade of work translat-ing the Edwin Smith Papyrus. Not a physician, he could not recognize its importance for neurology, but he did realize “the treatise to be unique by way of content, philosophy and form.”⁷

The Edwin Smith Papyrus contains the first written records of head injuries, of which there were 27. However, only 13 of these case histories concern skull fractures with neurological features, the others being soft tissue injuries only. The prog-nosis is divided into three categories: Verdict I, “an ailment which I will treat”; Verdict II, “an ailment with which I will contend”; and Verdict III, “an ailment not to be treated.” The approach to inju-ries is anatomical from above downward, and the case reports are systematized into these sections:

Title, Examination, Diagnosis, Treatment, and Definitions of Terms Used. Skull fractures are di-vided into: (1) splits (i.e., fissures), (2) smashes (i.e., comminuted), (3) compound comminuted, and (4) comminuted and depressed. There are also cases of fractures of the skull base, as evi-denced by bleeding from one or both ears.

Observation and palpation are emphasized.

Head posture is important, as is skin color. With

palpation, the patient’s brain may be felt to be

“throbbing [and] fluttering like the weak place of an infant’s crown before it becomes whole”

(Case 6), and the physician can feel and count the pulse of the head, neck and extremities.¹⁷ (Al-though this is the first note of pulse counting, the first done with a time measure was by Herophilus [c. 330–260 b.c.].⁵) The physician also elicits signs by asking the patient to rotate the neck and move the limbs. Speechlessness is an ominous sign.

Case 6 describes a gaping head wound with a comminuted fracture and rupture of the meningeal membranes that reveals the brain surface, which is compared to the surface of cooling molten cop-per. This was the first time that words meaning brain, meninges, and cerebrospinal fluid were used.⁵ The commentator compares what he sees with what is familiar; not only is the brain surface compared to molten slag, but a fractured skull is likened to a broken pottery jar and the mandibular ramus to a two-toed bird. In addition, this Papyrus provides the first mention of the cranial sutures, “which the ancient Arabs believed were the patient’s destiny written by the hands of Allah” (p. 276).¹²

Case 8 is also a comminuted fracture, but with-out any visible external injury. The patient had a

“smash in his skull under the skin of his head, there being no wound upon it.” The statement, “his eye on that side was askew,” suggests an ipsilateral ocu-lar palsy possibly due to an orbital fracture, rather than the facial palsy suggested by Elsberg.¹² There was also an ipsilateral hemiparesis, as evidenced by

“shuffling with his feet . . . walking with his sole drag-ging”; “the presence of nails in the middle of his palm” suggests contractures, and the ipsilateral pa-ralysis suggests a contrecoup injury. Several days after a head injury, the patient was “unable to look at his shoulders and his breast”—a clear reference to the nuchal rigidity of meningeal irritation. Other cases of neck stiffness are due to tetanus⁶ or injured cervical muscles or vertebrae. The Papyrus also in-cludes the first written description of tetanus: the patient had a drooping head posture, weeping facies with drawn eyebrows, thick saliva, a tightly closed mouth, and clammy skin; symptomatic treatment was heat to the clamped jaw “until [the patient] is comfortable.”

Case 20, of a temporal wound with a speech dis-turbance, is considered to be the first description of a cranial injury causing aphasia.¹²

Case 22, entitled “Compound comminuted

frac-be the work of Imhotep. Polymath, architect, statesman, and physician to the court of Pharoah Zoser, the author of the Pa-pyrus was possibly a military surgeon who knew about weapons and the injuries they inflict.” In 69 discussions, he explained anatomical terms and injuries, which give a good idea of the state of medical knowledge at that time. Although the ori-ginal documents were lost, a second contributor modernized the script several centuries later, and a third contributor, a Theban scribe, not knowing any medicine, wrote it down by hand around 1600 b.c.

The History of Cerebral Trauma 23 ture of the temporal bone,” is the most serious of

five cases of temporal injuries. The surgeon had to probe the ear and remove bone splinters. After this assessment, the prognosis was Verdict III—

no treatment recommended.

In ancient Egypt, head wounds were treated by application of a piece of meat on the first day, fol-lowed by a linen cloth soaked in honey or fat. With skull fractures, the patient was advised to maintain a sitting position, supported by bricks on either side—good advice to keep the intracranial pres-sure lower and help prevent intracranial bleed-ing. The treatment of penetrating injuries of the brain was the application of grease, but bandages were avoided to allow drainage. The fats applied, according to the Ebers Papyrus, were a mixture taken from snake, crocodile, ibex, lion, and hippo-potamus. Oral feeding was recommended through

“a wooden brace put into the mouth”; “a draught of fruit” was given to pale and exhausted patients.

Herodotus of Halicarnassus (c. 484–420 b.c.) relates that when he traveled to Egypt, medical practice was based on specialization, so that there were different doctors for the eyes, teeth, or head.

However, treatments were irrational. According to the Leiden Papyrus, charms were applied to the painful area or, for headaches, were hung around the neck or even the hand or foot.

The Bible

There are biblical references (c. 1300 b.c.) to brain injuries, such as when Joel slew the enemy King Sisera by driving “a metal tent stake through his temples while he slept” and Goliath (c. 1050 b.c.) was rendered unconscious by a stone that sunk into his forehead. Goliath had put on his helmet of brass but suffered a concussion, presumably with a de-pressed frontal fracture in the unprotected fron-tal region.

Ancient Greece

Homer

It has been estimated that, of 140 penetrating wounds of the body reported in Homer’s works, the mortality rate was over 75%. Mortality was higher with spear and sword wounds than with

those caused by arrows because, in the latter, if the vital structures were injured, there could be heal-ing without infection once the arrow was removed.

Cerebral trauma in animals was also recorded—

for example, Nestor’s horse: “In agony the horse sprang into the air as the missile passed into the brain. The man was thrown into confusion by the rolling of the wounded horse on the ground”

(Iliad). Presumably the arrow would have entered from the front and traveled by the side of the falx

(Iliad). Presumably the arrow would have entered from the front and traveled by the side of the falx