History of Home Neurosurgery: Some Pages
Part II

Kondakov E.N.

Polenov Research Neurosurgical Institute Saint Petersburg, Russia

 

A General Surgery Period

A general surgery period in development of home neurosurgery embraces the XIXth century and some preceding years. Surgical treatment of diseases and injuries of the nervous system was carried out by general surgeons on the basis of principles of general surgery. The beginning of this period coincided with opening of a Medico-Surgical Academy in Saint Petersburg.


Ivan Fedorovich
Bush (1771-1843)

The Academy had 7 chairs, including that of surgery. Its first chief was Ivan Fedorovich Bush. In 1800 he was given a clinical-surgical ward in a land military hospital.

Professor Bush I.F. was the only lecturer at the Chair during the first academic year. According to Regulations of 1799, graduates of the Medico-Surgical Academy became the so-called "surgical applicants" and were to undergo training in hospitals under guidance of their specialists; only after it they acquired the rank of a doctor.

When the order on organization of surgical and therapeutic clinics had been issued (1806), Bush I.F. was appointed a head of a 30-bedded surgical clinic. It became an independent research-and-practice establishment and a school for teaching surgery. It was recommended to bring teaching nearer to practical activities. At first, operations were performed on cadavers, but "an operator was to order all instruments and to keep them in such a state, as if operations were made on living objects themselves".

Elementary Principles of Manual Medical Science, written by Avgust Gotlibovich Rikhter (Saint Petersburg, 1801) was a book, which contained more detailed information on indications and contraindications for trephination, areas of burring and width of exposure of soft tissues. It read: "It is certainly more useful not to bur sutura cranii, if it is only possible to avoid it".

The main textbook of that time was a manuscript by Bush I.F., entitled A Manual on Teaching Surgery. It was printed in 1807. The book consisted of 3 parts: problems of general surgery, particular surgery and description of all operation, known at that time. It should be noted, that a chapter on particular surgery contained directions on necessity to perform interventions in case of cranial wounds with bone damage and their pressure on the brain. I.F. Bush described sequlae of craniocerebral wounds, manifesting themselves as seizures and paralysis. He recommended to apply a bandage around the brain base in case of its prolapse. It corresponds to a dressing with "a baranka" (ring-shaped roll), which was introduced into practice much later.

There were some other textbooks for students: A Brief Manual on the Most Important Surgical Operations by Ya.V. Villie (1806), A Manual on Teaching Surgery by V.M. Rikhter, A Brief Manual on Treatment by Simple Means by Ya. O. Sapolovich (1828), etc.

Describing torticollis, Bush wrote, that "one should try to study a nature of causes in its treatment". Torticollis was considered to be conditioned by cicatrices, resulting from injuries and burns, shortening of the sternocleidomastoid muscle or changes in a group of neck muscles, changes of cervical vertebrae. Thus, treatment was recommended in compliance with these causes. In 1820 N.I. Ellinsky defended his thesis Treatise on Mechanical Injuries of a Head. He was in charge of the Chair and Clinic of Surgery and used his observations and the textbook by Bush I.F. in his lectures. Treatise on the Spinal Cord was a thesis defended by I.V. Enokhin in 1836. Later he headed the Military-Medical Department and made a lot of useful changes in the system of Russian medical education. The above theses were among the first works in this field of medicine. However, we know little about them, as they were written in Latin.

Professor Kh.Kh. Salomon became a head of the Academy Surgical Clinic in 1820. He was one of the most famous disciples of Bush. He acquired the rank of an academician in 1838 for his outstanding achievements, among which one can mention A Manual on Operative Surgery, written in Russian (1840) and being the first manual on operative surgery. Salomon wrote in the preface to his book, that as a lecturer and clinician he "should be an example for his students, make his contribution into science improvement and at the same time promote recovery of patients". According to him, mastering descriptive anatomy only was insufficient, because an operator should have a precise knowledge of surgical anatomy as well. In 1842 The Academy of Sciences awarded Kh.Kh Salomon the Demidov Prize of the Academy of Sciences.

Thus, there appeared the first comprehensive book, which was a manual for surgeons during many years. It should be mentioned, that its first part contained description of operations on a head (including interventions on eyes and ears) and neck, known at that time.


Khristian Khristianovich
Salomon (1796-1851)

The manual summarized progressive research experience of that time and was a bright proof of a high level of Russian surgery. In 1840, i.e. fifty years earlier than V. Gorsley, Kh.Kh. Salomon proposed to use wax for arrest of bleeding from cranial bones and to dissect big nerve trunks of extremities and cutaneous nerves in trigeminal neuralgia and pain of another origin. He performed neurotomy of motor nerves in muscular cramps, which is called Stoffel's operation (1911) without any ground. Besides, Salomon proposed neurotomy of the accessory nerve in cramps of cervical muscles, which was performed for the first time by Buyalsky I.V. in 1833. This operation is unjustly attributed to Campbell-de-Maorgan, who recommended it only in 1866.

Teaching medicine in general and surgery in particular is closely connected with the name of I.V. Buyalsky, who was of the most talented followers of Bush.


Ilya Vasilyevich
Buyalsky (1789-1866)

I.V. Buyalsky mastered surgical technique perfectly. Undoubtedly, he was the most famous surgeon of his time. He discussed indications for an operation with great caution, considering it to be the last method of treatment. Buyalsky said: "Sometimes an operation is a life-saving measure, but we are to think of making this saved life as less burdensome as possible".

The most significant work by I.V. Buyalsky was his famous Anatomic-Surgical Plates, being an atlas on operative surgery and topographic anatomy. This first-class classical book was much better, than the most famous atlases of foreign authors. Detailed description of surgical technique and good illustrations of topographic-anatomic relations within a wound were the most distinct and important feature of the atlas. Further complete merging of topographic anatomy and surgery took place thanks to great works of N.I. Pirogov.

I.V. Buyalsky tried to improve surgical instruments. He headed a tool-making plant for several years and did much for creation of surgical kits for the Military Department and achievement of a higher quality of instruments.

I.V. Buyalsky carried out research in pathoanatomy and was the first to read lectures on this field of medicine in the Medico-Surgical Academy in 1836-1840. He wrote A Manual for Doctors on Correct Examination of Dead Bodies for Ascertaining a Cause of Death (1851) and carried out some rather valuable studies on forensic medicine, whose results were used in forensic-medical legislation.

One should also mention a manual by I.V. Rklitsky, entitled Operative Surgery or Description and Anatomic-Pathological Explanation of Performing Operations (1841), which was very popular; besides he wrote Dressings or a Doctrine of Surgical Bandages and Devices (1861).

Development of surgery in Moscow was connected with the activity of E.O. Mukhin, Professor of the Moscow Medico-Surgical Academy and the Medical Faculty of the Moscow University. His most famous works were Description of Surgical Operations (1807) and A Course of Anatomy, consisting of eight parts (1818).

In 1821 the Moscow Medical-Physical Journal published his Cases with Fractures of a Head Apex and Fractures of a Forehead, Observed and Reported at the Meeting of the Medical-Physical Society by Professor Mukhin. He was an initiator of creation of anatomic rooms for teaching anatomy, use of cadavers and making autopsied specimens out of frozen dead bodies (this method underwent further development by I.V. Buyalsky and N.I. Pirogov).

Thus, Russian surgery was characterized by great achievements and independent development before the epoch of N.I. Pirogov. It took the lead over foreign surgery rather often.


Efrem Osipovich
Mukhin (1766-1850)

In 1841 N.I. Pirogov became Professor of Surgery of the Medico-Surgical Academy. An important event, which happened after his appointment and conditioned further development of surgery and a process of teaching as a whole, was foundation of several chairs in hospital clinics and first of all the Chair of Hospital Surgery, proposed by Pirogov. It was the first precedent in history of medical education. Thus, clinics became training and research centers; it resulted in appearance of surgical schools. The first of them came into being in the oldest surgical clinic of the country, i.e. the Saint Petersburg Medico-Surgical Academy.

Many research works, carried out by representative of the first Russian surgical school became classical and were a valuable contribution into development of science both in Russia and the world.

Studying historical documents, medical manuals and some monographs of the XIXth century showed, that there was no craniocerebral surgery proper. Isolated operation for craniocerebral trauma, injuries of peripheral nerves and other components of the nervous system were performed only by outstanding surgeons of that time. Teaching foundations of such interventions was limited to information, given in the above manuals and atlases.

In the middle of the XIXth century profound studies, carried out by N.I. Pirogov, enriched surgery of the nervous system to a great extent and marked the dawn of operative surgery in general and field surgery in particular.


Nikolai Ivanovich
Pirogov (1810-1881)

N.I. Pirogov raised a problem of studying traumatic cerebral lesions and pathologic morphologic and physiologic processes, caused by them, in his book Elements of General Field Surgery (1865-1866).

Many of his statements are still valid. According to him, "concussion, compression and contusion of the brain do not differ greatly in their essence and it is doubtful, that this difference is so great, as it is usually considered to be. It is wise to strive for getting acquainted with signs, which would help to make a conclusion on progression or regression of a lesion, rather than to search for peculiar features of each of them". Pirogov performed more than 20 skull trephinations.

It seems, that this small number of operations (according to present views), made by such an outstanding surgeon as Pirogov, emphasizes correctness of the conception of that time, concerning complexity of diagnosis, inexpediency of surgical interventions and uncertainty of prognosis in lesions under discussion. However, it did not stop leading surgeons and researchers, believing in possible surgical treatment of nervous diseases.

N.I. Pirogov carried out research in craniocerebral trauma at a very high level and presented obtained results in a simple and clear way. He described various forms of consciousness disorders, different types of pulse and respiration disturbances, some general and focal symptoms, typical of craniocerebral trauma. Pirogov wrote: "…the most important and peculiar feature of a cerebral lesion is loss of consciousness". According to him, "unconsciousness can be explained by swelling of the brain soft tissue due to rush of blood". Pirogov's atlas Illustrated Topographic Anatomy of Sections, Performed in Three Directions through a Frozen Human Body (1852-1859) was the basis of topographic anatomy and operative surgery, as it was the first to describe principles of layer-by-layer topography of anatomic areas.

For example, he found out that "…not a single part of a body has empty spaces in a normal state… The brain, as any other organ, is closely adjacent to dura, covering an inner surface of a skull…".

The Saint Petersburg Academy of Sciences awarded N.I. Pirogov the Demidov Prize of the Saint Petersburg Academy of Sciences four times. It was the highest award for research achievements in Russia.

Considerable progress of general surgery and rapid development of thoracicoabdominal surgery were conditioned by introduction of antisepsis (1867) and asepsis (1892) into routine surgical practice.

Appearance of anesthesia (1846) resulted in considerable increase of a number of operations on the central and peripheral nervous systems.


Nikolai Vasilyevich
Sklifosovsky (1836-1904)


Ernst Bergman
(1836-1907)

Asepsis introduction is connected with the name of N.V. Sklifosovsky. An aseptic method was a last step in "surgical revolution", which had started with opening of antisepsis. E. Bergman, a graduate of the Derpt University, and K. Shchimellbush are considered to be founders of an aseptic method of arresting wound infection (a report, made at the International Congress in 1890). However, N.V. Sklifosovsky began to use it earlier. It is proved by data of his report on activity of the Clinic of Faculty Surgery of the Moscow University in 1890-1893.

It should be mentioned, that while working in Germany, E. Bergman published his book Surgical Treatment of Brain Diseases (1890). He discovered, that artificial increase of intracranial pressure led to growth of blood pressure (it was done before appearance of Cushing syndrome). During the same year this book was translated into Russian by P.I. Dyakonov, who was a head of the Chair of Operative Surgery and Topographic Anatomy of the Moscow University. He did much for appearance of medical periodicals. P.I. Dyakonov was a founder of the magazine Surgery (1897). The last operation, made by him in the Clinic, was trephination of a skull in a patient with cerebral tumor.

Being a very skillful surgeon, N.V. Sklifosovsky performed various difficult operations. He was one of the first surgeons of Russia, making operations for cerebral hernias.

Sklifosovsky demonstrated such patients and excellent outcomes at the conference of the Moscow Surgical Society. N.V. Sklifosovky was the first to remove congenital cerebral hernia under antiseptic conditions (1881).


Petr Ivanovich
Dyakonov (1855-1908)

The second half of the XIXth century was characterized by new achievements and discoveries, which had a great effect on progress of surgery of the nervous system and were favorable for appearance and development of neurosurgery.


Angular and bone gorges,
designed by P.I. Dyakonov (1894)

I.M. Sechenov and his works on reflexes of the brain made a great contribution into neurophysiology (1863). A method of experimental study of the CNS functions was introduced into clinical practice and widely used by V.M. Bekhterev and I.P. Pavlov. S.P. Botkin, a famous Russian scientist (1832-1889), promoted development of a neurologic trend in medicine and studied symptoms, watched in paralysis. Works by P.I. Uspensky, his follower (1838-1893), were very important, as they were devoted to impaired coordination of movements, myelitis, neuralgias, neuroses and a place of miliary aneurysms in pathogenesis of hemorrhages. G.A. Zakharyin (1829-1897) and A.A. Ostroumov (1844-1908) were outstanding representatives of the Russian therapeutic school, who studied semiotics, diagnosis and treatment of many nervous diseases. Professor E.O. Mukhin, a great anatomist and surgeon (1766-1850), worked at creation of Russian anatomic terms and was the first scientist in home medicine, elucidating foundations of reflex theory. Professor N.M. Yakubovich organized one of the first Russian physiologic laboratories in the Medico-Surgical Academy. His research in histological structure of the CNS formed correct understanding of the origin and relationships of different components of the nervous system. He published Notes on the Most Delicate Structures of the Brain and Spinal Cord in 1857.

At the same time research in localization of functions in the brain, on which modern neurology is based, was carried out (V.A. Bets, Broka, N.E. Vvdenesky, K. Vernike, Jackson, Govers, A.Ya. Kozhevnikov, L.S. Minor, K.P. Monakov, G.I. Rossolimo, P. Flegsig, etc.).

Clinical diagnosis was improved by such auxiliary methods of examination as opthalmoscopy (1881), lumbar puncture (1891), rentgenography (1895). It should be mentioned, that American doctors Brizaud and A. Lond had an X-ray of the skull taken a year later after K. Roentgen had reported about his discovery. In 1897 specialists from Bekhterev's clinic developed "a stereoscope", permitting to watch stereoscopic X-ray images.

I.P. Merzheevsky published his book on anatomy of the brain ventricular system in 1872, where he confirmed existence of Magendie's and Luschka's foramens and described areas of connection with a subarachnoid space in inferior horns of lateral ventricles. Later he wrote On Importance of Application of Some Operations for Treatment of Nervous and Psychic Diseases (1886), in which he discussed necessity of physiological substantiation of such interventions and advised surgeons and neuropathologists to think over indications very carefully.


Ivan Petrovich
Merzheevsky (1838-1908)

P.V. Rudanovsky, a famous zemsky surgeon (Zemstvo - an elective district council in a pre-revolutionary Russia) and Honorary Writing Member of the Paris Academy, was the first to invent preliminary freezing of tissues for preparation of histological specimens. In 1868 the Saint Petersburg Academy of Sciences awarded him the Prize named after Prof. I.V. Rklitsky.

P.V. Rudakovsky summarized results of his research in three issues, entitled About Structure of the Spinal Cord and Medulla Oblongata Roots in a Man and Animals and published in Kazan (1871-1876).

In 1871-1873 Yu.A. Kosmovsky wrote On Wound Healing after Trephination and On a Bone Trepanized from a Skull and Its Taking Root. In 1872 R. Kulisher defended his thesis Prolapse of Hernias via a Skull Fornix and Base.

V.G. Lashkevich was the first to give clinical-anatomic description of a cerebellar tumor (1883). In 1887 C.M. Untenberger published Four Cases with Trephination of a Skull.

In 1888 there appeared an article, written by Yu.L. Ventskovsky and entitled A Complicated Fracture of the Skull. Trephination with a Fatal Outcome. He emphasized existence of more precise indications for trephination and insisted, that a surgeon should take into account not any specific cerebral symptom and common disorders of cerebral activity, but "only peculiar signs of localized injury". While analyzing his results, Yu.L. Ventskovsky described these peculiarities from a physiologic point of view and in the light of localization of functions in the cortex, studied by Bekhterev.

P.N. Vilizhan developed an original and accurate method of studying physiologic fluctuations of intracranial pressure and measuring its value at any period of time. It was presented in About a Method of Assessing a Value of Fluctuations of Intracranial Pressure (1889).

L.V. Blumenau found out, that compression of brain substance resulted in blood circulation disorders, manifesting themselves as venous hyperemia and resulting in atrophy of nerve elements. He defended his thesis On Studying an Effect of Pressure on the Brain in 1889.

L.V. Blumenau was sent abroad, where he worked with Fleksig and Charcot. After coming back, he acquired the rank of a privat-docent (unestablished University lecturer) at the Chair of Nervous and Psychic Diseases of the Academy. In 1903 L.V. Blumenau became a professor of the Clinic of Nervous Diseases of the State (former Eleninsky) Clinical Institute.

In 1906 he published Human Brain, which was a manual and atlas. It was re-edited in 1925.

In 1896 G.F. Tseidler presented an acccount of successful application of Gorsley's operation in Jacksonian epilepsy. Areas of the cortex, being an epileptogenic focus and liable to removal, were determined during operation with the help of electric current; removed brain substance underwent histological examination. G.F. Tseidler was the first surgeon of the country, who removed glioma of the cerebellum, diagnosed by V.M. Kernig, a famous therapeutist and neuropathologist.


Leonid Vasilyevich
Blumenau (1862-1931)

V.M. Kernig was a head physician (1890-1911) of the Obukhovskaya Hospital for Women (Saint Petersburg). He was well-known for description of a symptom, watched in meningitis (1882).


German Fedorovich
Tseidler (1861-1929)


Vladimir Mikhailovich
Kernig (1840-1917)

In 1892 K.M. Sapezhko diagnosed and removed neoplasm of the brain occipital lobe.

G.F Tseidler made a report on treatment of craniocerebral injuries and indications for trephination from the point of view of general surgery at the IIIrd Congress of Russian Doctors (1898). He dwelt on a considerable number of cases, described in Russian medical literature.

A problem of indications for surgical treatment of focal cortical epilepsy was studied by F.A. Rein. He analyzed outcomes of cases, described in literature, in his Results of Surgical Treatment of Jacksonian Epilepsy and Indications for It (1897). The article On Modern Technique of Resection of a Skull Fornix by V.A. Sventsitsky (1897) was a survey of existing proposals and methods. Later V.A. Sventsitsky, who was a disciple of Professor S.P. Fedorov, defended his thesis Surgical (Bloody) Treatment of Fractures of the Spine and Accompanying Injuries of the Spinal Cord (1903).

In 1898 B.S. Kozlovsky, a famous zemsky surgeon and privat-docent of the Kiev University published an article on successful removal of endothelioma of meninges and diploe, made by him in the town of Smela. He reported the case at the conference of the Kiev Society in 1897 (Endothelioma of Meninges and Diploe Removed with the Help of Trephination).

The staff of the Obukhovskaya Hospital included such outstanding neurologists and surgeons as V.M. Kernig, mentioned above (Kernig's symptom), and L.G. Stukkey, who was the first to use a liquorodynamic test in a human being, e.i. abdominal wall compression (Stukkey's test).


Lev Genrikhovich
Stukkey (1872-1924)


Ivan Ivanovich
Grekov (1867-1934)

The Obukhovskaya Hospital was not only the oldest and biggest hospital for the poor, but also one of the main training establishments for Russian surgeons. Many famous surgeons started their carrier in this hospital. For example, I.I. Grekov was its external physician in 1895. Later he defended his thesis On Closure of Cranial Defects by Annealed Bone (1901) and became a head physician of the surgical department of this hospital (1905) Besides, I.I. Grekov headed the Chair of Surgery of the Petrogradsky Psychoneurologic Institute (since 1915).

One should not forget, that it was I.I. Grekov, who (together with N.N. Bolyarsky and N.K. Lysenkov) saved Pirogov's tomb in the village of Vishnya (1928). This event marked the beginning of Pirogov's museum.

In 1889 D.N. Zernov presented his report at the conference of the Physical-Medical Society of the Moscow University. He told about his research in craniocerebral topography and demonstrated an original encephalometer for determining projections of different cerebral areas on a skull. This device "allowed to lay a drawing of skull sutures, cerebral fissures and deeper structures on a globular surface and then to transfer this image to a plane surface…".

N. Altukhov, Zernov's follower, created detailed projection maps on the basis of studying 40 cadaveric heads. G.I. Rossolimo modified Zernov's device, using a perforated metal hemisphere. In 1907 he published his work A Cerebral Topographer (a device for projection of cerebral areas on a skull surface).

V. Vagner was the first to perform osteoplastic trephination (1889); however, introduction of this method was very slow due to poor technical support. Craniotomy was used more widely after appearance of Djilyi's wire chain saw, invented for cutting up pubic articulation. In 1897 A. Obalinsky proposed to use this saw instead of a chisel for raising a skin graft on a skull. A.G. Podrez made a guide from a watch spring with a thickened olive-like end for prevention of dura damage in cutting up bones. Different modifications of incisions of a head skin and dura, as well as new methods and instruments for bleeding control were introduced; research in cranioplasty was carried out.


A wire file saw by Djilyi.
A bone with a guide-protector (a) and
Podrez's spatula ("a watch spring") (b)

A.A. Bobrov, an outstanding surgeon and specialist in topographic anatomy, was the first to replace cranial defect, using the skull outer table (1890), and to develop an original method of osteoplastic closure of a spinal defect in congenital splitting of vertebral arches. In 1899 he removed a bullet from the brain, whose localization was determined with the help of X-rays, discovered in 1895.

Medical literature of the XIXth century contained many articles, devoted to problems of surgical treatment of brain abscesses, neuralgia of the trigeminal nerve (L.P. Malinovsky, V.I. Razumovsky), epilepsy (posttraumatic epilepsy with evident bone depression or a gross meningocerebral cicatrix).

Development of laminectomy and operations on contents of a vertebral canal started at the end of the 80s (A.D. Kni, 1887). Operations for hernias of the spinal cord (S.P. Fedorov, V.N. Zenenko, A.A. Bobrov, N.V. Sklifosovsky) and hydrocephalus (F.V. Chernomor-Zadernovsky, P.N. Dokhnevsky, S.P. Fedorov) were more frequent.


Alexander Alekseevich
Bobrov (1850-1904)


Sergei Petrovich
Fedorov (1869-1936)

In 1885 A.A. Schtoll invented an original device for operations on bones, including trephination of a skull, and called it a rikhanotrepan. Besides, it was provided with a special disk-shaped saw with a diameter of 10 cm, triggered by a flexible engine drive. Duaen's kit for operations on bones appeared many years later and did not differ much from Schtoll's instruments and saw.

Russian surgeons proposed and introduced several original devices. A.I. Dyakonov designed an angular chisel (1894), which permitted to raise a skin graft easier and with less damage. V.I. Razumovsky suggested using a polyhedral chisel for this purpose. At the end of the 90s S.P. Fedorov, who was greatly interested in craniocerebral surgery, worked out a new technique of trephination. Many surgeons tried to dissect bones with the help of a circular saw, using different devices, which ensured dura safety. S.P. Fedorov modified and improved Duaen's trephination system and began to use a circular saw and burrs. The report on potentialities of this apparatus was made by him at the Congress of German Surgeons in 1898.


A polyhedral chisel for skull trephination,
proposed by V.I. Razumovsky (1895)


A circular saw with a device
for dura protection


A circular saw with a hand-operated
mechanical drive for trephination


An electric engine for a saw,
trepan and burr

In 1890 M.O. Perfilyev compiled a book, containing a survey and summaries of works on brain surgery, published in Russian literature (55 articles).

The same year was marked by presentation of results of I.K. Spizharny's thesis Teaching on Brain Surgery and a Process of Wound Healing in This Organ. The main conclusion of the author, which was of great importance for further development of brain surgery, said, that trephination, explorative dissection of the brain and its puncture, performed under aseptic conditions, were not dangerous operative procedures for a skilled surgeon. Besides, Spizharny wrote On Surgery of Nerve Trunks (1915).


Ivan Konstantinovich
Spizharny (1857-1924)


Alexander Semenovich
Tauber (1848-1908)

A.S. Tauber, Professor of the Warsaw University, described a tometriphine, designed by him and used successfully during operations. This device excised a conic disk from a skull depth without touching dura. As soon as cutters went through a bone, a device moved back from a skull. Later a bone disk could be put to its place and its edges adjoined defect margins very tightly.


An instrument for skull trephination: Tauber's
tomotrephin

In 1898 Surgery of the Brain. Clinical Lectures by A.S. Tauber was published in Petersburg. It was the first home manual on craniocerebral surgery. The author's aim was as follows: "Rather diverse pathologic phenomena of the central nervous system… should be classified into definite clinical pictures, anatomic, physiologic and pathologic factors should be analyzed with the purpose of teaching a young doctor … to diagnose impaired integrity of definite territories of the brain and explaining to him goals of a modern surgeon at a patient's bed or in an operative field of the brain". V.D. Sobolevsky defended his thesis On Problem of Surgical Treatment of Paralyses Caused by Compression in Tuberculous Spondylitis in the Medico-Military Academy (1898). Topography and Operative Surgery of a Cranial Cavity by N.K. Lysenkov was published in Moscow in 1898. The book contained not only anatomic and operative sections, but also a large special part, describing indications for surgical opening of a skull and modifications of trephination methods in compliance with particular diseases. The author presented a clinical course of some surgical diseases and surgical technique, illustrating them by particular cases, reported in Russian medical literature.

Thus, the books by A.S. Tauber and N.K Lysenkov, summarizing existing knowledge, were an extremely valuable practical manual on surgery of injuries and diseases of "a skull cavity".

V.M. Bekhterev, L.O. Darshkevich, N.A. Mislavsky and V.I. Razumovsky are outstanding scientists, who worked at the Kazan University in the 80-90s. Bekhterev and Darshkevich studied pathogenesis and a clinical picture of the CNS diseases; Razumovsky worked at a problem of surgical treatment in the Clinic of Hospital Surgery, headed by Professor L.L. Levshin.

L.L. Levshin was the first to study peculiarities of wound ballistics in penetrating injuries of a skull and worked out recommendations on tactics of their surgical treatment.

He defined brain concussion as diffuse contusion of cerebral substance in his Injuries of the Skull and Its Contents (1903). Levshinov was a founder and co-editor of Russian Surgery (1902-1916), which consisted of many volumes.

L.A. Malinovsky, a surgeon who worked with Darshkevich, wrote an article (1983), dwelling on "anatomic explanations of conditions, under which abscesses, operated by him successfully, had developed just in a temporal lobe". It was published in Nevrologichesky Vestnik, a journal created by V.M. Bekhterev (1893). A report, entitled On Problems of Surgical Treatment of the CNS Diseases, was made by Malinovsky the same year. He was the first to put forward a problem of training a surgeon, operating on a nervous system. He considered, that a surgeon and neuropathologist were to solve diagnostic problems and as well as make decisions on indications for an operation, using achievements of anatomy, physiology and surgical technique. According to L.A. Malinovsky, early diagnosis and timely intervention were compulsory: "…I lay special emphasis on time…so far late surgical intervention has resulted mainly in its failure".


Lev Lvovich
Levshin (1842-1911)

N.I. Studentsky and V.M. Berkhterev were the first to perform operations on the brain at the end of the XIXth century in Kazan. Their activity was continued by V.I. Razumovsky and L.A. Malinovsky, working in close cooperation with L.O. Darshkevich, being an outstanding neuropathologist. Taking into account, that V.I. Razumovsky was an active supporter of Bekhterev's ideas and did much for their further development, it will be just to say a bit more about this extremely talented surgeon and doctor.

The thesis On Atrophic Process in Bones After Nerve Transection by Razumpvsky (1884) was the first profound study, which showed, that bone growth and trophism were regulated and controlled by the CNS. It was an important achievement of that time and the thesis won a high appraisal of many famous scientists.


Livery Osipovich
Darshkevich (1858-1925)


Vasily Ivanovich
Razumovsky (1857-1935)

In 1885 V.I. Razumovsky, who had worked in Saint Petersburg for some years, returned to Kazan. His scope widened considerably; he mastered methods of research and accumulated profound knowledge of general pathology, topographic anatomy, operative and clinical surgery.

One more great contribution of Razumovsky was further development and introduction into practice of Pirogov's precept to bring together anatomy and surgery. These disciplines were connected rather loosely during the years under discussion; surgeons underestimated anatomy's significance for surgery very often. Razumovsky popularized the latest achievement of European surgery of that time and enriched Russian and world surgery by new operations, worked out by him and introduced into practice.

V.I. Razumovsky made a great contribution into development of neurosurgery foundations. In 1901 there appeared his first work in the field of craniocerebral surgery. It was entitled On a Problem of Trephination in Cortical Epilepsy. Razumovsky summarized his profound experience in an original monograph The Latest Data on Craniocerebral Surgery, which was the 10th volume of the first home manual Russian Surgery (1903-1914). Endoneural administration of alcohol in causalgia was performed by Razumovsky much earlier, than by Sequard, to whom priority is ascribed to. In 1903 Razumosvky proposed resection of the second and third branches of the cranial nerve in its neuralgia; it was 12 years earlier in comparison with foreign doctors (1915).

Razumovsky's reports on craniocerebral surgery, made at the IVth and VIIIth Congresses of Russian surgeons in 1904 and 1908 were highly appreciated by his colleagues.

Joint activity of neuropathologists and surgeons of the Kazan University, which continued after Bekhterev's departure, promoted further development of fundamentals of brain surgery.

A Course of Nervous Diseases, written by L.O. Darshkevich in 1904 and reprinted several times, was a valuable contribution into medical science. His works on a structure of the posterior commissure, its nucleus (Darshkevich's nucleus), the nucleus of the anterior part of quadrigemina and physiology of the nervous system are among ever-green classical clinical studies. Besides, at the very beginning of the XXth century Darshkevich created an operating room in his clinic in Kazan, where intervention was performed by a surgeon, assisted by neuropathologists.

Concluding the report on a general surgery period, one should state, that it was characterized by original research, carried out by home doctors; though interventions on the nervous system were rare, they always attracted attention of outstanding surgeons and neuropathologists. Besides, there appeared signs of structural organization of brain surgery. A Historical Description of Trephination Doctrine since Ancient Times up to the XIXth Century by M.Yu. Lakhtin can be regarded as some final result of this period (1900), which was connected with the names of such outstanding surgeons as Pirogov, Bogoyavlensky, Salomon, Malinovsky, Bobrov, Razumovsky, Spasokukkotsky, Fedorov, Bakulev, Spizharny, Vreden, Grekov, Rosanov, Subbotin, Oppel, Ratimov, Sklifosovsky, Gertsen, Levshin, Lashkevich, etc.

At the end of the XIXth century V.M. Bekhterev said in his oration, devoted to opening of a new Clinic of Nervous Diseases of the Medicomilitary Academy: "Either a surgeon… must be armed with knowledge and bear responsibility for both correct diagnosis and sequelae of operations or a neuropathologist must study surgical methods within the limits of his specialty in detail and use them in practice himself".

According to Bekhterev, only in this case "one could expect correct surgical care of psychic and nervous patients and successful development of this youngest, but promising field of medicine in the future".

Part III         Part I