History of Home Neurosurgery: Some Pages
Part III

Kondakov E.N.

Polenov Research Neurosurgical Institute Saint Petersburg, Russia

 

A Period of Surgical Neuropathology
(Organizational Aspects of Neurosurgery Development)

In November 1897 V.M. Bekhterev opened a 20-bedded department in his new Clinic of Nervous Diseases of the Medicomilitary Academy. It had a special operating room for "cerebral surgery" and was called the Department of Surgical Neuropathology.

Interventions, which had become a routine very quickly, were performed by such leading surgeons of Saint Petersburg, as N.A. Velyaminov, M.S. Subbotin, R.R. Vreden, E.V. Pavlov.


Nikolai Aleksandrovich
Velyaminov (1855-1920)


Maxim Semenovich
Subbotin (1848-1913)

V.M. Bekhterev was the first doctor in history of medicine, who called for "making neuropathology a more surgical discipline" (1898). G. Cushing substantiated the necessity of "deeper immersion of surgeons into neurology" in 1905. It resulted in appearance of a new specialty, called surgical neuropathology or neurosurgery.

In 1897 V.M. Bekhterev began to issue a new journal, entitled Survey of Psychiatry, Neurology and Experimental Psychology. According to his opinion, one of its urgent goals was elucidating problems of surgery of the nervous system.

A.L. Polenov defended his thesis in the Medicomilitary Academy in 1900. It was devoted to a topic, which was new and original for that time. It was entitled Sympathectomy: An effect of This Operation on Experimental Epilepsy in Animals.


Roman Romanovich
Vreden (1867-1934)


Evgenyi Vasilyevich
Pavlov (1845-1916)

L.M. Pussep was Bekhterev's disciple. His thesis for a Degree of a Doctor of Medical Science was defended in 1902. His opponent at the defense was I.P. Pavlov, who became a head of the Physiologic Department of the Institute of Experimental Medicine in 1891, and whose estimation of Brain Paths by V.M. Bekhterev, given in 1895, was positive. In 1902 L.M. Pussep was appointed a head of the above Department of Surgical Neuropathology in the Clinic of Nervous Diseases, where operations for epilepsy, hydrocephalus, birth trauma, tumors of the brain and spinal cord, injuries of the peripheral nervous system were performed. Pussen presented his report On indications and Contraindications for Trephination of the Skull in Epilepsy and Idiocy at the IX Pirogov's Congress, held in 1904.

L.M. Pussep was given the rank of a privat-docent of the Chair of Mental and Nervous Diseases (the Medicomilitary Academy) in 1907. The same year he appealed to the Academy Conference for a permission to read lectures on surgical neuropathology. In 1907 V.M. Bekhterev published his Foundations of Learning on Brain Functions, consisting of 7 volumes.

He was allowed to set up a new educational establishment, named the Psychoneurological Institute, in 1907. L.M. Pussen took part in creation of the first Regulations of this Institute. He became a professor and director of a neuropathologic surgical clinic of the above Institute in 1910. "…A neuropathologic surgical clinic, attached to the Institute, has been opened on September 1, 1910; it occupies a reconstructed building of the Matveevskaya Hospital and is situated in 41, Bolshoi Prospect of the Petrogradskaya storona (district*). The mentioned clinic has 32 beds for patients - 6 in separate and 26 in general wards…".
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* The translator's notes.

Surgical Treatment of Nervous and Mental Diseases was the first elective course, organized on the initiative of V.M. Bekhterev and L.M. Pussep in 1909-1910 for students of the Academy. N.N. Burdenko published a report on suturing posterior roots of the spinal cord in experimental animals (1909). It was entitled Plasty of Cerebrospinal Roots inside the Vertebral Canal.

A medical faculty was opened at the Psychoneurologic Institute in 1911. L.M. Pussep began to lecture on surgical treatment of nervous diseases at the newly-created Chair of Surgical Neuropathology.

In 1913 V.M. Bekhterev, being the President of the Academy of the Psychoneurologic Institute, informed the Minister of Public Education, that "an activity of the Clinic of Nervous Diseases, carried out in Saint Petersburg, has given rise to such practical specialty, as operative neurology; thanks to it, operations on the brain and spinal cord, as well as on peripheral nerves, are performed in a great number and with excellent results".


V.M. Bekhterev and L.M. Pussep among employees and patients
of the Pirogov Neurosurgical Hospital

The Clinic of Neurosurgery was transformed into the Petrogradsky Military Infirmary, named after N.N. Pirogov, in 1915. It was the first local medical establishment for the wounded with injuries of the nervous system.

In 1917 L.M. Pussep published the first volume of a manual on surgical neuropathology, entitled Surgery of the Peripheral Nervous System.

A series of reports, published by L.M. Pussep in 1915-1918, formed principles of modern military neurosurgery. Among them one can mention A Report on the Infirmary Activity; Surgical Treatment of Traumatic Lesions of the Nervous System; Traumatic Neurosis of Wartime, etc.

N.N. Petrov continued to develop ideas of these Russian surgeons in his report Treatment of Infected Wounds in Wartime, made in 1917. He was the first to define such notions, as penetrating and non-penetrating wounds of the skull, dependent on the dura integrity. They have been generally accepted fundamentals since then and till now.

It should be mentioned, that N.N. Burdenko, who worked in the Second Army during WW I (1914), organized specialized sick quarters for casualties with craniocerebral wounds in such cities as Zhirardov, Vilna and Riga. L.M. Pussep opened a neurosurgical infirmary in Vilnus the same time year.

According to Order N 2327 of March 1, 1918, the Executive Committee of the Petrosoyuz (union*) of Disabled Military Men and its Medical-Technical Department set up a neurosurgical Institute. The Neurosurgical Clinic (the Pirogov Infirmary) of the Psychoneurological Institute was used as its base. The institute had 150 beds and 3 departments: neurosurgical (50 beds), paralytic (70 beds) and epileptic (30 beds). At the beginning of 1920 a number of operations for cerebral tumors, epilepsy and wounds of peripheral nerves was equal to 500, 327 and 275 respectively.

Reorganization of higher education in 1919 led to appearance of the State Institute of Medical Knowledge (the former medical faculty of the Psychoneurologic Institute). L.M. Pussep was appointed its director. Besides, he was the professor and leader of the Chair and Clinic of Surgical Neuropathology of the same Institute.

Collaboration of A.L. Polenov and M.P. Nikitin, being a neuropatologist, Bekhterev's disciple and leader of the Neurologic Chair of the Women's Medical Institute, started in this Clinic.


Andrei Lvovich
Polenov (1871-1947)


Mikhail Pavlovich
Nikitin (1879-1937)

Tumors of the Great Brain, written by I.M. Kron and published in Moscow in 1916, threw light on a clinical course of brain tumors with a different histological structure, diagnostic methods and data of pathoanatomical examinations, presented in the form of 60 macro- and micro-photographs of tumor specimens. He wrote, that "… a regrettable result of intervention, pointed out by statistics, depends on lack of consideration of a tumor sort during operation".

Professor S.I. Spasokukotsky from Saratov proposed a new method of treatment of brain abscesses with the help of punctures. He did it ten years earlier, than Dandy.

It is interesting to note, that in 1893 Spasokukotsky was trained in the clinic of Prof. L.L. Levshin; besides, he worked with L.A. Malinovsky, an adherent of surgical treatment of brain abscesses, during the last year before his leaving the Kazan University for Moscow.

There was the Physio-Surgical Institute in Petrograd (1917-1924), established and headed by A.L. Polenov. Medical, research and training activity was carried out there; it embraced some sections of surgery of the central and peripheral nervous systems. In 1921 an elective course on surgical neuropathology was included into the Institute's educational program.


Sergei Ivanovich
Spasokukotsky (1870-1943)

In 1920 the Neurosurgical Institute was reorganized; besides Pussep's Chair was closed down because of his departure. All equipment of its operating room and diagnostic devices were given to the Physio-Surgical Institute. In 1921 there appeared an independent department of surgical neurology. Anatomic-topographic works of Shevkunenko's school, published during this time, promoted further development of methods of neurosurgical operations. Among them one can mention On Surgical Asnatomy of the Sagittal Sinus by F.I. Valker (1920), Anatomic Data for Intervention on the Skull Base by P.A. Kupriyanov (1919). The latter defended his thesis On Surgical Anatomy of the Skull Base and Limits of Surgical Intervention in 1921.

Professor A.L. Polenov established the Chair of Surgical Neuropathology in the State Traumatologic Institute in 1924. It existed till 1934.

During the first decade there were three main trends of the Chair activity: research, training and treatment. Teaching was aimed at mastering the most important sections of surgery of the central and peripheral nervous systems. A great number of surgeons, traumatologists and neuropathologists took the courses at the Institute. They had different qualification and came from different regions of the country with the only purpose - to study and to get acquainted with a new field of knowledge, i.e. neurosurgery.


Aleksei Gavrilovich
Molotkov (1874-1950)

Experience of the Neurosurgical Clinic, headed by A.L. Polenov, was summarized in A Brief Course on Surgical Neuropathology (1935), which was the first manual of this type in the USSR. M.P. Nikitin was one of the co-authors, whose contribution into its preparation was rather great.

A.G. Molotkov, who had worked at the Chair of Surgical Neuropathology, headed by L.M. Pussep (the State University of Medical Knowledge), and defended his thesis for a Doctor's degree in 1910, was the initiator of organizing the Research and Practice Institute of Surgical Neuropathology (1926). Its opening was the most important landmark in strengthening a neurosurgical specialty both as a research-and-practice branch of medicine and educational discipline.

A.G. Molotkov became the first director of the Institute (1926); later this post was filled by S.P. Fedorov (1929-1936).

It is known, that S.P. Fedorov, being a head of a surgical clinic of the Medicomilitary Academy for many years, devoted himself to surgery of the nervous system. He did much for introduction of the latest technical achievements and surgical methods into clinical practice. His clinic became a place, where A.A. Opokin and V.N. Shamov developed a method of muscular tamponade for arrest of bleeding in operations on the brain for the first time in the world (1913). S.P. Fedorov and his followers introduced an electric trephine, surgical diathermy (11 years earlier, than American surgeons), illuminators of an operative field, original surgical instruments.

A.G. Molotkov did extremely much for creation of the Research and Practice Institute of Surgical Neuropathology and his services cannot be forgotten. While organizing it, he demonstrated complete devotion to an idea and striving for selection of the most experienced specialists, working in Leningrad of that time.


Sergei Petrovich
Fedorov (1869-1936)

The Institute had a 60-bedded clinic and the following laboratories: clinical biochemical (headed by E.S. Manoilov), pathoanatomical (headed by N.N. Anichkov), anatomic (headed by G.F. Ivanov), neurohistological (headed by B.S. Doinikov), pathophysiologic (headed by A.D. Speransky), roentgenologic or X-ray room (headed by A.K. Yanovsky). The staff consisted of 66 persons. The Institute carried out research in surgery of peripheral nerves and neurodystrophic disorders, pain surgery.

The Institute was opened on May 1, 1926. It occupied a building of the Aleksandrinskaya Hospital for Incurable Patients. Its address was 12, Nadezhdenskaya Street.

Besides this specialized medical establishment and above-mentioned departments, there were clinics, where native surgeons carried out research in cooperation with neuropathologists and performed neurosurgical operations. It is necessary to mention A.N. Bakulev and his Significance of Pneumography of the Brain in Pituitary Tumors (1925) and Practical Significance of Pneumograpgy of the Brain (1926). They were the first home books, describing application of this new specific method of neurosurgical diagnosis.


Nikolai Nilovich
Burdenko (1878-1946)

A new Institute appeared in Moscow in 1931. It was the Central Neurosurgical Research Institute, headed by N.N. Burdenko.

N.N. Burdenko and A.L. Polenov have a very high standing in the history of medicine, as they are considered to be founders and organizers of home neurosurgery.

Burdenko's interests in surgery were extremely many-sided and embraced theoretical, practical and organizational aspects. He was elected a professor of the First Moscow Medical Institute in 1923.

Soon after that (1924) there appeared a neurosurgical department, attached to its First Surgical Clinic. The previous head of the Clinic and Chair was Prof. I.K. Spizharny, who defended his thesis for a Doctor's degree in 1890; it was entitled On Surgery of the Brain and a Process of Wound Healing in This Organ.

In 1929 there appeared one more neurosurgical clinic; it was attached to the State Roentgenologic Institute of the People's Commissariat of Public Health. N.N. Burdenko and V.V. Kramer, being a neuropathologist, did much for organization of neurosurgical care, based on principles of complex examination of patients. Teaching on Localization: the Brain was a very important monograph by Burdenko, published in 1931. The above clinic became the Central Neurosurgical Institute in 1932. Besides research and treatment-and-diagnostic activity, the Institute played a leading, guiding and consolidating part in the field of development of home neurosurgery.

It was a period of important research and organizational undertakings. First of all, one can mention creation of the Neurosurgical Council, whose Bureau was responsible for holding annual All-Union neurosurgical sessions. They were a very significant factor in development of young science. Voprosy neirokhirurgii (Problems of Neurosurgery*) was a science-and-practice magazine, edited by N.N. Burdenko, which gave a detailed description of activity of existing neurosurgical establishments.

Its publishing started in 1937. Neurosurgical sessions, as well as the magazine, were aimed at uniting neurosurgeons of the country and stimulating their creative activity. Opening of the Central Neurosurgical Institute became a beginning of the so-called Moscow period of neurosurgery development in the USSR. Many outstanding enthusiasts, being both surgeons and specialists of adjacent disciplines, worked there. Thanks to their achievements, the Institute acquired not only All-Union, but also world fame.


Vasilyi Vasilyevich
Kramer (1876-1935)

It is worth to mention here B.G. Egorov, A.A. Arendt, A.I. Arutyunov, S.S. Bryusov, L.A. Koreish, K.G. Terman, A.A. Shlykov, S.Ya. Blinkov, L.I. Smirnov, V.V. Arkhangelsky, E.I. Kandel, N.Ya. Vasin, C.N. Fedorov, G.A. Gabibov, K.Ya. Ogleznev, etc.

The end of the 30s was a period of strengthening of neurosurgery as a specialty, opening of neurosurgical research Institutes and independent chairs, publication of important monographs and manuals, organization of a system of training personnel for practical public health.

In 1935 Prof. A.L. Polenov set up the Chair of Neurosurgery at the Leningrad State Institute of Postgraduate Education. It was the first Chair of this type in the USSR. He headed it till 1947.


Assitant professor I.S. Vaskin delivers a lecture at the Chair

A.L. Polenov and his school made an incontestable contribution into solution of the most important problems, which stood before a neurosurgical clinic in general. This period was extremely fruitful from the point of view of different original ideas, concerning both surgery and diagnosis. Neurosurgery was an "uncultivated land", which demanded understanding, development and making simple instruments and devices.




Some operations of A.L. Polenov or his modifications of known surgical interventions.

  1. Walls of an osseous hernial channel, sloping into the skull cavity; an external plate of the frontal eminence, introduced beyond margins of an internal opening of the channel.
  2. Pussep's operation for syringomyelia and Polenov's modification of it.
  3. Chordotomy (Polenov's method).
  4. A cylindrical glass drainage, used in brain abscesses.
  5. Plasty of the skull defect by an external plate of a bone, taken from the fontal eminence.
  6. An arbalest scalloped incision of the skin and cervical aponeurosis, performed in an approach to the posterior cranial fossa.

A.L. Polenov was the first to work out methods of surgery of the spinal cord paths, different modifications of chordotomy. He developed and performed intervention on cerebral paths, subcortical pyramidotomy in cortical epilepsy and athetosis for the first time in the world. A.L. Polenov proposed modifications of an arbalest incision for use during operations on the posterior cranial fossa and pituitary tumors, consisting in resection of the frontal pole and adenoma aspiration (1931). A range of activity of this brilliant scientist was extremely large and varied from designing a head support for an operating table up to writing a practical manual on neurosurgery, from establishing the Chair up to well-thought propositions on organization of neurosurgical service in the country.


Some instruments and devices for interventions.

  1. An oblique cut with Martel's saw (A.L. Polenov).
  2. An elevator-illuminator (Polenov's modification).
  3. Head and axillary supports for an operating table, used during interventions with a prone position of a patient (designed by Polenov).
  4. A bed for providing a prone position of a patient after intervention (designed by Polenov).
  5. Polenov's hook for applying ligatures in ligation of the occipital sinus.

One should keep in mind, that home medicine owes Prof. A.L. Polenov origination of home traumatology, i.e. its separating from general surgery and becoming an independent specialty.

Amalgamation of the Neurosurgical Clinic of the State Traumatologic Institute, headed by Polenov, and the Research and Practice Institute of Surgical Neuropathology took place in 1939 on his initiative. Today it is known as the Polenov Neurosurgical Institute. At first the Chair of Neurosurgery of this new Institute was headed by A.L. Polenov and then by his devoted disciples - professors I.S. Babchin and A.G. Zemskaya. There were 140 beds in clinics of the Institute.

This period can be regarded as a final stage of development of the Petersburg-Leningrad school of neurosurgeons and the Neurosurgical Institute. There appeared a lot of manuals and monographs, including:

Historical documents confirm continuity of all links in a chain of neurosurgery development and working out a system of its teaching in Petersburg-Leningrad. In other words, they confirm appearance and strengthening of the neurosurgical school, created by joint efforts of V.M. Bekhterev, L.M. Pussep, A.L. Polenov, I.S. Babchin and their numerous followers.


Prof. Ludvig Martinovich Pussep, Prof. Andrei Lvovich Polenov,
Prof. Isaac Savelyevich Babchin.

The main signs, indicative of appearance of a new specialty, are existence of a specialized clinical base, publication of a proper textbook or manual, availability of a specialized magazine, establishing a chair and providing a process of teaching and training in a new field.

Taking it into account, one can say, that appearance of a new specialty in Russia can be referred to the first decade of the XX century. By 1902 there had already been the specialized Department of Surgical Neuropathology (L.M. Pussep), A Review of Psychiatry, Neurology and Experimental Psychology (1897), publishing reports on cerebral surgery (V.M. Bekhterev), a course in surgical neuropathology (1909, L.M. Pussep). These sings and their ratio in different countries of the world in the 30s demonstrated, that neurosurgery had got a valid right to be an independent discipline and medical specialty.

There appeared such magazines, as:


Covers of Journal of Neurosurgery, Zentralblatt fur Neurochirurgie,
Voprosy Neirokhirurgii.

The Chairs of Neurosurgery were set up in:

Besides, these years (the end of the 30s of the XX century) were characterized by further development of leading neurosurgical schools of the country: that of Petersburg-Leningrad, guided by A.L. Polenov; that of Moscow, guided by N.N. Burdenko, and that of Rostov-on-Don, guided by P.I. Edmin (1883-1959) and then by V.A. Nikolsky (1899-1976).


Pavel Iosifovich
Emdin (1883 -1959)


Viktor Aleksandrovich
Nikolsky (1899-1976)

The medical faculty of the Rostov-on-Don University had the Clinic of Nervous and Mental Diseases. It was decided to organize an independent clinic of nervous diseases in 1924. It was named the Clinic of Neurology and Neurosurgery in 1930. A bit later there appeared the Chair of Neurology and Neurosurgery, where P.I. Edmin trained neuropathologists (but not surgeons) in neurosurgery. Thus, it resulted in birth of an original research-and-practice school of neurosurgeons-neuropathologists in Rostov-on-Don.


Nikolai Mikhailovich
Itsenko (1889-1954)

N.M. Itsenko, who was a senior lecturer of the Chair, described endocrinous-metabolic syndrome of an interstitial-pituitary area, known today as Itsenko-Cushing disease. He did it in 1925. Itsenko's interpretation was more exact and detailed from a pathogenetic point of view, as compared with that of Cushing, who described the same state only in 1932. Besides, N.M. Itsenko characterized a peculiar form of subcortical diencephalic epilepsy (1925-1926), resembling seizures, described by Varsaba (a Russian doctor) in 1863. Today this clinical entity is called Varsaba-Itsenko subcortical epilepsy. Neurologic studies, carried out in the Clinic, were accompanied by research in diagnosis and surgery of tumors of the fourth ventricle (L.Ya. Blekhman), epilepsy (S.A. Ginsburg), neurinomas of the acoustic nerve (V.A. Nikolsky). The results of the Chair and Clinic research activity during the first decade were presented in Tumors of the Brain and Problems of Neurosurgery (1935).

Beginning with 1951, the Chair was headed by Prof. Nikolsky. Neurosurgery occupied the main place in treatment and research work, as the Clinic had become the Interregional Neurosurgical Center of the south of Russia.

D.G. Shefer and Kh.I. Garkavi were brilliant representative of the Rostov-on-Don school. The former continued to develop its traditions in Sverdlovsk; the latter organized a neurosurgical department in the Clinic of Nervous Diseases of the Gorky Medical Institute. Thus, there was a gradual increase of a number of neurosurgical departments.

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