Polenov Research Neurosurgical Institute Saint Petersburg, Russia
Respect for the past is that very feature,
which distinguishes civilization from barbarism
Why do we know so little about our past,
forget it so deeply and deal with things,
awaiting us in the nearest future so easily?
A century has passed since professor Vladimir Mikhailovich Bekhterev said these prophetic words at the opening of an operating room for what he called cerebral surgery: "… Today it is obvious, that many cranial diseases, some lesions of the spinal cord and peripheral nerves are grounds for surgical intervention. However, even today diagnosis of a lesion, demanding surgical intervention, and, what is more, determination of a method of this intervention, are mainly under the authority of neuropathologists and only an act of performing of an operation belongs to surgeons. It is clear, that this state of things cannot be regarded as normal, because it is impossible to stay half-way for a long time…" (V.M. Bekhterev, 1897).
Professor Isaac Savelyevich Babchin wrote in one of his reviews (1947): "One should distinguish three main periods in the history of home neurosurgery development: general surgery, surgical neuropathology and modern neurosurgery".
To some extent, even conditional division of this single process is sure to result in better understanding of sources and ways of formation of neurosurgery as a specialty.
History of medicine has its roots in the remote past and is an object of special research. Thus, we would like to limit ourselves to brief presentation of information, describing how teaching of medicine in general and neurosurgery in particular emerged and developed in Russia.
The Scythians, settling our country many centuries ago, possessed medical skills, which were rather highly developed for that time. Greek historians (the Vth century B.C.; times of Hippocrates) wrote, that Scythian healers enjoyed great authority in Greece. This information was confirmed fully by excavations in southern regions of our country. The Slavs continued to improve medical skills and knowledge of the Scythians. The fact of existence of professional healers in Russia is mentioned in the most ancient documents. They, as well as healers of other ancient countries, were empiricists, who managed not only to gain their own experience of treating external and internal diseases, but also to perceive and preserve experience of former generations (more often of their direct ancestors).
Archaeological findings show, that healers of the Slavs, living in Kievan Russia, had a rather good knowledge of treatment of craniocerebral injuries. Belyashevsky N.F. found a skull with a burr hole in the area of the frontal eminence during excavations, carried out near the ancient Slavic settlement of Knyazhaya Gora, situated on the bank of the Dnieper in the Kanevsky uyezd (the last word is a synonym to district). According to other archaeological findings, this skull belonged to a man of the epoch of Grand Dukes, i.e. Kievan Russia (the IX-XIIth centuries B.C.). Smooth edges and regular contours of the defect indicated, that trephination was performed with the help of special instruments.
In 1895 D.N. Anuchin published his book An Amulet Made of a Bone of a Human Skull and Trephination of Skulls in Ancient Russia, containing a detailed description of archaeological findings and 13 illustrations.
While examining 600 skulls and other bones of skeletons from ancient burial places of the settlement Belaya Vezha (the X-XIth centuries), V.A. Goikhman from the Museum of Anthropology and Ethnography of the USSR Academy of Sciences (1954) detected signs of wounds in 15 skulls. These wounds were inflicted mainly by cold steel (mattocks and combat axes). Blunt lesions by cudgels were much less frequent. There were two skulls with signs of trephination, made in life time.
Appearance of classes in Russia led to a growing influence of religion on medicine. At first duties of healers were performed partially by soothsayers and then, after Christianisation, by priests. Thus, one could watch simultaneous existence of two types of healers: a folk healer-empiricist and a healer-priest. The first military doctors, treating princes, their armed force and families, came from these healers-empiricists.
One cannot say precisely, when the first hospitals appeared in Russia, but Christianity introduction led to building of cloisters with their almshouses and asylums, where treatment was carried out. Information on lechtsy (this Russian noun originates from the verb lechit, which is synonymous to the English verb treat; its meaning is a person, who treats) and hospitals can be found in the earliest samples of the Old Russian written language. Some rules and instructions, concerning everyday hygiene, were included into books of a general character, for example Domostroy (the XVIth century), being a manual on housekeeping. It was constantly supplemented by new details and did not lose its significance till reforms of Peter the Great. Besides, Domostroy contained instructions on treatment of various diseases. The book Stoglavny Sobor (1551) described how to take care of the sick and cripples and ways of their treatment. At the same time there appeared manuscripts, devoted to problems of treatment. Both herbals and the aforesaid manuscripts were based on profound experience of folk empiric medicine and knowledge of Russian professional healers. Besides, one could find works by Hippocrates, Aristotle, Galen, etc., translated into Russian.
There was no state body, governing medical activity, in Moscovite Russia. The Aptekarsky Prikaz (Chemist's Department), created at the end of the XVIth century and responsible for control of treatment of the tsar and his family, compensated the existing situation to some extent. The first drugstore in Russia, ruled by Ivan the IVth, was organized in 1581 with the same purpose. The second chemist's shop with free sale of drugs to everybody, who needed them, was opened in 1672 and called the lower one. At the end of the XVIIth century the Aptekarsky Prikaz started sending boxes with drugs to different regiments. Distribution of drugs among the sick and wounded was carried out by special persons, nominated by commanders. Besides, it became almost a tradition to invite doctors, healers and chemists from other countries. However, it was done only for treatment of the tsar's court. The first healers' school was organized in 1654. It was attached to the Aptekarsky Prikaz. Its pupils were chosen from strelets children (strelets - a soldier in the Russian regular army of the XVI-XVIIth centuries). They studied elements of anatomy, physiology, surgery, therapy and different drugs. When a theoretical course was over, the students had practical training under the guidance of experienced healers. Those, who managed to finish school, were sent to regiments for treatment of warriors.
Development of the state and book-printing had a serious impact on medicine. Epiphany Slavinetsky from Moscow translated into Russian a classical book by Andrei Vesalius, entitled On Anatomy of Human Body and other works on natural science and medicine.
Vesalius not only summarized existing data on anatomy of the nervous system, but also checked many of them on cadavers. The works by A. Vesalius contained both some exact information and suppositions on functional significance of this or that structure of the nervous system. Publication of his famous book On Anatomy of Human Body (1543) should be regarded as a starting point of development of a new trend, characterized by use of anatomic data for understanding of functional significance of organs and tissues. The book had sections, devoted to anatomy of the brain and nerves.
It is worth mentioning, that Vesalius treated don Carlos, the grandson of Karl the Great (Spain), and trepanized his skull with a favorable outcome.
In 1656 a military hospital was opened in Smolensk. A similar hospital was built in Moscow in 1678 on money, allocated from the State Treasury. It was followed by appearance of the edict, which was issued in 1682 and ordered to open two civilian hospitals in Moscow. It was planned to use them both for treating patients and training young doctors. This was a daring initiative in comparison with methods of teaching, used in western Universities.
A period of medieval scholasticism in Europe was characterized by use of only those medical textbooks, which were reviewed by clergymen. Revival of clinical training in Western Europe in the XVIth century was connected the name of Giovanni Battista Montano, Professor of the Padua University, according to whom "studying was possible only in case of visiting patients".
The Leiden University (Holland) played a decisive role in development and introduction of clinical training at the end of the XVIIth and beginning of the XVIIIth centuries. The University had a clinic, headed by Herman Burhaave, who was a doctor, chemist and lecturer. Besides, he was in charge of the University and the Chairs of Medicine and Botany, Chemistry, Practical Medicine. Burhaave considered, that "clinical medicine was medicine, dealing with patients near their beds". The clinical school, created by him, was of extreme importance and contributed much to development of European and world medicine. Students and doctors from many countries came to his clinic. His brilliant lectures were attended by many famous people of that time, including Peter I.
There was no surgery in pre-Petrine Russia. Some operations and manipulations were performed by craftsmen (bone-setters, barbers). When a case was of exceptional importance, they were done by foreign doctors, being a rarity in Russia of that time.
In 1692 Peter I sent P.V. Postnikov to Padua. The latter was a person of great abilities and defended his thesis for a doctor's degree brilliantly. It was entitled Signs Indicative of Saprogenic Fevers. Other young people from Russia, sent to the Padua University later on, graduated from it quite successfully as well. Peter I invited 150 doctors from abroad (a great number for that time). It allowed to satisfy the requirements in medical care.
One more important person, who did much for development of higher medical education in Russia, was Nikolai Lambertovich Bidloo, a native of Amsterdam. He entered the Leiden University and studied medicine under the guidance of Burhaave. Bidloo was invited to Russia in 1702 and became a private doctor of Peter I. In 1707 he was put at the head of the first Russian hospital school, opened on the initiative of the sovereign in the first military land hospital (today it is the Burdenko Chief Military Hospital). Bidloo was in charge of both the school and hospital for nearly 30 years. The Moscow hospital was a good training base for its time, where one could find abundant clinical material. The school had a dissecting room and botanic garden.
The school program included teaching anatomy, surgery, dressing, internal diseases with postmortem examinations, pharmaceutical science, Latin, drawing. Surgical technique was studied on cadavers. A period of training was equal to 7-11 years. There were no textbooks. Thus, Bidloo taught student using his manuscripts: A Mirror of Anatomy, A Treasure of Medical-Practical Lectures, Instructions for Those Who Study Surgery in a Dissecting Room. The latter was published in Latin and Russian.
Instructions for Those Who Study Surgery in a Dissecting Room, dated 1710, was the first manual on surgery in Russia. Bidloo's surgery was based on settled elements of anatomy. In 1712 he wrote a letter to Peter I, informing him about the first graduates of the school. It read: "I have taught them surgery on an anatomic basis". There were 3 graduates in 1712, 6 in 1713 and 12 in 1714. Bidloo N.L. went down in history of home surgery as its first teacher and an author of Instructions for Those Who Study Surgery in a Dissecting Room, being the first manual of this type in Russia.
The above school became a large center of training and played a very important part in history of Russian medical education. Further improvement of medical education in Russia was connected with opening of two general hospitals: a land military hospital in Petersburg (1717) and an admiralty hospital in Kronshtadt (1719). Healers' schools, attached to these hospitals, were organized in 1733. They were called medical-surgical schools. M.I. Shein (at first a graduate of the Kronshtadt hospital school and then professor of anatomy) translated Anatomy by Geister (1757) and Thorough Surgical Instructions by Platner (1761).
Peter I, who was an ardent reformer, made a serious attempt to introduce surgical education in the hospital, founded by him (Bidloo's school in Moscow). Then similar schools were opened in some hospitals of Saint Petersburg.
Central general hospitals (Moscow, Petersburg) had officially appointed operators, who, at the same time, were responsible for teaching surgery in medical schools. Despite existence of hospital operators in Moscow and other cities, interventions were made by ordinary empirics, whose knowledge of medicine was very poor, but who had skills of performing this or that single operation.
Development of Russian medical education was greatly effected by opening of the Academy of Science in Saint Petersburg in 1725. Its first President was L.L. Blumentrost, Peter's physician-in-ordinary. The Academy was both a scientific and educational establishment. It comprised a gymnasium, academic University, library, Cabinet of Curiosities, astronomic observatory, dissecting room and botanic garden.
Members of Blumentrost's family occupy an important place in history of Russian medicine. It consisted of famous doctors, who worked in Russia at the end of the XVIIth and beginning of the XVIIIth centuries. Lavrenty Alfyorovich Blumentrost (1619-1705) was a famous German doctor, invited by Aleksei Mikhailovich (the Russian tsar) to serve as a physician-in-ordinary (1668). He studied in Helmstedt, Leipzig, Jena and was conferred his doctor's degree in 1648.
Ivan Lavrentyevich Blumentrost (1676-1756) was his elder son. He worked out a project, aimed at reorganization of medical business. According to it, all medical institutions of the state should be governed by a medical office or board. I.L. Blumentrost studied in Kenigsburg and Halle, where he defended his thesis in 1702. He was a military doctor and physician-in-ordinary. When his project was approved, he filled a high post and headed the Medical Office during many years (1721-1730).
Lavrenty Lavrentyevich Blumentrost (1692-1755) was his younger son. He (together with Schumacher) worked at a project of creation of the Saint Petersburg Academy of Sciences and then became its first President (1725-1733). L.L. Blumentrost was a physician-in-ordinary of Peter the Great. He studied medicine in Halle, Oxford and Leiden, where he was taught by famous Burhaave. L.L. Blumentrost defended his thesis in Leiden. He accompanied Peter I during his trip to Europe, where he entered into negotiations with an owner of the museum of anatomic specimens with the purpose of buying it for the Cabinet of Curiosities. After 1738 he was a senior doctor of the hospital and director of the hospital school in Moscow.
The reform of medical education was carried out by P.Z. Kondoidi, who was an official of high standing and President of the Medical Office (it was founded in 1719 instead of the Aptekarsky Prikaz). It resulted in certain changes: including physiology, obstetrics, women's and childhood diseases into the program of medical-surgical schools and introducing a seven-year term of study and examinations (since 1753). Kondoidi P.Z. did much for creation of the first Russian medical library (1756). Hospital schools were detached from hospitals in 1786. They became independent establishments with a more complicated educational program, whose goal was training both practical doctors and scientists.
A new reform of medical education was carried out in 1795. Its initiator was A.I. Vasilyev, who filled the post of Chief Director of the Medical Board (it was founded in 1763 instead of the Medical Office). The last step of the reform was an edict, ordering to create the Petersburg Medical-Surgical Academy (1798). Besides, there appeared the Moscow Medical-Surgical Academy, closed in 1846.
The opening of the Moscow University (1755) with its medical faculty was a great event in the cultural life of the country. It was the first Russian University, planned by M.V. Lomonosov, the most outstanding scientist of the country. The first lecture at the medical faculty was delivered Erazmuz I., Professor of anatomy, surgery and obstetric aid, in September 1764. From the very beginning the Moscow University became a center of training lecturers and researchers. The University was authorized to confer a degree of Doctor of Medicine in 1791. History of the system of attesting scientific and teaching personnel numbers more than eight centuries. It is likely to go back to the XIIth century, when the Bologna University conferred the first doctor's degree (1130). The Russian attestation system appeared in the XVIIIth century, during which ideology and traditions of national scientific elite were formed. The latter was represented by members of the Russian Academy of Sciences, professorial and teaching staff of the Academic and Moscow Universities and other educational establishments.
Conferring medical degrees became a prerogative of councils, created in Universities and medical schools of equivalent importance. Their practical activity was based on the Statute of Medical Degrees of 1819, worked out for the Saint Petersburg Medical-Surgical Academy.
Some laws, rules and regulations, issued later (1837, 1838, 1845, 1864, 1884), became a legal basis for the system of scientific attestation of the XIXth and the first decades of the XXth centuries. At first there was no common and independent organization for conferring medical degrees. It was responsibility (till October 1917) of professorial boards of the above Universities, Military Medical Academy and Women's Medical Institute, whose programs were identical to those of Universities' medical faculties.
After the revolution (1917) scientific degrees were annulled by the decree of October 1, 1918, issued by the Council of People's Commissars of the Russian Federation and entitled On Some Changes in Staff and Structure of State Scientists and Higher Educational Establishments of Russia. Scientific degrees of a Candidate and Doctor of Medical Science were introduced only in 1934 by the edict of the same Council, entitled On Scientific Degrees and Statuses. Besides, the first members of the Higher Attestation Commission were elected.
Opening of the Petersburg Medical-Surgical Academy (1798) was an important landmark in Russia's life. The Academy contribution into training of medical officers is enormous. Its history of more than 200 years is full of wonderful events and it has always been the biggest scientific-medical center of Russia.
The foundation of Medical-Surgical Academy was that very step, which resulted in further development of surgery, based on scientific principles, and appearance of some famous scientists, who created scientific-practical surgical schools of their own.