The management of cranial injuries in antiquity and beyond.

Cranial injuries were among the earliest neurosurgical problems faced by ancient physicians and surgeons. In this review, the authors trace the development of neurosurgical theory and practice for the treatment of cranial injuries beginning from the earliest ancient evidence available to the collapse of the Greco-Roman civilizations. The earliest neurosurgical procedure was trephination, which modern scientists believe was used to treat skull fractures in some civilizations. The Egyptian papyri of Edwin Smith provide a thorough description of 27 head injuries with astute observations of clinical signs and symptoms, but little information on the treatment of these injuries. Hippocrates offered the first classification of skull fractures and discussion of which types required trephining, in addition to refining this technique. Hippocrates was also the first to understand the basis of increased intracranial pressure. After Hippocrates, the physicians of the Alexandrian school provided further insight into the clinical evaluation of patients with head trauma, including the rudiments of a Glasgow Coma Scale. Finally, Galen of Pergamon, a physician to fallen gladiators, substantially contributed to the understanding of the neuroanatomy and physiology. He also described his own classification system for skull fractures and further refined the surgical technique of trephination. From the study of these important ancient figures, it is clearly evident that the knowledge and experience gained from the management of cranial injuries has laid the foundation not only for how these injuries are managed today, but also for the development of the field of neurosurgery.