History of Cranial Trauma Surgery and the Meninges

To trace the evolution of ideas and practice in the management of meningeal injury from the ancient world to the end of the 18th century. The texts of significant surgical practitioners from Hippocrates to the 18th century were examined and analyzed. The dura was first described in ancient Egypt. Hippocrates insisted that it should be protected and not penetrated. Celsus proposed an association between clinical findings and intracranial damage. Galen proposed that the dura was attached only at the sutures, and he was the first to describe the pia. In the Middle Ages, new interest in the management of meningeal injuries arose, with renewed interest in relating clinical changes to intracranial injuries. These associations were neither consistent nor accurate. The Renaissance brought little change. It was in the 18th century that it became clear that the indication for opening the cranium following trauma was to relieve pressure from hematomas. Moreover, the important clinical findings on which to base an indication for intervention were changes in the level of consciousness. The evolution of the management of meningeal injury was colored by erroneous concepts. It was not until the Renaissance and finally the Enlightenment that a milieu developed that permitted examination, analysis, and clarification of the underlying processes that could lead to rational management.