The evolution of field neurosurgery in the British Army

During the First World War there were no special facilities for the treatment of head injuries until it was realized that early operation and the avoidance of slow and distressing evacuation gave much better results and less infection of the wounds. Hospitals located a few miles from the front were therefore designated for the reception of head-wounded soldiers, and postoperative cases were held there for two or three weeks before being sent on. The principles of what came to be known as neurosurgery were formulated by Harvey Cushing, an American working in Boston. There were very few surgeons with expertise in the treatment of war wounds of the head; however, the need for a thorough exploration and the removal of all bone fragments was slowly appreciated and, when it was possible, primary wound closure soon after injury avoided herniation of brain into the skull defect and scalp wound—a very undesirable condition known as brain fungus. The postoperative mortality was about 50% but many died before reaching a surgeon. The work of these pioneers was reported in several papers that were a valuable record,1-7 though unfortunately not all their experience was remembered twenty years later. There were great advances in technique and equipment in the years between the two World Wars but neurosurgery remained a very small specialty practised by men who had also to care for general cases.