In this second special episode we continue our look at the medical side of war with a special focus on neurosurgery.
Hello everyone, over the next hour or so we are going to continue our look at the medical side of the First World War, this time focusing specifically on areas and topics surrounding neurosurgery. There will be several topics in this area that we will need to cover, starting with just sort of the overall state of neurosurgery in 1914 when the war started, with particular focus on the British and American schools. Then we will dive into treatments for brain injuries which were developed and refined during the war, focusing primarily on the treatments pioneered and standardized by the American doctor Harvey Cushing. We will then talk a bit about Shell Shock, or PTSD as it is more commonly known as today. From a modern perspective the inclusion of a discussion about PTSD while discussing physical injuries to the brain may seem like an odd combination, however during the war, and especially in its early years, this association would not have been out of place, for reasons that we will discuss. The very name for the condition, Shell-Shock gives a pretty good hint as to why. We will close out by just doing a quick overview of some of the impacts that the war had on neurosurgery. AS with my previous talk I feel like I need to give a bit of disclaimer here up front that I am not a doctor, and I have no medical training, so just be prepared for me to mispronounce some big long medical sounding names. I also believe that there will be questions at the end, probably a bit more than my previous talk which I was a bit long-winded on.
People have been studying the brain throughout all of history, and there have been brain surgery attempts with varying degrees of success throughout most of that time. For the Americans there was a lot of work put into a sort of proto-modern neurosurgery during the American Civil War with men like Silas Weir Mitchel and William Hammond taking advantage, which is sort of an odd word to use here, but anyway taking advantage of the wounded soldiers from the war. During conflicts the experiences that doctors could get, and this is in no way limited to the Americans or the Civil war, but the amount of experience they could get in a short time was so much higher than during peace time. Cushing would discuss this quite a bit in his accounts of the war, with the number, variety, and severity of the cases that he treated being so much more than what he encountered before the war. By the time that you get to 1914 there were many developments around the practice of neurosurgery. Most importantly they had gotten to a place where there was a much higher rate of not just survival, but actual success in the operations. One of the advantages we have when looking at the experience of doctors during the war is that we have really good statistics about injuries, treatments, and survival rates and that can really give us insight into how successful various treatments were. While we are going to be focus on the Americans and British today there was a good amount of communication between doctors from various countries before the war. Doctors from America and Europe would meet pretty regularly to discuss findings, observe practices, and generally just learn from each other. There were also several available medical journals that assisted these doctors when it came to learning and distributing their findings.
The last few decades of the 1800s and then the years leading up to the start of the war were very important years for Neurosurgery. All over the world doctors were starting to learn all kinds of different procedures that resulted in a laundry list of operations that were first successfully performed during this time period. One of these doctors was the German Neurosurgeon Fedor Krause. He was born in 1857 and would begin his work in neurosurgery in 1883. He would be a key player in the introduction of epilepsy surgeries into Germany and then move on to a pioneering role in the use of electricity during surgery. In what is the first instance today, here is something that I barely understand the meaning of, but it sounds important. He would be the first doctor to perform “intraoperative electrical stimulation on the cerebral cortex.” As with most of other doctors of his generation when the war started he would provide services for the army, in his case the German army where he would serve as a surgical consultant for the duration of the war. He would use the experiences he gained during this time as the basis for a quite lengthy work that he would publish after the war. These books would include hundreds of hand drawn illustrations which were known around the world for their detail and accuracy.
One thing to keep in mind as we discuss Krause, and most of the other doctors during the war, is that anytime you are talking about doctors from this era of history you have to consider the fact that specialization was not really common at this time. Modern medicine is full of specialists, and doctors may be incredibly focused in their area, since I am currently standing in a school of neurosurgery I believe I am contractually obligated to say that this is a good thing. However, if you talked to a doctor in say 1900 you might get a very different opinion on the role of specialization in medicine. The most rabid anti-specialists could often be found in Britain. While in many countries the concepts and value of specialization would eventually become accepted at the very least after the end of the war, in Britain there would be strong resistance to the idea into the middle of the 20th century. This resistance was rooted in the idea that specialists were simply not practicing medicine properly. They believed that you had to consider and interact with the whole body, not just a piece of it and it was only through broadly considering the whole body that a doctor could be as efficient and effective as possible. Because of this negative view of specialists, doctors that were making discoveries in what we would today consider specialist areas would do whatever they could to resist getting the specialist label applied to them, this included neurosurgeons. This type of anti-specialization can be seen all over late Victorian British society. Men that we would now consider to be some of the pioneers of British neurosurgery, like Sir Victor Horsely that I will discuss more of here in a bit found ways to make sure that they were not sort of shoved into the specialist classification. This meant that their research was both narrow and then made intentionally broad at the same time. One of the easiest criticisms to lay against this type of system is that doctors who could have spent all of their time specializing and probably moving those specialities forward in important ways instead spent their time trying to take their findings in a specialist area and then apply them to other parts of medicine, or spent time just doing research on other areas to make sure they were not pigeon holed into a specialty. The First World War, by its very nature would end up playing a role in breaking this resistance to specialization in many countries, and in Britain it would create the first cracks in the wall. The reason was pretty simple, efficiency was very important. The sheer number of casualties that were experienced during the war was staggering, hundreds of thousands, millions, of men were wounded at the front. Efficiently providing them with treatment was critical to making sure that people did not die unnecessarily. This forced the medical organizations of all of the armies to create specialist treatment centers that only dealt with one type of injury, and there was no shortage of just about any type of injury. This setup was done mostly to try and save lives, but it also ended up forcing doctors into becoming specialists. If a doctor was at a hospital that was made into a hospital that only saw brain injuries then that doctor would become a specialist in brain injuries. This system allowed doctors to see hundreds of the same cases over and over again, really on a scale never before considered, and it allowed them to iterate on and refine treatments. Neurosurgery was a great example of this because there would be no shortage of head wounds that would need to be operated on.
One of the best known of these British non-specialist specialists was Sir Victor Horsely. Horsely was born in 1857 and was the third of seven siblings. He would go on to become one of the most well known neurosurgeons in the world. In 1886 the Queen Square Medical Board, when trying to find a new surgeon to continue research on cranial surgery would name Horsely as their new surgeon, with a new title, neurosurgeon. I am pretty sure that this is the first time that there was an official position created with the title of neurosurgeon. His first surgery after his appointment would be a successful surgery on a child who had contracted epilepsy after a blow to the head, this surgery involved the removal of a cortical scar, which was at the time a dangerous and somewhat novel procedure. During his time at Queen’s Square Horsely would perform numerous surgeries, including several world’s first procedures. One example of this was the successful removal of a spinal tumor. Horsely was known as a surgeon who was very nice to his patients, but also very rude to other surgeons, especially those who were considered colleagues. When it came to surgical technique he was known for his confidence and speed. Without drugs or X-Rays he would use his neuro-anatomical knowledge to, pretty much, boldly go where no man had gone before. One of the most famous descriptions of one of these procedures comes from Cushing. Now, before describing Cushing’s account of this procedure it is important to point out that Cushing and Horsely subscribed to very different theories on surgery. Cushing was slow, methodical, patient, obsessed with every detail. Horsely was essentially the opposite, to borrow a sports term he was something of a gunslinger, but he was still considered one of the very best in the wrold. This meant that when Cushing went to Europe in 1900 to meet with neurosurgeons he made a stop in London to see Horsely. One of the first surgeries that he observed was the removal of a Gasserian ganglion which Horsely would perform in less than an hour, a speed that Cushing found utterly shocking. Cushing would write that he found Horsely’s laxity and lack of technique, or at least technique as Cushing defined it, to be utterly horrifying. He would even cut his London visit short, believing that there was nothing that he could learn from the British doctor. I guess it is only fair to point out that Horsely was also not a huge fan of Cushing, he would call him a ‘brash self-confident American.’ When the war started, Horsely would find his, let’s call it unfavorable, reputation among his colleagues to be a detriment to his services during the conflict. Honestly the army did not really want him, but he was an officer in the Territorial Army, and they needed everyone that they could get. He would spend just over a month in France before being sent to the Middle East. First he spent some time inspecting medical facilities at Mudros, an island in the Eastern Mediterranean, and then he would do the same at Gallipoli near modern day Istanbul. After these inspections were complete he would be sent to the Mesopoatmia in modern day Iraq. The British were attempting at that point to advance up the Tigris and Euphrates to capture Baghdad, and the conditions were less than optimal. In the heat of the desert Horsely, by this point 59 years old, did not properly scale back his workload. On July 14th, on a day when it was 110 F in the shade, he would suffer from heat exhaustion, and he would die just two days later.
Now it is time to talk about Harvey Cushing, I believe I have already mentioned him 4 or 5 times a situation which is almost unavoidable when discussing neurosurgery at this point in history. He would be at the very foundation of American neurosurgery and his often cited as one of the primary drivers in changing brain wound care during the war in ways that greatly reduced the mortality rate suffered by patients. He was born in 1869, the last of 10 children, which as a father of one child seems like almost too many. He would attend Yale, and then Harvard Medical School, and then perform a surgical residency at Johns Hopkins. While he was at Johns Hopkins he would be greatly influced by Doctor William Halsted, and it would be during this time that Cushing would really buy into the techniques that Halsted championed, techniques that emphasized precision, efficiency, and patience, the exact techniques that were so at odds with Horsely all those years later in London. Cushing would be a key player in the growing world of American neurosurgery before the war, but it would really be his experiences during and immediately after the war that would cement Cushing’s place in history. But before we get to all of that, I have to give a huge shoutout to Miss Julia Shepley. Miss Shepley was Cushing’s personal secretary before and during the war. Shepley would keep detailed records of the day to day events of Cushing’s life and would be the one to organize the incredibly detailed case histories for his patients. These details would be kept for all of the thousands of men that Cushing would operate on during the war. Shepley is the real hero of this story, behind every great man is a great secretary, and in this story that secretary is Miss Julia Shepley. While American would not enter the war until 1917, American doctors would be overseas as early as 1915 working in hospitals in France and their experiences, and the experiences of other doctors would begin arriving back in America soon after the war started. This information was read and discussed in America, but Cushing would not really be involved with the war directly until America’s entry into the war in 1917. He would be among the first large groups of medical personnel to go overseas as part of Base Hospital No. 5 which would arrive in France in late May 1917. This would begin a year of mostly clinical activities for Cushing, which would be the period where most of his experience and surgeries would take place. During large portions of this time he would be operating over 12 hours a day, and due to the volume of cases he would find that his methods were sort of at odds with the overal priorities of the medical hospitals.
As I mentioned earlier Cushing was slow and methodical when operating, but there were a lot of men who needed surgery. Cushing was adamant that it was better to spend more time on one patient, and give them the best possible chance of success rather than rushing through two surgeries in the same amount of time. He would say “In the long run it is far better in an advanced hospital to get one successful primary closure of a penetrating wound of the brain, and to send two others to the base as yet untreated, than to do three incomplete operations in the same period of time with the probability that all three wounds will break down, and at best undergo subsequently at the base the tedious and uncertain course of secondary wound-healing over an exposed and fungating brain.” I am not really sure I am at a position to judge him on this viewpoint, but I will just point out that this method resulted in patients dying in his waiting room. The question would be whether or not the benefits to the patients that he did see were worth it, an answer I do not have and I am not sure is possible to determine. Cushing’s early experiences in military medicine are interesting, he makes a lot of observations about military medicine, for example his observation about the records that are kept about the patients that he oeprates on “The histories are all interesting, citing, as they do, the man’s name, regiment, the place where he received the injury and under what circumstances, how long he had had on his clothes without changing them, where he got his first, second, and possibly third dressing before reaching our ambulance, and so on each item full of horrible, though fascinating, possibilities. No doubt this will all seem very commonplace after we have been here a few days.” These types of observations are not at all uncommon among doctors coming to the front for the first time. While most of his time would be spent doing surgeries, Cushing would not just stay in one place and would instead find himself at various points behind the front as the needs of the armies changed. For example, he would spend the last half of 1917 behind the front in Flanders as the British launched their ill-fated Passchendaele offensive. This battle would continue with only brief pauses from the end of July until the beginning of November, with around 750,000 casualties suffered during that time. Around this time he would make some notes that contained a bit of insight about wounds that would be present during a large battle like that of Passchendaele “The wounds in most cases of course are multiple. “Multiple” indeed may hardly convey the impression. Mostly shell explosion effects —very few bullet wounds in a game like yesterday’s. Indeed the more trifling the wound appears to be, the more serious it may prove on investigation. Or the reverse may be true —an ugly-looking wound that proved relatively trifling.” During the five months of the battle Cushing would operate on hundreds of cases, almost all of which were head wounds, most of which involved brain injuries. He would later use these experiences as the foundation for two papers, one of just a few pages and then one of over 100 that he would publish in April 1918.
While he spent most of his time working on head wounds, he would be exposed to other types of wounds as well, like gas victims. Victims of gas attacks often play an important role in the first hand accounts of doctors during the war due to the effect that they would have on those at the hospital. Depending on the gas that was used gas casualties could be as minor as eye irritation from tear gas, but it could also leave the victim blinded, or experiencing extreme skin irritation, at the most severe, and impactful end of the spectrum were the gases that would destroy the respiratory system of its victims. Cushing would say this of some of the gas victims that he saw in late 1917 “Then we saw many of the severely “gassed” men who had come in this morning— a terrible business —one man, blue as asailor’s serge, simply pouring out with every cough a thick al- buminous secretion, and too busy fighting for air to bother much about anything else— a most horrible form of death for a strong man. Others seemed to be pulling through, though they looked bad enough.”
We are going to dig into the details of some of Cushing’s treatments very shortly, but before we do that I do want to discuss how revolutionary, or maybe non-revolutionary, some of his treatments were. The paper that he published in April 1918, from his experiences in 1917, sort of forms the foundation of his reputation as the originator of some of the most effective brain wound care procedures from the war period. However, a lot of the things that Cushing describes was already being used by other doctors, some of them from other countries. Most of his practices were already being used by European Surgeons, but Cushing fails to properly mention this or to properly credit the original creator of the treatments. I would not go so far as to say that Cushing plagiarized, or was actively involved in hiding the contributions of others, but he was certainly standing on the shoulders of other doctors. You can find some pretty scathing critiques of Cushing for his, I’ll call it borrowing, of the work of others. I generally fall into the category of saying that Cushing may have been a bit dishonest with his attribution, mostly dishonest by ommission. However, he did show skill in taking all the sort of disperate ideas from other doctors and combining them into the best possible treatments. Finding the best bits from others, and then properly combining them is still work, and important work. I like this bit from Doctor Neuhof of Columbia University, who is describing both Cushing and American surgeons as a whole “To the credit of American surgeons it can be stated that under the leadership of Colonel Harvey Cushing they contributed a real share to whatever progress (in the treatment of brain wounds [M.E.C.]) has been made. This was not arrived at through the development of new or original methods but by the adoption of the most desirable elements in the methods of Continental surgeons.”
One final thing before we dive into Cushing’s and other doctor’s, treatments that were developed and refined during the war. We are going to do a little thought exercise, I want everybody to think about a modern soldier, that is the only qualifications, just a modern day soldier. Now, everybody probably came up with a different mental image, but I bet that for the vast majority of you there is one major similarity, I bet that soldier is wearing a helmet. Helmets, and head protection as a whole, has become an important part of not just modern militaries but also modern society. Sports, activities, transportation, warfare, all of them are now full of instances where it is basically mandatory that the participant wears a helmet, either plastic or something a bit more durable. This was not always the case. None of the militaries of Europe provided their soldiers with head protection when they went to war in 1914, the soldiers at that time wore nothing more than felt or cloth caps that were more about protecting them from the rain and sun instead of shell fragments. They were surprisingly slow to change this, even as the evidence mounted that it was necessary. I do want to give one specific example of where this was really dangerous. Obviously warfare at this time was full of artillery, and machine guns, all kinds of things that are not good when they impact heads at high velocity. But there was one area of the war that took this to another level. There was fighting by the Italian and Austro-Hungarian armies in what is today northern Italy and Slovenia. They were fighting on mountains, honest to goodness giant pieces of rock mountains. They had artillery in this area as well, and I am sure you can imagine what very large explosions due to very large rock formation. It was not a fun time. Even with all of these problems though it would not be until 1916 that the armies around Europe would even begin to issue steel helmets and it would not be until 1917 that they were standard issue. I always like to bring this up before discussing anything about head wounds, because most people, if they have any mental picture of the soldiers of the First World War picture either the large quite iconic German Stahlhelsm or the equally iconic English dinner plate helmets but for a good portion of the war the soldiers would be fighting with about as much head proctection as a baseball cap would provide, to the detriment of their cranial integrity.
Now it is time to dig into Cushing’s treatments and experiences, most of this information comes from two works published in 1918, the larger of the two being A Study of a Series of Wounds Involving the Brain and its Enveloping Structures which is 127 pages in total. This is the second of his works, the first, weighing in at just 6 pages, is very focused on providing best practices for the treatment of wounds. The far larger work is far more detailed and contains a large number of very specific examples with all of the pertinent information on the various cases that Cushing saw during his time behind the front in 1917. It also has some pictures of patients, drawings, and x-rays. While providing all of these details both about the patients and the treatments provided, Cushing is very quick to point out that not everything in the document is perfectly correct, in the very first paragraph in the introduction he tries to put things in perspective by saying “When novel surgical experiences, no matter how numerous, are crowded into the period of a few weeks, it is unsafe to draw too many deductions there from. The past three years have shown how often favourable opinions which were not based on the study of end-results have had to be retracted-how often unfavourable opinions, based on improperly conducted operations, have had to give way to the results of those better planned. One needs but recall the story of many of the antiseptics, of abdominal operations, of experiences with wounds of the thorax and joints, of primary and secondary suture of wounds. Hence, what may be said in these pages is said with all reservation and with full admission of a brief apprenticeship.” Cushing also states that one of the primary goals of the paper is to counteract the typical feeling among medical personnel that chances of successful treatment and then proper recovery for head wounds is very small.
Cushing organizes this paper based on his categorization of cranial injuries, which he breaks down into 9 different levels. These levels range from simple scalp wounds at level 1 to “widespread cerebral contusion” at the top end. He believes that this type of new categorization scheme is necessary because far too often doctors were only considering the damage done to the scalp and skull and were not properly taking into account what was happening within the cranial cavity. This caused the wounds to be classified based on how bad the exterior, and easily identified wound was instead of properly accounting for the possible issues that external injuries could have on the brain. The bulk of the paper is spent going through each of the 9 categories and giving examples for each one, this includes example patients, treatments that were tried and how sucessful they were, and then general information about how to identify and treat the wounds. I am not going to go through each of these categories here, if only because I am completely unqualified for such a detailed discussion. However, I will give just a few examples of the types of information that can be found, specifically around scalp wounds. This would be the lowest classification Cushing would provide, and would also be the most common type of head wound during the war. Cushing would caution while many scalp wounds seem serious but end up being trivial even more appear trivial but then prove to be quite serious. The difficulty lies in determining which of these two situations a wound falls into. The process can be easy when there is plenty of time to properly examine the wound, but this time is very often not present at times when there are large numbers of wounded soldiers present. This type of information seems a bit rudimentary, but spelling it out in detail was important, especially in the presence of the large number of actual case examples that Cushing was able to provide, because this information was often given to doctors with little experience with head wounds who were being asked to properly identify and treat these problems at the front and under great stress.
One thing that becomes clear as you read through Cushing’s first hand accounts, both in his papers published during the war and then memoirs in the years after, is that sometimes things did not go as planned and that often nobody really knew what they were doing. My favorite story in this vein is around the process that was taken to extract a small piece of steel from a patient’s head. This was one of the very first patient’s that Cushing operated on in Europe. “We had tried every possible thing in our own cabinet and in those on the lower floors without success. Finally, while I was at lunch, Boothby hit upon precisely what was needed in the shape of a large wire nail about 6 inches long, the point of which he had carefully rounded off.” They would then attempt to use the nail to remove the object three times before, on the fourth try, it finally worked. “I slipped the brutal thing down the track, 3.5 inches to the base of the brain, and again Cutler gingerly swung the big magnet down and made contact. The current was switched on and as before we slowly drew out the nail, and there it was, the little fragment of rough steel hanging on its tip.” These types of very crude operations often get excluded from later literature and can be lost, but they showcase both the knowledge and ingenuity of many of these doctors.
There were a lot of topics of conversation during the war that were not just related to the actual surgical procedures that were performed, or how, where, why to cut or excise or suture, etc. Many of these conversations would come down to some very basic principles of medical care and opinions about how to apply them. One example of this is anesthesia, should doctors use local or general anesthesia when working on head injuries? At the start of the war general anesthesia was definitely preferred, but over time things began to change as doctors began to favor local anesthesia more often and to great effect. By the time that Cushing comes into the picture the local version was much more widespread and Cushing would give an overview of his specific views on the subject. “Cranial cases in more or less shock need not undergo a period of resuscitation. The operation should be done under local anesthesia combined with morphine…Only in exceptional cases, when patients are irrational or uncooperative is a general anesthetic necessary. Its administration always adds to the difficulty of the operation, and by increasing intracranial pressure causes extrusion of brain and tends to increase the damage already done.”
While anesthesia still sort of ties into the medical conversation and the specifics of surgical treatment one of the largest and loudest discussions that was had both around neurosurgery and just medical care during the war was at a much more macro and meta level, basically where precisely should certain procedures be performed. There was a kind of balance that had to be struck, and there was not a specific concrete answer to the question, which is what made the debate so ferocious. The balance was between providing care quickly, when the wound was fresh and perhaps infection had not taken hold, and then providing it further back from the front where the patient would receive objectively better treatment in better facilities and possibly by more specialized care givers. In my last talk I touched on the problems of infection and how its prevelance in wounds came as a shock to many doctors, and this pushed doctors to recommend that treatment be provided as quickly and as close to the front as possible to try and stave off that infection. There were also the logistical problems of transporting the wounded, many of which might die in transit. There were attempts to mitigate this problem by properly determining which patients should or should not be transported, but there was no guaranteed way to be sure. One method that was used for head wounds was by looking at the pulse, but there was always huge risk in transporting patients before they received treatment. One American doctor, W.W. Keen, who would write his own book in 1918 which is an overview of wartime wound treatment would say this about where the perform treatment “Especially do I indorse, on general principles…that the only proper hospital to interfere surgically with a cranial wound is one in which facilities and skilled men, both neurologic and surgical, and the best x-ray apparatus are to be had. I am told that at preesnt…some hospitals much nearer the trenches than formerly, are thus equipped. An incompletely studied case and an indifferent facility for diagnosis and operation have no place in cranial wounds. The late results of such surgery are lamentable.” In some ways technology would play a role in moving these arguments forward. One example that Keen mentions was the case was around x-ray machines. When the war started what x-ray machines were available were only found in base hospitals far behind the front. However by 1918 they would not have been out of place in casualty clearing stations very close to the fighting. This helped to move really good care closer to the front and allowed doctors there to make much better treatment decisions. There was also just the general trend of doctors becoming more efficient and skilled at providing care as treatments became better documented and more successful methods were determined. Cushing would weigh in on this topic, and would follow much the same line of reasoning that Keen did, however he does add a small addendum that warns against doing incomplete operations at any point in the evacuation chain “‘All or nothing’ is a good rule to apply to craniocerebral injuries-in short, evacuate these cases untreated to the nearest base rather than do incomplete operations.”
As I previously mentioned, in his six page work, Notes on Penetrating Wounds of the Brain, Cushing goes into detail about what he believes are the best practices for treating head wounds. In that document he outlines a 4 step process that should be used for operations on the brain, and specifically on wounds that involve the penetration of both the skull and brain tissue. The first step is to remove any particles from the area of cranial penetration. Cushing prefers that large pieces of the scalp and skull are remmoved from these areas rather than trying to do small bit and pieces which was the tendency of surgeons at the time. The preference for large removals is an effort to reduce the chances of contaminated tissue hanging around and causing problems. Cushing also notes that if any decompression operations are needed then the work should be done, if at all possible, on the side of the head away from the wound. This is again another preference to reduce the likelihood of infection. If this is not possible than the scalp, which should be considered possibly infected even if it is not confirmed, should be loosened and pulled back. The second step in the process is to explore the penetration to determine the presence of any fragments or foreign debris. A very important piece of this step is that this exploration should not be done with the finger. The use of the doctors finger was a very common method for exploring head wounds at this time. Cushing’s concern with using a finger is that introducing a finger, which is often quite large in comparison to the wound, can cause fragments or damaged tissue to be pushed outward from the damaged area into the undamaged areas of the brain. He suggests using flexible rubber catheter tubing for this purpose. This should be slowly moved through the injury, trying as much as possible to follow the path that the foreign object took into the brain. Step three is to use suction to remove as much of the damaged tissue and foreign object as possible. This is done through a tube by applying very light suction. It can be expected that this will remove some small foreign objects, but anything that is very large will need to be very carefully removed with forceps. The final step is to clean and close the wound, then treat against infection, for which he recommends dichloramine-T.
Obviously, when talking about medical care, and especially when discussing how doctors like Cushing changed medical care we have to talk about results. When you are talking about military medicine, results is all about mortality rates. This is an incredibly challenging statistic to discuss because there are so many variables at play that can effect whether or not a patient or group of patients lives or dies. I can give you the top line number that Cushing cites when discussing the success of his surgical techniques, that number is a reduction in the mortality rate for penetrating head wounds from 54.4% down to 28.8%, a very solid change. But even Cushing, just a few paragraphs after giving those numbers, cautions people about how to apply and interpret them. Part of this comes back to the conversation about where in the evacuation change an operation occurs, when and how to transport patients, and who can and cannot be operated on. Cushing pushes the variables even closer to the front, starting with the stretcher bearers out on the battlefield, “The more daring the bearer parties are and the more quickly the wounded are brought in the more lives will be saved, but contradictory as it may seem, the higher will be the hospital death-rate, for more desperately wounded men will reach the casualty clearing station alive than when a corps less energetic and less indifferent to danger is in the field. This applies to cranio-cerebral no less than to abdominal or thoracic wounds.” All of these variables meant that Cushing, either in a Casualty Clearing Station or in a Base Hospital could see drastically different cases depending on decisions made by doctors closer to the front. The most impactful way in which this affected the numbers was through the fact that the longer a patient stayed at the front, and as the understanding of shock grew throughout the war the patients would often stay near the front longer, the greater chance that they would survive an operation behind the front, if they made it that long. To put it quite simply, severely wounded patients would die before they got to the operating table, be it Cushing or some other doctor. This reduced mortality rate just because the surgeons were being called up on to work on fewer patients who were experiencing massive problems. But, there were also trends that worked in the other direction as well. The longer a patient went without surgery, especially for penetrating wounds, the greater the chance that the wound would become infected. All of these factors do not completely remove the fact that Cushing’s treatments were helping more patients to survive, but it is important to remember that there is far more at play then just what happened to the patients while on Cushing’s operating table.
I mentioned at the start of this talk that I would be discussing shell-shock today, which may seem a bit out of place. Mental conditions, which we know today as Post Traumatic Stress Disorder, have been a fact of life for soldiers since at least the early Greeks. That is at least the time period for the oldest surviving written account of what we think of today as PTSD. However, in 1914 this long history of mental problems due to the strain placed on soldiers during combat was not well understood. After the fighting started in 1914, and really within the first month of the war, there started to be widespread reports of men suffering from some kind of mental breakdown. The symptoms were all over the place, sometimes it manifested as paralysis or blindness or loss of the ability to speak or halluciantions or memory loss or night terrors, or any combination of any of those symptoms. We know today that these problems were caused by the stress of combat and it is a psychological problem, but during the early years of the First World War this was not the accepted cause. The study of psychology was relatively new at this point in history, and more importantly it was not necessarily widely accepted, and therefore the medical services tried to find a physical cause for the symptoms. Medical science, and neuroscience just as much as any other, had up to this point in history a pretty good track record of eventually finding the physical causes for a whole host of conditions that would have previously been attributed to a whole host of non-physical causes. This meant that when suddenly a bunch of men started coming into hospitals showing no physical injuries, but were obviously having some issues the hunt for the cause began. As I mentioned earlier, they did not really connect the problems they were having with those from the past, and so they believed that the problem must be new, and that meant a new cuase. So they looked at the current state of the war and started identifying things that were different than during previous military conflicts, the most obvious being the prevelance of artillery. There were almost constant explosions happening around the soldiers at the front, and so the common belief became that these explosions were doing something to the brain, even if they could not see it. One doctor would describe it as ‘an invisibily fine molecular commotion in the brain’ while other doctors would often use descriptions like ‘injuries of the central nervous sytem without visible injury.’ When the phrase ‘shell-shock’ appeared in a British medical journal it just sort of stuck, although it would gain different names in different countries, kriegsneurose, or war nervousness for the Germans and la confusion metale de la guerre for the French. I bring this up because we often discard basically everything about this trip down the wrong path, of trying to find the physical cause of shell-shock, but neurologists and neurosurgeons would devote a huge amount of time to investigating it, and trying to also cure it, during the war. Unfortunately for the patients, even once it was determined that the cause was not physical, that did not prevent some pretty drastic treatments from being tried. It would take several more massive conflicts before the proper classification of PTSD would be completed, and treatment is still a topic of study.
Even if shell-shock would remain a problem for the future, the world after the war did see a huge number of medical and neurosurgical advancements which made the year 1919 very different than the year 1913. An event like the first world war was certain to change countless things in societies all over the world, and the medical profession would be among them. In many countries the experiences during the war accelerated the move towards specialization, even if there were still some doctors who resisted. For neurosurgery it would take several more years before its separation from the general medical term ‘internal medicine’ was finalized. There were also, I would probably call them, less technical changes that are very impactful to the world of today. One example of this is the trend of doctors in the post war years to form group practices. These were the doctors and surgeons who had just spent 4 years working on giant medical teams and so when they came back to their civilian lives they sought to recreate these teams, albeit on a smaller scale, in the civilian world. They were also a generation of medical professionals who were more willing than those who had come before to push forward and away from the traditions and norms that had typified the pre-war era. Not every move was in the right direction of course, for example after the war British neurologists would spend years investigating whether or not shell-shock really did have a physical cause, even though most believed it did not by the time that the war ended. Even though there were a few misteps many of the trends that the war kickstarted did move the medical profession in the direction that we today would judge to be correct. For Cushing, well, he would find himself at the forefront of an American medical community that was experiencing a massive increase in international prestige. In late 1919 Cushing would present a paper at the American College of Surgeons, he would be discussing statistics of brain tumors, after the presentation Dr. William Mayo, as in Mayo Clinic Dr. Mayo would say that “Gentlemen, we have this day witnessed the birth of a new specialty–neurological surgery.” Roughly a year later he would be one of the co-founders of the world’s first Neurosurgical Society, cementing it as a separate discipline that required a special set of skills and knowledge. In his post-war push to make neurosurgery its own discipline, Cushing would always refer back to his experiences from the war, and how having doctors who specialized in head trauma and brain surgery saved the lives of countless patients, and at the end of the day, that is what really matters.