James Hill of Dumfries: First modern neurosurgical procedures

James Hill (1703-1776) was a surgeon from Dumfries in Scotland who can lay claim to being the first to treat head injury patients in a thoroughly modern manner. He was highly regarded in his lifetime and for a century afterwards but has subsequently been forgotten. He had the lowest surgical mortality for trepanation of any surgeon of his time. He uniquely presented his results after a lengthy follow-up of many years. His management of cranial fractures was advanced. He did not use the trepan for fissures as others did and his conservative management of depressed fractures was based on biological rather than mechanical notions. He had an instinct for the management of raised intracranial pressure (ICP) unique in his day even though he could not have understood it in modern terms. He operated on head injuries only if there was a disturbance of consciousness. He was aware of the importance of cerebral pulsation and was alone in recording it in a majority of operated patients. He was ready to open the dura when necessary and did so six times. He introduced non-compressive bandaging over skull defects after surgery. In three cases he shaved off brain hernias which resulted in marked clinical improvement. He not only understood that an injury or disease on one side caused a deficit on the other side but uniquely encompassed this knowledge in his treatment planning. In view of these many insights and achievements, he deserves to be considered as the first surgeon whose neurosurgical management is recognisably close to modern practice.