Neurological surgery during the Great War: the influence of Colonel Cushing

Despite von Bergmann's work in the Franco-Prussian War and Makins' experiences in the Boer conflict, military surgeons in World War I were unprepared for the nature and extent of intracranial injuries. Poor triage, disorganized transportation, incomplete surgery, and sepsis resulted in a mortality of over 50%. In 1915, as a volunteer to the Ambulance Américaine near Paris, Harvey Cushing spent 5 weeks observing the Allied medical system. He quickly recognized the technical importance of early, definitive intracranial surgery and the logistical requirements for a unified triage system located along the main lines of traffic. Cushing returned to France in 1917 as director of Base Hospital #5, known as the Harvard Unit. Immediately detached to the British Expeditionary Force, he operated at a smaller casualty clearing station close to the Belgian front. The patients treated during the third battle of Ypres (Passchendaele) formed the basis of his technical reports. He standardized intracranial injuries into nine categories with separate mortality rates. In addition, he recommended the surgical techniques of en bloc bone resection under local anesthesia with suction debridement and primary two-layer closure. Shell fragments were removed by magnets when possible; dichloramine-T was used as an antiseptic. By reducing infection and secondary complications, Cushing halved the earlier mortality rates. In September 1918, as senior consultant to the American Expeditionary Force, Cushing was in charge of organizing the neurosurgical care for the St. Mihiel and Meuse-Argonne offensives. His instruction of individual surgeons in operative techniques and the creation of identified hospital centers with suitable equipment and trained personnel helped to establish neurological surgery as a military specialty.