The year 1993 marked the centennial of the publication of Sir William Macewen's monograph, Pyogenic Infective Diseases of the Brain and Spinal Cord, and its accompanying volume, Atlas of Head Sections. As Harvey Cushing noted, the text on pyogenic diseases of the brain was a landmark in surgery of the nervous system. At the time of its publication, Macewen's work was the most comprehensive study of pyogenic brain diseases. In this paper the author reviews the state of knowledge of brain abscess existing in the 19th and 20th centuries, with particular emphasis on the late 19th century, and elucidates factors contributing to Macewen's remarkable success. His thorough knowledge of the natural history of pyogenic diseases of the temporal bone and nasal sinuses, in addition to his clear description of cranial anatomy, as illustrated in his Atlas of Head Sections, were especially important in developing his successful treatment of brain abscess. The x-ray had not yet been discovered; Macewen's diagnosis was based on clinical findings superbly illustrated by his three clinical stages of brain abscess development. His clinical observations are as relevant today as when he described them 100 years ago. Macewen recorded 25 cases of brain abscess. Nineteen of these patients came to his attention in time to undergo surgery, resulting in 18 recoveries. All five of his patients with extradural abscess recovered. These results were achieved in the era known as "the most glorious period in British surgery." Neurosurgery was in its infancy; nevertheless, even as the 20th century closes, Macewen's results still have not been surpassed.

Harvey Cushing made fundamental and seminal contributions to pediatric neurosurgery. Early in his surgical career, he described the diagnosis and treatment of subdural hematomas in newborn infants. Important investigations on the cerebrospinal fluid and the nature of hydrocephalus were carried out under his direction, first by Walter Dandy and Kenneth Blackfan in the Hunterian Laboratory at the Johns Hopkins School of Medicine, and shortly afterward by Lewis Weed at the Laboratory of Surgical Research at Harvard. Cushing's principle interest throughout his professional career was the surgical treatment of brain tumors. By his careful clinical examination of patients. Cushing described for the first time a typical and composite picture of the more common tumors of the posterior fossa in children, particularly the cerebellar astrocytomas and medulloblastomas. Percival Bailey, working under Cushing's supervision at Harvard, studied and classified the glioma group of brain tumors. This contribution by Bailey was a major factor in the understanding of the characteristics and natural history of these tumors. In the closing years of Cushing's surgical practice, he published three major papers summarizing the characteristics, clinical picture, and treatment of the more common brain tumors in the pediatric age group. As a result of his exceptional surgical skill and innovations, he was able to achieve a surgical mortality of only 4% in operations on brain tumors in children. These landmark papers secured Cushing's place as a pioneer in pediatric neurosurgery.

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As a specialty, neurosurgery was not on firm footing at the turn of the century (1900); however, it was brought into being in the American South early in the 20th century by seven young surgeons, all of whom performed neurosurgical procedures as part of their general surgery practice. A close look at the seven reveals that they were trained and/or influenced in varying degrees by either Dr. Harvey Cushing or Dr. Victor Horsley, two outstanding surgeons and teachers of this period. After overcoming many obstacles, these seven men firmly established the surgical specialty of neurosurgery in the South.