The influence of war on the development of neurosurgery

Abstract

I would remind you again how large and various was the experience of the battlefield, and how fertile the blood of warriors in rearing good surgeons. Hieronymous BrunscHwig, 16tH century 3Since the dawn of humankind, a symbiotic relationship has existed between casualties of human conflicts and those tasked with the treatment of these casualties. As humankind has developed more effective combat weaponry and methodology, so has humanity evolved in its ability to treat the resultant wounds of war. This relationship has been a critical factor behind the development of medicine and surgery and, in the nascent field of neurosurgery, an important driving force in the early growth of the specialty. Prehistoric Times Until the 19th Century: From Ancient Trephinations to the Beginning of the Modern AgeThe discovery of a trephined Peruvian skull by Squier in the 1860s and the excavation of Neolithic skulls in Central France by Prunières in the 1870s showcased the art of trephination to an increasingly modern and scientific world.19 Anthropologists subsequently sought to determine the circumstances under which prehistoric peoples would venture into the intracranial spaces as early as 10,000 years ago. Several theories were proposed. Paul Broca postulated in 1874 that these ancient trephinations were performed mostly in children for relief of evil spirits. 19 Sir Victor Horsley disagreed, advancing his theory in 1887 that these ancient forays into the skull were for the relief of epilepsy due to depressed skull fractures overlying the motor cortex. 29 After investigation of a large number of trephined Peruvian skulls excavated near an ancient fort, paleopathologist Roy Moodie concluded that the practice was most commonly used for the treatment of battle injuries. 48 Although it is not completely certain why ancient trephiners on different continents chose to delve into the cranial contents millennia before aseptic principles and a modern understanding of cerebral function existed, the relief of war wounds was one of the primary indications.The art of cranial surgery was thought to have remained primarily in the purview of primitive, prescientific surgeons until discovery of the Edwin Smith Surgical Papyrus in 1862 and its subsequent translation in 1930 (Fig. 1). This historic document provided the first evidence of a decidedly scientific approach to the cranial contents that dated back to approximately several thousand years BC. In fact, this Egyptian treatise on battle surgery provides many of the first descriptions of neuroanatomical structures as well as being the first known document to chronicle the The influence of war on the development of neurosurgery Historical vignetteJustin DowDy, M.D., anD t. Glenn Pait, M.D. Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, ArkansasThe treatment of craniospinal war wounds proved to be a significant driving force in the early growth of neurosurgery as a specialty. This publication explores the historical relationship between the evolution of ...

The shipboard Beirut terrorist bombing experience: a historical account and recommendations for preparedness in events of mass neurological injuries

“…War and neurosurgical understanding have shared a reciprocal relationship that extends millennia. 8 There is no debate that mass casualty situations are better handled by the prepared provider and facility. 9 Much of the evidence supporting current triage protocols has been gathered from database review of events that occurred in resourcerich cities, where "over-triage" was not only permissible but preferred, a notable difference from many battlefield scenarios.…”

Impact of 20th Century Wars on the Development of Neurosurgery

“…Whereas surgeons dating back to WWI advocated aggressive debridement, exploration and removal of bone fragments, including re-operation if fragments were later discovered on radiographs, Iranian and Israeli surgeons were able to embrace a less aggressive strategy of leaving indriven fragments alone unless they otherwise readily presented themselves [24,25] . The Iran-Iraq War also provided the conditions for a groundbreaking study of traumatic cerebrovascular injuries and led to the discovery that approximately 3-6% of soldiers with high-velocity missile head wounds showed angiographic evidence of aneurysm formation; these soldiers were treated with clip ligation or observation [27,28] . The experiences of the Iranian and Israeli neurosurgeons involved in the Iran-Iraq War and the Lebanese-Israeli conflict not only highlight the potential for advanced neuroimaging to modify the treatment strategies of head-injured soldiers but also lend credence to the application of these strategies to civilian cases.…”

“…Consequently, these devices can often be fashioned by relatively poorly trained insurgents on modern day battlefields using little more than an internet connection and rudimentary and available explosives materiel. The resulting increases in the numbers of head-injured soldiers suffering from severe TBI has prompted somewhat of a paradigm shift amongst military neurosurgeons towards aggressive use of early hemicraniectomies in severely injured soldiers [28] -an echo of the WWI and WWII improvements in the mortality of headinjured soldiers conferred by early neurosurgical intervention. Much like increasing numbers of surviving WWII soldiers harboring large skull defects drove corresponding advances in cranioplasty technology, it seems likely that an increased number of blast-injured soldiers recovering from severe TBI will yield further insights into the rehabilitative approach to brain-injured soldiers.…”

Neurosurgery in Aberdeen Royal Infirmary C. 1920– C.1940: Knowledge, Skills and Styles

“…Experience in the management of head and spinal wounds sustained during WWI further contributed towards the evolution of this speciality. 34,35 As neurosurgery was in its infancy, it was devoid of any standard protocols. The surgical technique adopted by surgeons wishing to operate on the nervous system was of paramount importance for the undertaking of these procedures.…”

“…The development of neurosurgery is acknowledged to have had a large military component 34,35 and the skills and knowledge acquired from WWI clearly played a major role in Aberdeen. Many general surgeons from ARI were serving as surgeons during the war.…”