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Sir Hugh Cairns and World War II British Advances in Head Injury Management, Diffuse Brain Injury, and Concussion: an Oxford Tale

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Sir Hugh Cairns and World War II British Advances in Head Injury Management, Diffuse Brain Injury, and Concussion: an Oxford Tale HISTORICAL VIGNETTE J Neurosurg 125:1301–1314, 2016 Sir Hugh Cairns and World War II British advances in head injury management, diffuse brain injury, and concussion: an Oxford tale James L. Stone, MD, Vimal Patel, PhD, and Julian E. Bailes, MD Department of Neurosurgery, NorthShore Neurological Institute, NorthShore University HealthSystem, Evanston, Illinois The authors trace the Oxford, England, roots of World War II (WWII)–related advances in head injury management, the biomechanics of concussion and brain injury, and postwar delineation of pathological findings in severe concussion and diffuse brain injury in man. The prominent figure in these developments was the charismatic and innovative Harvey Cushing–trained neurosurgeon Sir Hugh Cairns. Cairns, who was to closely emulate Cushing’s surgical and scholarly approach, is credited with saving thousands of lives during WWII by introducing and implementing innovative programs such as helmets for motorcyclists, mobile neurosurgical units near battle zones, and the military usage of penicillin. In addition, he inspired and taught a generation of neurosurgeons, neurologists, and neurological nurses in the care of brain and spinal cord injuries at Oxford’s Military Hospital for Head Injuries. During this time Cairns also trained the first full-time female neurosurgeon. Pivotal in supporting animal research demonstrating the critical role of acceleration in the causation of concussion, Cairns recruited the physicist Hylas Holbourn, whose research implicated rotary acceleration and shear strains as particularly damaging. Cairns’ work in military medicine and head injury remain highly influential in efforts to mitigate and manage brain injury. http://thejns.org/doi/abs/10.3171/2015.8.JNS142613 KEY WORDS Hugh Cairns; biomechanics; head injury; diffuse brain injury; concussion; helmets; Harvey Cushing; British neurosurgery; history N 1934, Winston Churchill (1874–1965), the future The British military’s neurosurgical and neurological British prime minister, informed Parliament of the response to the challenges of World War II (WWII) result- threat of German hostility leading to a European war ed in significant progress in the organizational structure, thatI could include massive aerial bombing of London. By management, and resultant outcome from head injuries, autumn of 1938 war seemed inevitable, and it was feared which was of much relevance to future military and ci- that Germany could begin bombardment at any time. A vilian trauma management. Head injury research in pri- trial nighttime blackout in London was held in August of mates and in vitro modeling of human head injury led to 1939, and after Germany invaded Poland in early Septem- biomechanical theories of brain injury that continue to be ber of that year, blackouts at sunset were mandated with no influential today. These theories include the critical roles lights allowed after dark for one-half of a decade. A month of acceleration/deceleration forces in the production of later Germany invaded and occupied multiple neighbor- concussion, and of rotary or angular forces in shear force ing countries, prompting the United Kingdom (UK) and injuries of the brain. France to declare war on Germany. In June of 1940, Ger- The dynamic and pioneering Oxford-based British neu- many invaded and began the occupation of France, and rosurgeon Sir High Cairns (1896–1952) was personally by September of that year London was bombarded by the involved in the conduct of all phases of these uniquely in- Germans for 57 consecutive nights. More than 1 million fluential neurological and neurosurgical initiatives during London homes were damaged or destroyed and more than WWII. He had the foresight, gained the necessary high- 40,000 civilians were killed, approximately one-half in level political and military trust and financial support, and London, and the remainder in other industrial UK cities carried out the critical organizational planning and imple- and ports.15,43,89 mentation. In the fashion of his neurosurgical mentor Har- ABBREVIATIONS EMS = Emergency Medical Services; MNSU = Mobile Neurosurgical Unit; MRC = British Medical Research Council; RAMC = Royal Army Medical Corps; UK = United Kingdom; WWI = World War I; WWII = World War II. SUBMITTED November 14, 2014. ACCEPTED August 13, 2015. INCLUDE WHEN CITING Published online February 19, 2016; DOI: 10.3171/2015.8.JNS142613. ©AANS, 2016 J Neurosurg Volume 125 • November 2016 1301 Unauthenticated | Downloaded 10/06/21 09:47 AM UTC J. L. Stone, V. Patel, and J. E. Bailes vey Cushing (1869–1939), Cairns insisted upon extensive clinical documentation and outcome analyses, and person- ally oversaw a multitude of in-depth, well-written publica- tions resulting from these WWII experiences. Hugh Cairns Early Career and Neurosurgical Training With Cushing Hugh William Bell Cairns was born and raised in South Australia, where he finished secondary and medi- cal school at Adelaide, served as a World War I (WWI) physician in the Middle East and France, and came as a Rhodes Scholar to Oxford’s Balliol College in early 1919 (Fig. 1). 89 Handsome, athletic, bright, and outgoing, with a captivating personality, Cairns caught the attention and was an invited guest to the home of his physiology teacher, Sir Charles Sherrington (1857–1952), and the internist Sir William Osler (1849–1919), with whom he had rounded at the Radcliffe Infirmary.43 Lady Osler first introduced Cairns to the well-known American neurosurgeon Harvey Cushing (1869–1939).43 At Oxford, Cairns did a surgical residency and spent a period as anatomy demonstrator at the Radcliffe Infirmary. He married a gifted daughter of A. L. Smith, a well-respected teacher and the Headmaster of Balliol College.72 In 1921 Cairns became a fellow of the Royal College of Surgeons, went to the London Hos- pital as house surgeon, and later was appointed as first as- sistant to the notable general surgeon Sir Henry Souttar (1875–1964). Souttar, who performed some neurosurgical procedures and described the bicoronal incision, was also a founder of the Society of British Neurological Surgeons in 1926.22 Sherrington, and especially London neurologist FIG. 1. Hugh Cairns (1896–1952). Papers of Hugh Cairns, Bodleian Library, Oxford; scanned with permission of his daughter, Elizabeth George Riddoch (1888–1947), saw distinctive potential in Nussbaum. Cairns, who exhibited boundless energy and determina- tion, “qualities necessary to develop modern neurosur- gery” in London.11,70,72 Sir Walter Morley Fletcher (1873– 1933) of the British Medical Research Council (MRC) and who pointed the path to the advancement of this newest a close friend of Cushing also came to know Cairns.44 branch of surgery by physiological experimentation in ad- The above individuals helped Cairns obtain a Rock- dition to clinical and pathological contributions…he was efeller traveling fellowship to spend a full year of neuro- the first surgeon to devote the bulk of his time to neu- surgical training under Harvey Cushing in Boston (1926– rological surgery…about 60%, 40% general surgery.”55 1927). Soon after Cairns’ arrival, Cushing’s astute sec- Cairns, however, is considered the first surgeon in Great retary Ms. Stanton noted, “Cairns here for a year…Runs Britain to devote himself exclusively to neurosurgery. around everywhere so as to waste no time…Going to be Geoffrey Jefferson (1886–1961) of Manchester, England, a great success.”8 In the fall of 1927 Cairns returned to had briefly visited Cushing and is credited with initiating London as one of the first neurosurgeons in that city to be neurological surgery as an actual surgical “specialty” in trained in modern methods. In a lengthy letter to Cairns Great Britain after WWI but performed general surgery immediately after his training, Cushing emphasized the as well.58,82 Norman M. Dott (1897–1973), of Edinburgh, critical need for neurosurgical specialization to properly Scotland, who trained with Cushing several years before advance this demanding field.44 It was clear that Cairns’ Cairns, continued pediatric general surgery in addition to goal in London was to develop a dedicated neurosurgical neurosurgery.82 These modern neurosurgical pioneers and service emulating the meticulous and painstaking opera- friends shared the same struggles, ideals, and goal of “a tive techniques, clinic organization, and system of record self-contained unit with the ambition to raise [neurosurgi- collection he learned from Cushing.43,89 cal] work…to the top level of international ranking.”59,89 Sir William Macewen (1848–1924) of Glasgow, Scot- Cairns developed a fine reputation at the London Hos- land, and Sir Victor Horsley (1857–1916) of London, pital with its first neurological surgery service. This was England, pioneered neurosurgery in the late 19th and due to his diligence, perseverance, engaging personality, early 20th centuries.39 Although Macewen antedated and surgical results. Cairns was a particular favorite of 43 Horsley by 6–7 years in performing successful antisep- Cushing, who wrote to the Rockefeller Foundation: tic brain operations based on cerebral localization, Hors- …young Cairns…with all the necessary qualifications for ley is often labeled the “father of neurological surgery… success – ambition, vigorous health, enthusiasm, good train- 1302 J Neurosurg Volume 125 • November 2016 Unauthenticated | Downloaded 10/06/21 09:47 AM UTC Hugh Cairns: an Oxford tale ing, breeding, and most winning personal qualities…wants ing. Cairns was believed
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