The Glasgow Knife: Pioneer of Modern Brain Surgery

Antisepsis to Asepsis: Extending Lister, Not Inventing Him

Let us dispose of the biggest potential overclaim first. Macewen did not invent antiseptic surgery. That was Lister. What Macewen did — and it matters enormously — was to take Listerian principles further than Lister himself and apply them with obsessive rigour, moving from antisepsis (killing germs with chemicals such as carbolic) toward asepsis (excluding germs altogether through sterilisation, scrubbing, and clean technique). He sterilised instruments, insisted on the deep cleansing of hands and arms, used surgical gowns, and — tellingly — had his osteotomes forged in a single piece with no wooden handles, because crevices and porous wood harboured bacteria.

This is the hinge on which everything else turns. Brain surgery before antisepsis was very nearly a death sentence, with infection the near-inevitable killer; in the pre-antiseptic era the mortality for any operation that opened the skull ran to around 90 percent. Macewen's fanatical cleanliness is precisely what made intracranial surgery survivable. His achievement in neurosurgery is inseparable from, and downstream of, his mastery of aseptic technique. He was not the first to apply antisepsis; he was arguably the man who most convincingly demonstrated what it made newly possible.

He also understood that surgery is a team endeavour. Around 1880 he began a training programme for nurses focused on sterilisation, working with the Glasgow Royal Infirmary's matron, Rebecca Strong. Together they developed the "block system" of nurse training — periods of classroom instruction alternating with ward practice, formalised at the Preliminary Training School opened in January 1893 — which was later adopted worldwide. It is a reminder that Macewen's legacy is institutional as well as surgical.

The Localisation Revolution — and the Priority War

The intellectual heart of Macewen's neurosurgery was cerebral localisation: the then-radical idea that specific functions map to specific brain regions, so that symptoms can reveal the location of a lesion. This was not Macewen's discovery. It rested on the physiological work of John Hughlings Jackson, on the experimental cortical mapping of David Ferrier, on the German experiments of Gustav Fritsch and Eduard Hitzig, and further back on Paul Broca's identification of a speech centre in the frontal lobe. Macewen's genius was translational: he was among the first to trust localisation enough to cut.

He began cautiously. In 1876 he correctly diagnosed a frontal-lobe abscess in a boy, but the family refused permission to operate; at autopsy his localisation was vindicated. His documented neurosurgical debut, in August 1876, was actually a post-mortem study. Then came Barbara Watson in July 1879, and a growing series of operations on abscesses, haematomas, and the spine.

Here the historical record becomes genuinely contested, and honesty requires laying the dispute out plainly. The operation conventionally credited as the founding event of modern brain-tumour surgery is not Macewen's at all: it is the 25 November 1884 operation in London in which the neurologist Alexander Hughes Bennett localised a tumour and the surgeon Rickman Godlee removed it — from a patient named Henderson, a farmer from Dumfries, who died 28 days later of infection. Within weeks of that celebrated operation, supporters of Macewen went to the newspapers and medical journals arguing that the Glasgow surgeon had done comparable work years earlier. In an 1888 address in Glasgow, Macewen described seven pre-1884 cases.

Who is right? The most rigorous modern assessment comes from the historian of neuroscience Malcolm Macmillan, whose two-part study examined Macewen's private journals and the Glasgow Royal Infirmary ward records. Macmillan concluded that the primary sources confirm the operations happened when Macewen said they did, and broadly support his priority — while cautioning that gaps in the records make it hard to establish exactly how much explicit localisation reasoning Macewen used at the time versus reconstructed later. The fairest verdict: Macewen very probably did operate successfully on localised intracranial lesions before Bennett and Godlee, but his work was poorly publicised, buried in Glasgow, while the London operation was a media sensation that galvanised the field. Priority and influence are not the same thing.

And even Macewen's 1879 tumour operation was not the first brain-tumour removal in absolute terms. Nearly half a century earlier, in 1835, the Italian surgeon Zanobi Pecchioli of Siena successfully removed a "fungus of the dura mater" — a meningioma — from a 45-year-old farmer, who recovered and remained free of recurrence for at least thirty months. So the precise, defensible claim for Macewen is narrow and specific: the first documented successful removal of a brain tumour localised purely by clinical signs and performed under antiseptic technique. Not the first brain-tumour operation full stop, and not the internationally best-known one — that recognition, for better or worse, went to London.

Brain Abscess: the Quieter, Larger Achievement

If the tumour case is the dramatic set-piece, Macewen's work on brain abscess may be his most substantial and least disputed neurosurgical contribution. Without X-rays, he diagnosed and localised intracranial abscesses — many arising from chronic ear and sinus infection — using clinical reasoning grounded in his deep knowledge of the anatomy of the temporal bone. His 1893 monograph, Pyogenic Infective Diseases of the Brain and Spinal Cord, accompanied by his Atlas of Head Sections, reported extraordinary results for the era. As D.J. Canale documented in his centennial study in the Journal of Neurosurgery (1996), Macewen recorded 25 cases of brain abscess; 19 patients reached him in time for surgery, of whom 18 recovered — and all five of his patients with extradural abscess recovered. At a time when intracranial infection was almost uniformly fatal, these were near-miraculous outcomes, and they rested on the marriage of anatomical mastery and aseptic technique.

Bone: the First Inter-Human Graft — With Caveats

Macewen was, if anything, more revolutionary in bone than in brain. Working in a Glasgow where rickets was endemic among the urban poor, he developed the antiseptic osteotomy to correct deformities such as genu valgum (knock-knee), and designed the bevelled, single-piece chisel still known as the "Macewen osteotome," engineered to cut without producing bone dust or splinters that could seed infection.

His most celebrated bone achievement is the one most prone to exaggeration, so it deserves care. Macewen rebuilt the destroyed humeral shaft of a young boy — roughly three years old — who had lost the middle two-thirds of the bone to infection. He did this by implanting small wedges of healthy tibia harvested from other children undergoing osteotomy for rickets. Because the donor bone came from other living humans, this was an allograft, and Macewen published it in the Proceedings of the Royal Society in 1881 under the title "Observations concerning transplantation of bone." Sources scatter the operation across 1877 to 1881; the best reconstruction, based on Macewen's own account, is that the initial operation was in 1878, the grafting was staged across 1879–1880, and he demonstrated the restored limb — only about half an inch shorter than its opposite — to the Pathological and Clinical Society of Glasgow in 1881.

Is it "the first inter-human tissue transplantation in medical history," as a 2013–14 orthopaedic history paper in Knee Surgery, Sports Traumatology, Arthroscopy claims? That framing is too strong — and worth noting, it is a Level V (expert-opinion) historical review. Bone grafting long predates Macewen: Jacob van Meekeren performed a bone xenograft (dog to human skull) in 1668, and Philipp von Walther performed a bone autograft around 1820, while Louis Ollier's experimental work in the 1860s established the science of bone regeneration. The defensible claim is narrower and still remarkable: Macewen performed the first documented, successful human-to-human (living-donor) bone allograft — a genuine landmark in transplantation, but one standing on identifiable shoulders. Notably, Macewen disagreed with Ollier about the osteogenic role of the periosteum, and pursued his own experimental programme, later gathered in The Growth of Bone (1912).

Airways, Lungs, Hernias, and a Family of Eponyms

Macewen's restless ingenuity spilled across surgery. On 5 July 1878 he performed what is generally described as the first elective oral endotracheal intubation for anaesthesia, passing a tube into the trachea of a patient — famously by feel, by the mouth — as an alternative to tracheotomy, and reporting several cases in the British Medical Journal in 1880. Even here the prior-art caution applies: Friedrich Trendelenburg in Germany had performed endotracheal anaesthesia via tracheotomy cannula in 1869, and Wilhelm Hack was working on orotracheal intubation in the same period. Macewen's contribution was the elective oral route as a deliberate airway for anaesthesia — a direct ancestor of modern practice, later transformed by Magill and others.

In 1895 he performed what is generally credited as the first successful pneumonectomy, removing a tuberculous, infected lung in stages. As the American College of Surgeons' Bulletin recounted (February 2025), the lung "was riddled with both tuberculosis and bacterial infection" and Macewen removed it "by essentially shelling it out" — there was "no attempt to control hilar structures." Crude as it was, it worked: the patient, a porter identified as R.W., was still working in 1906, could walk ten miles at a stretch, and — Macewen noted with evident satisfaction — could climb the 80 stairs to his clinic without arriving out of breath.

His name is stamped across the anatomy and vocabulary of surgery: Macewen's sign, the resonant "cracked-pot" percussion note over the skull indicating raised intracranial pressure in hydrocephalus and abscess; Macewen's triangle (the suprameatal triangle), a landmark of the temporal bone; and Macewen's operation for inguinal hernia. A myth-busting note is warranted on the sign: Macewen himself did not use the phrase "cracked pot." He described a "differential cranial percussion note," and the folksier "cracked-pot" label was popularised later, partly through an 1898 paper by Norman Bruce Carson on cerebellar tumours. On hydrocephalus specifically, Macewen contributed the diagnostic sign rather than a definitive cure; the surgical treatment of hydrocephalus was advanced by contemporaries such as Wernicke, Quincke, and Mikulicz.

Father of Neurosurgery?

So is Macewen the "father of neurosurgery"? The honest answer is that the title is contested and probably belongs to no single man. In the United States, the paternity is near-universally assigned to Harvey Cushing, who in the early twentieth century systematised the specialty and, over more than two thousand brain-tumour operations, drove neurosurgical mortality down from roughly 90 percent to under 10 percent. In Britain, Victor Horsley — appointed in 1886 to the National Hospital at Queen Square in the world's first dedicated neurosurgical post — is frequently called the first true neurosurgeon, and Cushing himself acknowledged Horsley as the forebear of the specialty. Macewen's own claim is real but different in kind: he was a versatile general surgeon who demonstrated, earlier than almost anyone, that the brain could be operated on successfully and survivably. He proved the possibility; Horsley and Cushing built the profession.

The fairest formulation is the one used by careful medical historians: Macewen was among the earliest — arguably the first — to perform successful, deliberate, localisation-guided intracranial surgery under aseptic conditions, and thus a founder of modern neurosurgery, but not its sole father. To crown him "the" father is to flatter Scotland at the expense of accuracy.

The Long Shadow

In his later years Macewen's energies turned outward. In 1916, during the First World War, he helped found the Princess Louise Scottish Hospital for Limbless Sailors and Soldiers at Erskine, near Glasgow, serving as its first chief surgeon and designing — with engineers from the nearby Clydeside shipyards — the "Erskine limb," a mass-producible artificial limb for the war's flood of amputees. He died in Glasgow on 22 March 1924, aged 75, and was buried near his home at Garrochty on the Isle of Bute, in the churchyard of St Blane's at Kingarth.

His honours multiplied after death. The Macewen Medal in Surgical Nursing was established at the Glasgow Royal Infirmary in 1942; a laboratory block at the Infirmary was named for him when it opened in 1981; and his archives are preserved by the University of Glasgow and the Royal College of Physicians and Surgeons of Glasgow. He was, in the end, a Victorian titan whose reputation has been both under-sung (he was genuinely first at several difficult things, and poorly publicised for it) and over-sung (the sweeping "firsts" need trimming). The truest tribute is the precise one: a surgeon of formidable technique and colder nerve who, more than most, turned the human brain from forbidden territory into operable ground.

Timeline

1. 1848

   William Macewen born near Port Bannatyne, Isle of Bute

   Youngest of twelve children of a Clyde maritime-trade family

2. 1869–72

   Studies medicine at the University of Glasgow under Joseph Lister

   Takes MB, CM (1869) and MD (1872); absorbs Listerian antisepsis directly

3. 1875

   Appointed assistant surgeon at Glasgow Royal Infirmary

   Begins his surgical career under Lister's antiseptic regime

4. 1876

   Correctly diagnoses a frontal-lobe abscess in a boy by clinical signs

   Family refuses operation; autopsy later vindicates the localisation

5. 1877

   Made full surgeon at Glasgow Royal Infirmary, aged 29

   Rapid rise reflecting his technical reputation

6. 5 July 1878

   Performs an early elective oral endotracheal intubation for anaesthesia

   Reported in the British Medical Journal, 1880; Trendelenburg (1869) and Hack precede him with related approaches

7. 1878

   Begins the staged bone-allograft reconstruction of a child's humerus

   Uses tibial wedges from other children undergoing osteotomy for rickets

8. July 1879

   Localises and removes a brain tumour from 14-year-old Barbara Watson

   Diagnosis made purely from clinical signs; patient survives another eight years

9. 1879–80

   Bone-graft procedure staged and completed

   Restored limb demonstrated as only about half an inch shorter than its opposite

10. 1881

    Publishes 'Observations concerning transplantation of bone' in Proceedings of the Royal Society

    First documented, successful human-to-human living-donor bone allograft

11. 1888

    Macewen describes seven pre-1884 localisation cases in a Glasgow address

    Responds to the 1884 Bennett–Godlee sensation by asserting his own priority

12. 25 November 1884

    Alexander Hughes Bennett localises and Rickman Godlee removes a brain tumour in London

    Patient dies 28 days later of infection; operation becomes the internationally cited 'first' brain-tumour removal

13. 1892

    Macewen becomes Regius Professor of Surgery, University of Glasgow

    Occupies the chair once held by his teacher, Joseph Lister

14. 1893

    Publishes Pyogenic Infective Diseases of the Brain and Spinal Cord

    Reports 18 of 19 operable brain-abscess patients recovering

15. 1895

    Performs what is generally credited as the first successful pneumonectomy

    Removes a tuberculous lung in stages; patient still active a decade later

16. 1895

    Elected Fellow of the Royal Society

    Recognition of his surgical and scientific standing

17. 1902

    Knighted

    Formal national recognition

18. 1916

    Co-founds the Princess Louise Scottish Hospital for Limbless Sailors and Soldiers, Erskine

    Designs the mass-producible 'Erskine limb' with Clydeside shipyard engineers

19. 1922

    Serves as President of the British Medical Association

    Caps a career of institutional as well as surgical leadership

20. 1924

    Sir William Macewen dies in Glasgow, aged 75

    Buried at St Blane's, Kingarth, Isle of Bute

Myths & Facts

Did You Know?

• Barbara Watson, the fourteen-year-old whose brain tumour Macewen localised and removed in 1879, lived a further eight years — a remarkable outcome for the era.
• Macewen had his surgical osteotomes forged in a single piece with no wooden handle, purely to eliminate the crevices where bacteria could hide.
• Rickman Godlee, whose 1884 London operation is often called the founding event of brain-tumour surgery, was Joseph Lister's nephew.
• The Italian surgeon Zanobi Pecchioli removed a brain tumour in Siena as early as 1835 — nearly half a century before Macewen's operation.
• Macewen's own writing describes a 'differential cranial percussion note', not the folksier 'cracked-pot sound' later attached to his name.
• Macewen designed the wartime 'Erskine limb' with engineers from the Clydeside shipyards, applying industrial manufacturing logic to prosthetics.
• Macewen occupied the same Regius Chair of Surgery at Glasgow once held by his own teacher, Joseph Lister.

Honest Caveats

Macewen did not invent antisepsis or cerebral localisation. He is a translator and extender of both — antisepsis from Lister, localisation from Broca, Fritsch and Hitzig, Ferrier, and Hughlings Jackson — not their originator.

His priority over Bennett and Godlee cannot be resolved with total certainty. This article follows the weight of specialist historical opinion, notably Malcolm Macmillan's archival study, rather than asserting an uncontested Scottish triumph.

Date discrepancies dog the bone-graft story, with sources citing years from 1877 to 1881; the staged 1878–1881 reconstruction used here is the best available, but rests partly on secondary interpretation of Macewen's own 1881 paper.

The intubation and pneumonectomy "firsts" have international parallels (Trendelenburg, Hack) and, for the pneumonectomy, some doubt in the literature as to whether the 1895 procedure meets the strict modern definition.

The "father of neurosurgery" title is not awarded to Macewen alone in this article. Victor Horsley and Harvey Cushing are named as co-claimants with stronger institutional claims to founding the specialty.