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A History of Neurosurgery.

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    A History of Neurosurgery. Edited by samuel h greenblatt. (Pp 623; £72.00). Illinois:The American Association of Neurological Surgeons, 1997. ISBN 1-879284-17-0.

    Reviewing this book has given me considerable pleasure and as one who knew little of the historical development of neurosurgery this has been a real voyage of discovery. I cannot help but admire the remarkable achievements of our predecessors which have led to the evolution of a surgical discipline the scope and effectiveness of which could never have been contemplated even 50 years ago.

    The long history of surgery of the head and brain before the late 19th century is of some interest, but it was really the major advances made in bacteriology, cerebral localisation, and anaesthesia at the end of the last century which allowed the birth of neurosurgery. The early development of the specialty relied very heavily on cross fertilisation of ideas from doctors and physiologists working in different centres in Europe and the United States. The importance and sheer excitement of the early scientific meetings is well described. The heady mix of important clinical discoveries together with a dramatic personae of eminent and innovative people could not be reproduced today.

    In the early days it is amazing that any patient survived an operation on their head. Picture an operating theatre in which a neurologist is directing the surgeon to look elsewhere when the initial exposure has not uncovered the lesion. This is what Gowers did for Horsley in 1887, computerised image guidance—who needs it? Imagine controlling scalp haemorrhage without artery forceps, clips, or diathermy and, although Horsley introduced bone wax at a relatively early date, once the surgeons entered the brain there was no effective or safe means of achieving haemostasis. They relied on the use of galvanic cautery, just a hot wire loop and both brain damage and reactive swelling were frequent complications. Attempts were made to tie off bleeding vessels in the brain with heavy silk or linen suture and the result was that satisfactory haemostasis was rarely achieved and operations would be abandoned as a result of uncontrollable haemorrhage and many patients had postoperative haematomas. Control of intracranial pressure during surgery was rudimentary to say the least. Coughing and straining associated with open drop ether and an uncertain airway often led to sudden deaths and there were no reliable methods for monitoring the depth of anaesthesia. Many surgeons tried one or two brain cases before deciding that there was little to be gained in this field of surgery.

    In this rather unpromising environment it is remarkable that Cushing announced his intention to specialise in neurosurgery in 1901 and although his name remains pre-eminent in the subject, it is perhaps William McKewan of Glasgow and Sir Victor Horsley of Queen Square who should be recognised as the fathers of modern neurosurgery. Cushing’s remarkable contribution to neurological surgery was both to expand neurosurgical knowledge and techniques and at the same time to synthesise what knowledge was already available. He managed to do all this despite a very heavy clinical workload and without the benefit of modern research tools and methods. After an address by Cushing to the American College of Surgeons in 1919 the chairman of the session Dr William Mayo rose and solemnly announced “Gentlemen, we have this day witnessed the birth of a new specialty neurological surgery.” However, Cushing was not admired by all and was in many ways a difficult colleague. Amongst others Dandy thought that his approach to research was flawed, in that he was inclined to have a theory and then use all of his efforts and ingenuity to prove the validity of it. Although this can be an effective approach to scientific advance it can also lead to serious errors. This book contains a very thorough account of the historical development of the specialty, much of it written by neurosurgeons who are able to appreciate the importance of the individual contributions and technical advances. The text also succeeds in giving the reader a feel for the intellectual milieu in which these developments took place. The Editor, Dr Greenblatt, initially trained as a historian, but his opening chapter was disappointing. The reader should not be discouraged by his rather ponderous and quasiscientific analysis of the historical developments of neurosurgery. Although his use of English may be off putting, especially to a British audience, his achievement in editing this splendid book should not go unrecognised. Overall this is an interesting and well written book and I am sure many neurosurgeons would wish to have their own personal copy. Among other reasons for buying it is that the illustrations are a rich source of material for slides which may enliven even the most tedious lecture.