The history of neurosurgery is an extraordinary part of the history of science. Some might argue that it is too narrow a perspective to command interest as real history, or as interesting history to a real historian. I thoroughly disagree. Such a perspective is analogous to saying there should be no interest in the history of the Oregon trail because it is only a small part of the planet, no interest in ancient Rome because many civilizations came before and after, or even no interest the history of human civilization because Earth is only one of an unfathomable number of galactic entities. The history of neurosurgery is extraordinary because of the questions it embraced, the ideas it invoked, the people it involved, the problems it addressed, the technologies it inspired, the information it engendered and the good that ensued. Whether one assigns the beginning of neurosurgery to the development of cerebral localization in the middle of the nineteenth century; to Sir Victor Horsley’s appointment as the first British neurosurgeon in 1886i, or to early attempts at the resection of brain tumors in the 1880s in New York City ii, or, perhaps to Harvey Cushing’s famous essay, The Special Field of Neurological Surgery, which appeared in 1905,iii neurosurgery is a young specialty in comparison to general surgery or some of the other surgical specialties such as orthopaedics, ophthalmology and urology. And yet, for reasons nicely outlined in Sir Geoffrey Jefferson’s 1939 article in the British Medical Journal, neurosurgery has always seen itself, and equally, was held to be, a “special field.”iv
What made it special? The answer is precisely what makes the history of neurosurgery worth knowing.
Robert Heinlein (1907-1988), the famous American science fiction writer and libertarian, was fascinated by the prospect of extending the human influence beyond the planetary boundaries of its home planet. A mathematician and engineer, he was no stranger to hard science, and often addressed the problem of epistemology: how we know we know something. This is not a new problem. Plato and other after him wrote and philosophized about it.
Heinlein, however, had a talent to articulate major issues simply. He was profoundly annoyed by received limitations on knowledge, for example, and wrote:
There are but two ways of forming an opinion in science. One is the scientific method; the other, the scholastic. One can judge from experiment, or one can blindly accept authority. To the scientific mind, experimental proof is all important and theory is merely a convenience in description, to be junked when it no longer fits. To the academic mind, authority is everything and facts are junked when they do not fit theory laid down by authority.v
Moreover, he maintained,
Everything is theoretically impossible, until it is done. One could write a history of science in reverse by assembling the solemn pronouncements of highest authority about what could not be done and could never happen.vi
One of the things that makes neurosurgery historically unique is the way in which these two ideas, the first intellectually demanding and the second intellectually defiant, were joined to standards of technical proficiency which verged on virtuosity. The standards themselves have been notable and, and in many instances, arguably exceptional.
The history of neurosurgery can be parsed in many ways. One interesting perspective is the progressions from a series of historical proscriptions to current practice. Thus, we find the profession self-consciously moving from a surgical reticence to an assertive pursuit of new operative approaches and techniques , that expand what can be accomplished to improve patient outcomes. This progression is classically illustrated, for example, by the history of the management of subarachnoid hemorrhage and aneurysms.
The history of neurosurgery contemplates how surgeons, physicians and scientists understood the nervous system, its structures, its functions, and its pathologies, and how surgical treatments developed on these pillars. It also illustrates the means by which hypotheses led to scientific inquiry and ultimately research led to translational medicine.
Not everyone thought or thinks the same way. Differences in perspective have regularly led to intersections and combinations of ideas and technologies. Historically and technically, many of the most useful innovations arose from unexpected combinations of technologies and ideas. Many advances developed in non-linear fashion. Both incrementality and epiphany had roles in developing breakthroughs in patient care.
The history of neurosurgery includes the accounts of and narratives by surgeons, scientists and patients. These are the elements that shaped the culture of neurosurgery, as opposed to its practice alone. They help us critically look at the practice through the lenses of the past, present, and future in an attempt to define a moral purpose.
True biography – not simply hagiography – also leads to an understanding of personal characteristics and virtues that matter in the making of a neurosurgeon. Reflections on the history of the profession often challenge us to reexamine our current thinking and revisit conventional wisdoms. History, it turns out,doesn’t have to be about the past alone: it also guides future investigation. In fact, skilled scientific writers are often also impromptu historians when they conceive of new investigations, when they introduce a scientific paper, and when they discuss their results. It is not only the experiment, the innovation, the results, and the paper that matter: it is also, and often especially, the historical context that bestows significance on the investigation, the innovation, the trial, and the report.
History allows for the admission of errors and regrets in ways that contemporaneous accounts find daunting. Historical mistakes are easier to discuss; they are less threatening and often depersonalized. If one thinks of error as something ill-advised, the failure analysis can be very instructive. Indeed, staying out of trouble by studying the superseded experiences of the past is a very good way of broadening expertise and adding to one’s judgement at very low risk. It is also a good way to develop and legitimize new areas of research. The ability to question and evaluate information based on historical information sharpens with use and leads to the development of profoundly useful and reliable heuristics.
Vicarious wisdom is no less valuable than lessons learned personally.
While history is often construed in terms of chronological events, it is about seismic shifts, large and small. Not all are “revolutionary,” but some may be. When studying seismic shifts in science and medicine, it is helpful to understand the key events that contributed to them, and why they mattered. This exercise helps identify and establish patterns containing large amounts of digestible information; ultimately this can produce ideas.
Finally, history does not depend on a given book, a given paper, or a given narrative. It invites one to utilize all sources to understand ideas and trends at one or more points in time, and how these evolved over time. It is notably dynamic. History allows one to show gaps. The “white space” of what is not known is at least as important as the areas in which good knowledge is claimed to exist. The white spaces often serve as leading indicators of change.
Good historical research entails and invites ongoing critical analysis. In the history of science, including neurosurgery, the focus should be “why did X matter,” no less than “when did X happen.” “What happened next?” and “What should happen next” are some of most important follow-up questions to be posed.
Why, then, the history of neurosurgery? Neurosurgical history is an extraordinarily useful tool for research, writing, teaching, clinical care, medical systems development and innovation. It helps understand what matters and why, what we have tried, what has succeeded, and often, what we might want to pursue in the future. Most importantly, it provides context for what we do and offers a framework for moral purpose.
