doi:10.1093/brain/awu219
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BRAIN
A JOURNAL OF NEUROLOGY
DORSAL COLUMN
Book Review
The tardy development of UK neurology
This carefully planned and well-organized volume, presented in
lucid, readable prose, arose out of a doctoral thesis presented by
Dr Stephen Casper, an American, while he worked at the
Wellcome Trust Centre for the History of Medicine at University
College London, and publication was supported by a grant from
the Association of British Neurologists (ABN). There is a suitably
analytical and complimentary foreword by Robert Y. Moore, the
Love Family Professor Emeritus of Neurology at the University of
Pittsburgh, and the author has provided a comprehensive preface,
in which he pays tribute to the many historians and others who
have guided him, and also lists many British neurologists, including
myself, whom he interviewed. It is some years since I met him, so
that the gestation period leading to publication has been lengthy;
but, having read the book, I believe that it has been worth waiting
for. Following an introduction entitled From Physician to
Neurologist, there are five major chapters, the first dealing with
physicians in neurological societies and neurologists in general
medical societies, the second with World War I and the transformation of neurology, the third with neurology in inter-war Britain,
the fourth with neurology and state medicine, and finally a comment upon the integrated legacy of contemporary specialists in
neurology up until the year 2000.
One major topic recurs in many different guises, namely the
pervasive conflict between the generalists on the one hand and
the specialists on the other; the dead hand of the former plainly
delayed the development of neurology as a specialty in Britain,
much more so than in much of continental Europe and in North
America. In the author’s view, the eventual victory of the specialists shed light on a phenomenon which emerged in the last
decades of the 20th century—the rise of a culture ascribing
ever-increasing importance to the brain.
The opening sentence of the book is also revealing; in 1934,
Cushing asked Edwin Bramwell, son of the neurologist Byron
Bramwell, whether there were any professors of neurology in
Great Britain. The answer was plainly in the negative. Philip
Cloake of Birmingham became the first honorary professor of
neurology on retiring from his professorship of medicine in
1946. The National Hospital for Nervous Diseases, as it later
became after its founding in 1859, and which was for many
years the fountain head of British neurological teaching and prac-
THE NEUROLOGISTS: A
HISTORY OF A MEDICAL
SPECIALTY IN MODERN
BRITAIN c.1789–2000
By Stephen T. Casper 2014.
Manchester and New York:
Manchester University Press
ISBN: 978-0-79190-9192-6
Price: £65.
tice, was staffed by consultants, each of whom also held an
appointment in a London teaching hospital. It did not appoint a
whole time academic until John Marshall became reader in the late
1950s; this post ultimately became a professorship. The historian
Christopher Lawrence identified a patrician mindset in the consultant class of medical professionals in modern Britain, who were
almost universally opposed to specialization. Casper confirms
that, despite increasing regulation of the profession, following
the Medical Act of 1858 which established a General Medical
Council and a Medical Register, many organizations resisted efforts to cultivate the specialist mystique. They agreed that a consultant in medicine had to have general abilities; some even
thought that specialization, by contrast, hinted at narrowness, mediocrity and perhaps even quackery. This was so despite the slow
accretion of knowledge of the anatomy and physiology of the nervous system in health and disease. This dichotomy was almost as
entrenched as it was between studies of mind on the one hand
and brain on the other, despite the growth of departments of
neuropsychiatry in continental Europe. In Britain nervous and
mental functions were looked upon as being different, and neurology and psychiatry were regarded as separate disciplines.
Sir Francis Walshe once said that ‘neuropsychiatry, like the mule,
has neither pride of ancestry nor hope of progeny.’ The journal
MIND was founded in 1876, whereas Brain, a Journal of
Received July 21, 2014. Accepted July 21, 2014
ß The Author (2014). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
For Permissions, please email: [email protected]
Book Review
Neurology was not first published until 2 years later; it has been a
shining exemplar of neurological knowledge, research and development. Even the specialist hospitals in London such as the
National Hospital Queen Square, opened in 1859, were not the
result of a dream of like-minded doctors, but rather a realization
of Victorian families concerned to place ailing patients in an appropriate milieu, distinct from the Victorian asylums. Amusingly,
the author describes the establishment of competing neurological
hospitals at Maida Vale and at the West End in London as being
the pet projects of less reputable doctors.
The development of specialized societies did, however, play an
important role; the opening of the Neurological Society of London
in 1886 was a significant development; it embraced within its members not only clinical neurologists but also physiologists, anatomists
and other neuroscientists, as well as ophthalmologists; many members were fellows of the Royal Society. But yet the anti-specialization
atmosphere still held sway and was a reason, though there were
many more creditable, which persuaded most medical societies of
London, including the Neurological Society, to combine in 1906 to
form the Royal Society of Medicine (RSM), in which the section of
neurology continued to function. Only the Medical Society of
London refused to join in that merger. In maintaining the credibility
of neurology as a clinical and scientific discipline through the RSM
section, the neurologist Henry Head played a major role.
Further significant development was, however, delayed during
World War I. Russell Brain, who was never on the staff at Queen
Square but practised at the London Hospital and at Maida Vale,
was a conscientious objector, but served effectively with the
French Ambulance Unit in France. His subsequent distinguished
career led to his Presidency of the English Royal College of
Physicians. Charles Symonds, Brain’s friend and a medical officer
in France, suggested in a letter to his fiancée that many public
attitudes towards World War I and especially the quality of
the comments in London newspapers, were proportional to the
number of ‘stupid and pompous old buffers’ back home. Sadly,
Victor Horsley, one of the first neurosurgeons at Queen Square,
died of what was then called heat stroke in Mesopotamia. Those
neurologists who worked with wounded soldiers made important
contributions to knowledge about the effects of injuries of head,
spinal cord and nerves. Gordon Holmes, in particular, studied head
injuries, and did so again during World War II, publishing many
substantial works of scholarship. The inter-war years saw slow
increases in appointments of consultants who, if not whole time
neurologists, had an interest in the specialty, in many UK regions.
My own revered teacher, Professor F.J. Nattrass, was Professor of
Medicine in Newcastle but published a short textbook entitled The
Commoner Nervous Diseases in the late 1930s, and also wrote a
paper on recurrent polyneuritis, which later became known in the
French literature as Maladie de Nattrass.
One feature which characterized British neurology was the remarkable ability of many of the leading exponents to reach an
accurate diagnosis based upon a careful analysis of the patient’s
history and physical signs. Sir Charles Symonds in particular was a
master of history-taking. But basic research in clinical neuroscience
had to await the opening of the MRC Neurology Research Unit
under E.A. Carmichael which later received substantial additional
funding from the Rockefellers. At the same time, clinicians made
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notable contributions to clinical research, before and after World
War II. It was often said, however, with some justification, that
neurology was a diagnostic specialty, as so few chronic neurological disorders were amenable to any form of effective treatment. Neurologists, even in the 1950s and 60s, paid relatively
little attention to rehabilitation or to measures designed to improve the lot of patients with severe and progressive diseases
of the nervous system. Despite the excellent work done by
Carmichael’s MRC unit there was little emphasis on fundamental
research, even in neuropathology, though J.G. Greenfield and
Dorothy Russell among others made significant contributions. It
was not, however, until the establishment of the John Marshall’s
readership and the arrival of people with major research interests
such as Roger Gilliatt, P.K. Thomas, Ian McDonald, David Marsden,
and later still Anita Harding, who died tragically young, that fundamental research began at Queen Square, while many consultants
appointed to the London teaching hospitals, and in centres like
Hammersmith, began to be noticed for their research contributions.
Slowly, too, in the latter half of the 20th century, academic appointments and research fellowships, funded by organizations such
as the Medical Research Council and the Wellcome Trust among
others, began to be established, so that at last there was a programme of neurological research in the UK, in centres such as
Edinburgh, Glasgow, Oxford, Cambridge and Belfast among
others. Amusingly, the development and contributions of
Newcastle neurology are covered in one sentence in this book.
Throughout the 20th century British neurology gained a much
clearer form in internationalism, fuelled by neurological and neuroscience developments in the USA, with a regular exchange of doctors and scientists between the two countries. An international
meeting, arranged jointly by the American Neurological Association
and the RSM section of neurology in 1927, was a huge success and
led to many more joint meetings in centres across the world.
In his comprehensive coverage, the author does not neglect the
development of neurological societies. In 1932 Gordon Holmes
chaired in his home a meeting of senior neurologists, mostly
from London, but including Henry Cohen from Liverpool, who
created an Association of British Neurologists. This body was elitist, and any aspiring neurologist hoping to become a member had
to present a paper, which was sometimes listened to generously
and more often with pernickety criticism. The patrician attitude of
the senior membership did lead eventually to some significant revolts with spirited speeches being made at business meetings,
criticizing the attitude of the glitterati. At one meeting in 1959,
when the association hosted the Society of British Neurosurgeons,
Charles Symonds remarked at the formal dinner, ‘There was some
difficulty in finding a time when they (i.e. all of the neurologists)
were all on speaking terms with one another.’ Slowly, however,
the atmosphere thawed, so that everyone appointed as a consultant neurologist could immediately become a member. The association was also slow to admit women, with Helen Dimsdale,
Pauline Munro and Marcia Williamson being among the first. It
was not, however, until the 1950s that the ABN began to realize
that it had a pseudo-political role, and the Royal College of
Physicians eventually established a neurological committee, and
the Department of Health appointed an advisor in neurology.
These developments were particularly important in the 1950s,
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when Britain had by far the smallest number of neurologists in any
developed country of the Western world. The 1950s, too, was an
era when many senior registrars in neurology, frustrated at being
unable to obtain a consultant post, emigrated to adorn the neurological services of many other countries, not least Canada,
Australia and the USA. Happily, sense prevailed, and slowly but
surely there was a substantial increase in the number of consultant
neurologists in the UK in the second half of the 20th century, even
though the total numbers are not regarded by many as yet being
sufficient. Perhaps, too, the author, or some other, will subsequently write a sequel, demonstrating how massive developments
in imaging, biochemistry, immunology, genetics and molecular
biology have transformed neurological diagnosis and management
so that the achievements of British neurology from 1990 to the
present day can be fully documented.
This volume breaks new ice. There have been several books on
the history of neurology, not least Founders of Neurology by
Book Review
Haymaker and Schiller, of which the second edition in 1970 sold
2836 copies and which included biographies of many British pioneers in the field. Lawrence McHenry also published a volume on the
history of neurology, and more recently the late Dr Frank Clifford
Rose edited two short volumes on the history of British neurology.
This book is an able work of scholarship. In the final chapter
the author provides detailed reflections upon the history of neurology and its identity, and the influence of professional paternalism, territorial boundaries, exclusivity versus comprehensiveness,
rationalizations versus emotionalism, generalization versus specialization. It is an impressive and cogent analysis with a persuasive
aura throughout of attention to detail. I commend it warmly.
John Walton (Lord Walton of Detchant)
Belford, Northumberland