Book Review: The Special Field: A History of Neurosurgery at Johns Hopkins

Goodrich, James Tait MD, PhD, DSci (Hon)

doi: 10.1227/NEU.0000000000001375
Book Reviews
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Division of Pediatric Neurosurgery, Leo Davidoff Department of Neurological Surgery, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York

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Neurosurgery at the Johns Hopkins University has had a long and important history when it comes to the field of neurosurgery. Neil A. Grauer, who is currently a senior writer and assistant director at the Johns Hopkins Medicine Office of Marketing and Communications, has elegantly detailed how this all came about. Mr Grauer took a most unusual way to develop and point out the many unique contributions from this institution and the department of neurosurgery that have developed over the years since its founding in the latter half of the 19th century. The final product is a book that has an immediate effect on you the first time you pick it up. The dust jacket is richly illustrated with graphics by Ian Suk that immediately catch your eye. The sensual feeling of the dust jacket is quite unique, because it imparts a richness in feeling that makes me realize a “real” book clearly stands out over the e-book, but that is only a start. As the reader leaves through the pages, one is immediately struck by the copious and colorful illustrations that abound throughout the book. The graphics are mostly from the institutional archives and are done in high resolution, making them very pleasing to look at. Getting into the various chapters, the reader is taken on a historical voyage through the history of neurosurgery, as seen from one institution's perspective; but, having said that, the voyage is not through a single historical channel, but rather through many.

The first chapter is an interesting overview of the history of neurosurgery, starting with antiquity, including the origins of trephinations. A number of the historical figures that helped define the specialty of neurosurgery are reviewed. The biographical vignettes and historical images richly enhance this chapter and provide an excellent introduction. Although head trauma and its surgical treatment are as ancient as humans, the development of its treatment remains a very modern concept. We had to wait until the latter half of the 19th century to see the fundamental changes and developments that allowed surgery, and especially neurosurgery, to flourish and define itself as a subspecialty. By the end of the 19th century, the surgical team had available antisepsis, anesthesia, cerebral localization, blood pressure monitoring, and a whole host of other developments. Individuals such as Lister, Broca, Gigli, Macewen, Horsley, and others all provided the foundation materials for neurosurgery as a subspecialty. This chapter provides the reader with a nicely styled introduction, and the book only gets better.

The second chapter goes into the history of the university's benefactor—Johns Hopkins, a man who made himself rich despite having little formal education. It is interesting to note that a man who did not even finish high school founded one of the leading American medical institutions. A further interesting part of the story is well described with the founding faculty—the “big four”—William Osler, Howard Kelly, William Halsted, and William Henry Welch. What a dream team to hire to develop a medical school. All these individuals developed into powerful figures in American medicine, and all were committed to the finest principles in academic medicine and surgery. At the end of the 19th century, most medical schools were profit-making proprietary schools with little or no regulation. Full-time salaried faculty was a rarity. The Abraham Flexner report, which led to the development and formal regulation of medical schools as we know them now, was not to come out until 1910. In the 1890s, Hopkins was already setting the model for medical education, and how this came about is nicely detailed in this chapter. The text illustrations provided of the school, the hospital, and faculty are all treasures that come from the university's archives.

The third chapter is appropriately titled “Competing Hopkins Titans,” and here the reader gets some unique insights into 2 giants in neurosurgery: Harvey Cushing and Walter Dandy. This chapter details the contributions of these 2 seminal figures, along with well-written insight into their personalities, both of which led to some legendary academic battles. The early illustrations, again from the Hopkins archives, add both color and depth to the written text. In one photograph, Cushing is dressed as a “dapper dandy” with a straw hat and bamboo cane; even as a young man, his personality is already showing through. This was a very formative period for Cushing. The details on his European travels and the prominent people he met with are well detailed and give a good insight on how he developed his training and its focus on neurosurgery. In the first decade of the 19th century, we see the formation of the “special field of neurosurgery” and why Cushing was so critical to this new development. Cushing's decision to not take Dandy to Boston is well reviewed and insightful. Again, the chapter is lavishly illustrated with archival images that provide useful additional details. The second part of this chapter goes into elaborate detail on Dandy's contributions, his personality, and his relationship with others. Dandy was clearly the more innovative and aggressive surgeon. In addition, he put in a prodigious typical week, with often as many as 20 surgical cases per week. The overviews of his writings and discoveries in neurosurgery clearly enlighten the reader on his enormous contributions. Also interesting to read was his design of the baseball cap liner for head injury protection and his surgical headlight used for illumination during surgery. Dandy clearly covered many facets of neurosurgery, and, in retrospect, it was clearly a better decision for him to stay at Hopkins. With Cushing's retirement in 1932, he had risen to the top of the academic pile, a position he clearly earned and deserved. In this chapter are included some wonderful vignettes on well-known and prominent individuals and celebrities that Dandy had cared for professionally. This section is again particularly well illustrated with archival materials showing some of the personalities involved.

In chapter 4, with Dandy's passing, Earl Walker takes over as chairman. In the Walker era, neurosurgery at Hopkins progressed from a division to a full academic department. Walker goes on to develop a full curriculum for neurosurgery and forms its first formal neurosurgical residency. In discussing Walker, the author notes that he could be extremely aloof, stern, and demanding. Yet when Walker traveled or was in a social situation, he could be extremely gracious, charming, gentle, and on the best behavior. Walker would add enormously to Hopkins with various researches and development in head trauma and epilepsy, among other areas of interest. Associated with Walker was a special individual who immensely contributed to the Hopkins environs: George Udvarhely. A Hungarian by birth and fluent in 5 languages, his erudition and charming personality added immensely to developing neurosurgery at this time. My own association with him was wonderful; no conversation was ever a dull one. His work with Milton Edgerton and plastic surgery led to some of the earliest and most advanced cranial facial technique procedures during this period of development. Udvarhely was influential in the development of charitable organizations for support and surgical care in developing countries.

Upon Walker's retirement at the age of 65, Donlin Long would take over the department, leading to a new Hopkins era of neurosurgery. Long is portrayed as a most interesting neurosurgeon, much softer in style than Walker and, again, one who would move the direction of Hopkins forward. Long became chairman at the age of 39, with an already-well-developed career in research. His research and clinical work on the use of steroids had clearly enhanced his career. Long's research work on spinal stimulators, spine surgery, and pain management were, at this time, quite innovative. Long would also be responsible for hiring some of the current generations of neurosurgeons at Hopkins, who have continued the tradition of neurosurgery at the university. Included in this group are Ben Carson and Henry Brem. The author goes into extensive detail on the contributions of these 2 neurosurgeons, along with some personal vignettes from each, detailing their respective careers. An interesting comment is reported by Henry Brem, who was told by his residency chairman that it was not necessarily a good idea to pursue both a career in research and clinical neurosurgery. Clearly, Brem went his own way, proving this prophecy to be wrong. Again, the author has richly enhanced the text material with illustrations and photographs from the Hopkins archives.

The final 3 chapters detail the “Henry Brem” era at Hopkins, when the department began a rapid expansion in both clinical and basic science research. It was interesting to read about Dr Brem's parents, who clearly had a strong influence on his goals and directions. Both parents were survivors of Auschwitz and Buchenwald; that mere fact of survival provided an unusual onus to Dr Brem's drive and the department's subsequent development. This chapter is well detailed in discussing the additional faculty brought on board and each of the contributions made by the various members. The contributions of George Jallo, Ben Carson, Rafael Tamargo, and others are well reviewed here. Having known a number of the staff over the years, some since they were medical students, it was fascinating to read of the development of skills and research that have continued to propel this department forward. The biographies and contributions are well detailed and add significantly to the history of this department.

In looking back over this monograph, the reader finds a well-detailed book that provides a historical overview not only of the development of neurosurgery but also the enormous contributions that Johns Hopkins would make to develop and solidify the field as its own unique specialty. The book is rich in illustrations and historical details. This institution has been extremely fortunate in its selection of leaders in medicine and surgery. From Cushing and Dandy through Walker, Long, and Brem, the institution has continued to thrive and excel. How this was accomplished has been beautifully detailed here.

As for the audience who might be interested in this book, it is actually a wide-ranging one. Although the book is focused on one institution, the fact is that Johns Hopkins has been, from the beginning, an enormous influence on the development of neurosurgery. The style of presentation and the written details plus illustrations make this book an enjoyable read for a large and wide-ranging population of readers. This book is clearly a reference work for libraries, both medical and general. For readers interested in the history and the development of surgery, and especially neurosurgery, this is a particularly good read. For a graduating chief resident in neurosurgery, this is clearly a great gift to consider for the program director. It is a beautiful book visually, with great scholarship in the writing, and a book that, for the reader interested in the history of neurosurgery, makes a great addition to one's own library.

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The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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