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Neurosurgery in Aberdeen Royal Infirmary C. 1920–C. 1940

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Neurosurgery in Aberdeen Royal Infirmary C. 1920–C. 1940 J R Coll Physicians Edinb 2019; 49: 70–7 | doi: 10.4997/JRCPE.2019.115 PAPER Neurosurgery in Aberdeen Royal In rmary c. 1920–c.1940: knowledge, skills and styles HistoryNicola Newall1, Peter Bodkin2 & Humanities A neurosurgical unit was established in Aberdeen Royal In rmary (ARI) Correspondence to: in 1948 with the appointment of Martin Nichols as its first full-time Nicola Newall Abstract neurosurgeon. Despite there being no formal neurosurgical ward or specialist 23 Albert Den dedicated to neurosurgery in ARI prior to this, a number of neurosurgical Aberdeen AB25 1SY procedures were undertaken between 1920 and 1940. From 1923 to 1932, UK the procedures were predominantly cranial and were performed by general surgeons. The operations evolved in 1933 to include the spine and peripheral nerves after the Email: arrival of Sir James Learmonth. This paper chronicles the development of surgical neurology [email protected] at the ARI in the 30 years preceding a formal unit. It considers the factors and background that enabled neurosurgical practices to be undertaken and led to evolution of neurosurgery from general surgery. Keywords: Aberdeen Royal Infi rmary, Henry Gray, James Learmonth, neurosurgery, William Anderson Financial and Competing Interests: No confl ict of interests declared Introduction To help inform this gap in the literature, this paper chronicles the development of neurosurgery in ARI during the early The fi eld of neurosurgery has a rich and fascinating history. twentieth century. A large body of evidence sourced from Much of the literature on the history of Scottish neurosurgery the National Health Service (NHS) Grampian Operations focuses primarily on the innovative work of Sir William Log Books and Statistical Table of Procedural Cases has Macewan (1848–1924) in Glasgow,1 and the establishment been utilised to show its early development. Examination of the modern era through Norman Dott (1897–1973) of of neurosurgical research during the early twentieth century Edinburgh.2 Development of this speciality has been mapped and the review of publications by key surgeons demonstrates in several institutions but documentation of its history in the neurosurgical knowledge available during that time Aberdeen Royal Infi rmary (ARI) has been limited. Levack and and confi rms that surgeons were able carry out certain Dudley made a brief description regarding the inception of neurosurgical procedures. the neurosurgical ward in 1948 through the appointment of Martin Nichols.3 They further acknowledged that prior By considering the mentors and the institutions where to the appointment of Nichols, it was William Anderson the surgeons worked, their surgical style can be deduced. (1886–1949) who led surgical practice in Aberdeen during Archival sources from the Society of British Neurological the Second World War (WWII) with his ‘pioneering work in Surgeons have been examined to understand the infl uences neurological and thoracic surgery’. This was repeated by of the medical societies in the fostering of particular styles, Casper’s authoritative work on British neurology.4 There is negotiating surgical knowledge and demonstrating surgical evidence that neurosurgical practices were being undertaken skills. The study will demonstrate the period during which in the Infi rmary prior to WWII and to Nichols’ appointment.5–25 neurosurgery emerged as an independent clinical discipline It has been shown that several surgeons working in ARI in ARI and consider the factors that enabled this evolution. between 1920 and 1940 were well versed in neurosurgical practices; with one having published on the basic management General surgery and the emergence of principles of cranial and spinal injuries during the First World neurosurgery War (WWI)26,27 and another having trained in North America alongside the innovators in the fi eld of neurosurgery.28 Yet no Historically, Great Britain had many prominent figures formal documentation has been made with respect to those in neurosurgery. The Glaswegian, Sir William Macewan, surgeons performing neurosurgical procedures, the types of diagnosed, localised and resected a cranial tumour in 1879 procedures that were undertaken and the background that and performed further cranial operations for trauma and enabled these practices to be carried out. infection.29 Sir Victor Horsley contributed to the understanding 1Year 4 MBChB Student, University of Aberdeen, Aberdeen, UK; 2Consultant Neurosurgeon, Aberdeen Royal Infi rmary, Aberdeen, UK 70 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 49 ISSUE 1 MARCH 2019 Neurosurgery in Aberdeen Royal Infirmary c. 1920–c.1940 Figure 1 Sir Henry MW Gray. Reproduced with kind permission of epilepsy and was an innovator in spinal tumour surgery from Ann Boyer and Thomas Scotland40 and brain surgery. He also carried out experimental studies on animals to establish the neurophysiological principles underlying human neurosurgery.30 Notably, both these surgeons began their careers in general surgery. At the beginning of the twentieth century, neurosurgery was not considered a distinct speciality in Great Britain and neurosurgical procedures were mainly undertaken by general surgeons with an interest in the nervous system.31,32 Standards were not codifi ed, so the early twentieth century was a time for great adventure in surgery.33 Although there were no set guidelines for neurosurgical procedures, research publications and surgical teaching played a key role in the dissemination of the knowledge, skills and surgical styles required. Experience in the management of head and spinal wounds sustained during WWI further contributed towards the evolution of this speciality.34,35 As neurosurgery was in its infancy, it was devoid of any standard protocols. The surgical technique adopted by surgeons wishing to operate on the nervous system was of paramount importance for the undertaking of these procedures. In neurosurgery, this surgical technique was shaped during the early twentieth century by the American founding father and then undisputed leader of neurosurgery at the time, Harvey Cushing (1869–1939). Cushing advocated a slow, meticulous operative style. He changed the rules of good surgery from ‘…the stirring, slap-dash, and spectacular’ to the ‘quiet, patient, and undramatic performance’. Although this was regarded as a ‘tedious and dull show’, it meant that the nervous system began to propagate throughout Great this slow, careful performance with delicate tissue handling Britain to a number of institutions, including Aberdeen where led to a reduction in mortality.36 it became integrated into the hospitals’ practices. The way to acquire a surgical technique was through the Evidence from the earliest surviving records from the imitation of others and by operative experience.37 During the ‘Aberdeen Royal Infi rmary Statistical Tables of Procedural 1920s three British men had become interested in surgery Cases’ – a list of the admissions, treatments and clinical on the nervous system and had appreciated the importance outcomes – show that neurosurgical procedures were being of learning this technique directly from the innovators. Hugh undertaken in 1923.5 These operations comprised cerebral Cairns in London, Jeffery Geofferson in Manchester and decompressions, trepanations and excision of brain tumours. Norman Dott in Edinburgh, independently went on to train It is further reported that in subsequent years this practice in Boston under the tutelage of Cushing.32 They adopted of neurosurgery continued. The procedures now expanded Cushing’s principles and brought back his infl uences to Great to include peripheral nerve operations, consisting of both Britain, implementing his neurosurgical techniques in their the suturing9 and transplantation of the ulnar nerve,10 and institutions, disseminating his methods to others and leading the repair of the brachial plexus.11 Although the presenting neurosurgical practices during the 1920s.32 complaint and the type of surgical procedure were well documented, the operating surgeon and any surgical notes During that time, more sophisticated approaches towards were, however, not documented. It is therefore diffi cult to brain surgery and tumour diagnosis were also being developed, trace the surgeon who performed neurosurgery from these which contributed towards better outcomes for neurosurgical times as specifi c records are scarce. patients. The creation of pneumoencephalography and X-ray allowed for a gross localisation of space-occupying lesions.38 The development of neurosurgery is acknowledged to Anaesthesia, aseptics and antiseptics were available, have had a large military component34,35 and the skills and which permitted a relatively safe operation and a reduction knowledge acquired from WWI clearly played a major role in postoperative mortality.39 Patient case studies, and in Aberdeen. Many general surgeons from ARI were serving descriptions and illustrations of surgical approaches were as surgeons during the war. One worthy of special mention disseminated in research publications, providing surgeons is Sir Henry MW Gray (1870–1938), who was a Consultant wishing to operate on the nervous system with relevant up- Surgeon to ARI from 1904. Gray (Figure 1)40 was described to-date information. With this knowledge base, surgery on as a ‘courageous, industrious Aberdonian surgeon of great MARCH 2019 VOLUME 49 ISSUE 1 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 71 N Newall, P Bodkin Table 1 Neurosurgical procedures
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