The Neurological Tradition at The Royal London
Professor Michael Swash
In his Schorstein Lecture given at the London in 1959, Lord Brain addressed this subject, publishing it in the Lancet in the same year. His lecture was subtitled “on the importance of being thirty”, that being the mean age of consultant appointments in Neurology at the London until post-war bottlenecks in NHS preferment resulted in a surfeit of Senior Registrars, many approaching 40 years of age before appointment to the consultant grade. Brain’s thesis was that a neurologist’s best work is commenced before the age of 30 years, and the lecture proved influential.
The London Hospital was founded in 1740, famously after a meeting in the Feathers public house in the City. From the start there seems to have been an interest in neurological illness. John Andrée, the first physician appointed to the staff in 1740, published a two-volume book on epilepsy and related disorders in 1753. John Cooke (1756-1823), also an early physician to the hospital, published his ‘Treatise on Nervous Diseases’, one of the first comprehensive textbooks of neurology written in English, in 1820. His book is organized in three general sections; Epilepsy, Apoplexy and Palsy, with extensive historical introductions to each section.
James Parkinson (1755-1824) described paralysis agitans in a now scarce monograph in 1817. He had been a dresser at the London Hospital for six months in 1776, and afterwards was a practitioner in East London, maintaining close professional relations with the London. His monograph provides a remarkably complete description of the disease, except for the omission of rigidity. It was only with the advent of more complete schemata of clinical examination that this feature was later recognized by Jean-Martin Charcot, in Paris, and it was Charcot who first used the eponymous nomenclature that remains in use today. Parkinson himself, a prolific pamphleteer and agitator for political reform, often unpopular with the authorities of the day was also a distinguished geologist and fossil collector, and the founder of the Royal Geological Society.
William John Little:
In 1834 WJ Little (1810-1894), a surgeon with a special interest in orthopaedics, described cerebral palsy and recognized its association with birth trauma and hypoxia. He was an apothecary's apprentice before entering medical school at the London Hospital at the age of 18. He was admitted to the Royal College of Surgeons in 1832. Little introduced tenotomy to Britain for the management of talipes, a technique he had learned in Germany, and founded the National Orthopaedic Hospital in London.
John Haydon Langdon Down:
In 1853 Down (1828-1897) broke away from a career in chemistry with Michael Faraday and entered the London as a medical student. On qualifying he took a appointment as superintendent of the newly formed Earlswood Asylum for Idiots in Surrey where he set about classifying and studying the patients under his care. His classical description of the disorder now known as Down’s syndrome was published in the LondonHospital Reports in 1866. He was a pioneer in working for the ethical care of the mentally defective, and in his strongly views on the unity of mankind, regardless of race and ethnicity. There have been Langdon-Downs as students at the London among many later generations of his family.
Jonathan Hutchinson and Hughlings Jackson:
Sir Jonathan Hutchinson (1828-1913) was influential and productive in many areas of medicine throughout his long life. His neurological contributions included papers on neurosyphilis, optic neuritis (not then distinguished from papilloedema), the syndromes of internal carotid artery aneurysms and carotid occlusion, and on torticollis. He contributed a seminal paper on the pupils to the first volume of Brain in 1878. He was a founder member and President of the Neurological Society of London – later subsumed into the Royal Society of Medicine. It was he who encouraged the young John Hughlings Jackson (1836-1911) to study neurology. Jackson is now widely recognized as perhaps the most original of the “founders of neurology”. Like Hutchinson, Jackson was a graduate of the York Medical School under Thomas Laycock. With Hutchinson’s support and influence Jackson joined the staff of the London in 1859, as well as the newly formed Hospital for the Paralysed and Epileptic at Queen Square. Jackson codified clinical phenomena, especially eye movements, epilepsy, language disorders, disorders of motor control, and right hemisphere functions, interpreting them as positive or negative phenomena in the light of Darwinian evolution. In this approach he was much influenced by his friend, Herbert Spencer, the philosopher. His concept of levels of function in the brain was especially influential, extending also into European psychiatry.
Warren Tay (1844-1927), a surgeon and dermatologist with an interest in disorders of the eyes, made the first description of the characteristic fundoscopic appearance of Tay-Sachs disease in 1881, recognizing the familial causation of the disease in 1884, when the ophthalmoscope was still a novel instrument. Bernard Sachs, a New York neurologist, described the pathology in 1887.
Henry Head (1861-1940), perhaps the first clinical neuroscientist, was educated, as were many of his generation, in both England and Germany, before his appointment at the London (Queen Square having declined to appoint him). He became one of the leading figures in European neurology, making major contributions to knowledge of the segmental dermatomal distributions on the body, to visceral sensation and, with WHR Rivers, to sensory physiology itself, introducing von Frey’s hairs into clinical and research practice in Britain. His observations on the recovery of sensation after nerve injury were made following section of his own superficial radial nerve by his colleague at the London, Sir James Sherren who, himself, wrote an important monograph on peripheral nerve injuries and their management (1908). With his neurological colleagues at the London, George Riddoch (1888-1947) and Theodore Thompson (1878-1938), he published extensively on spinal cord injury. Head made a major contribution to understanding aphasia and to the neurophysiology of language (1926), painstakingly studying patients brain-injured in the First War in relation to their brain lesions. With EG Fearnsides (1883-1919), in the Department of Morbid Anatomy, he studied neurosyphilis. Fearnsides, continuing to work with HM Turnbull in Morbid Anatomy, made the first comprehensive description of intracerebral aneurysms in 1916, but his career was tragically cut short in a boating accident aged only 36 years. Head was selected by Sir Walter Fletcher, Secretary of the newly formed Medical Research Council, as a suitable candidate to develop the first academic unit of medicine in Britain, at the London Hospital, but Head was unable to persuade the House Committee to designate his required total of 100 beds and suitable staff to the project, and the opportunity passed when he retired, aged only 58 years, with Parkinson’s disease.
Russell Brain and later:
After Head retired, W Russell Brain (1895-1966) joined Riddoch on the staff, quickly establishing a reputation as a skilled and knowledgeable clinician. He wrote extensively on neurological topics, including defining contributions on carpal tunnel syndrome and with Marcia Wilkinson, on the neurological complications of cervical spondylosis, including its differential diagnosis from multiple sclerosis. His hugely influential Textbook of Neurological Disorders was first published in 1933, and went through five personally written editions until 1962. Later editions have been multi-authored. With Ronald Henson (1915-1994), and Henry Urich, he described and classified the paraneoplastic syndromes. Brain had a national reputation as a diagnostician. Although essentially a very private man, his teaching rounds, serious affairs though they were, were highly valued. When Brain retired in 1962 Christopher Earl, another superb clinician and teacher, joined Henson in the neurological unit. Alan Ridley was appointed when Earl resigned and Michael Swash, a London Hospital graduate trained both at the London and in the USA, who became the first Professor of Neurology in the Medical School in 1993, was appointed as third neurologist in 1972. The merger with Barts induced a major and long-overdue increase in staffing levels in the department. Gavin Giovannoni succeeded Michael Swash as Professor of Neurology, with an expanded department, in 2006.
HM Turnbull (1875-1955), renowned as a pathologist, very much encouraged neuropathology, then in its infancy. He followed up Fearnsides’ observations on intracranial aneurysm in work that enabled Charles Symonds, working at Guys and Queen Square, to describe the clinical diagnosis of subarachnoid haemorrhage. With James MacIntosh (1882-1948) Turnbull described the clinical and pathological features of post-vaccinial encephalomyelitis. MacIntosh and Sir Paul Fildes (1882-1971), then working in the Department of Microbiology at the London, confirmed Noguchi’s discovery of the treponemal basis of syphilis, a discovery that led to a revolution in neurological diagnosis, causing the reclassification of a number of syndromes previously misattributed to syphilitic infection. Dorothy Russell (1895-1983) succeeded Turnbull as Professor of Morbid Anatomy in 1944 – the first woman to achieve professorial status in pathology in Europe. She had been one of the first lady medical students at the London, and had trained there and later in Montreal with Wilder Penfield, who had learned silver stain technology from Dr Pio del Rio Hortega, Ramon y Cajal’s former student and colleague in Madrid. With the outbreak of war in 1939 Russell moved to Oxford where Hortega was working with Hugh Cairns in the military Neurosurgical Head Injury Unit at St High’s College. Ronald Henson was also relocated to St Hugh’s during the bombing of London; Russell Brain was relocated with JG Greenfield, the neuropathologist, Chase Farm Hospital in North London. Dorothy Russell transferred this silver technology to the London and used it to great effect with Lucien Rubinstein (1924-1983) in their defining monograph “Tumours of the Nervous System”, a book that ran through five editions and continues to this day, long after both its original authors have passed away. In addition, Russell made huge contributions, often with Crooke, to knowledge of the pituitary gland, to the classification and causation of hydrocephalus, and to general neuropathology. When Rubinstein moved to the USA (first to Columbia, and then to Stanford), Henry Urich took over the neuropathological department continuing the tradition of expertise in cerebral tumours and brain malformations. He was followed by Carl Scholtz, and then by Jennian Geddes.
Sir Hugh Cairns and Neurosurgery:
The neurosurgical unit at the London was founded by Cairns (1896-1952), although neurosurgical procedures were of course frequently performed before his appointment in 1926. Cairns, an Australian Rhodes scholar, first spent a year in pathology with Turnbull, and then worked in general and renal surgery at the London. Prior to his taking up this appointment as Neurosurgeon, the Hospital Governors sent him in 1926 to Boston to work with Harvey Cushing, so that on his return he could introduce the innovative techniques pioneered by Cushing to Britain. Once the Unit was fully established, in 1933, there were hosts of visitors keen to learn the new methods. In 1938 Cairns was tempted by Lord Nuffield’s offer to join his new School of Medicine at Oxford as Professor of Surgery, leaving the neurosurgical department at the London in the capable hands of his former student, Douglas Northfield (1902-1976), who was later joined by JV Crawford. Northfield developed pioneering procedures in tumour surgery, spinal surgery, the management of hydrocephalus, and epilepsy surgery. Northfield’s book “Surgery of the Nervous System’ (1973) represented the apogee of neurosurgical technique and knowledge to that time. Crawford was succeeded by Tom King, himself a meticulous surgeon with a major interest, in collaboration with Andrew Morrison, in acoustic Schwannoma surgery. ES Watkins, the first Professor of Neurosurgery, who brought new methods of stereotaxic surgery moved to the London from the USA, succeeded Northfield. Fary Afshar, himself a London Hospital graduate, rejoined the London as Neurosurgeon when the neurosurgical unit at Barts closed. He and his colleagues were joined by Peter Richardson, who succeeded Watkins, and by other colleagues.
Associated skills and facilities are essential to the practice of a specialty. For neurology and neurosurgery, neuropathology, neuroradiology, clinical neurophysiology, various laboratory studies, and specialized therapies such as physiotherapy, occupational therapy, as well as oncology and radiotherapy are pre-requisites to modern practice. The London was in the forefront in the provision of these modalities. Skull X-rays were available before the First War, EEG recordings using two saline pad Berger electrodes were in use for the diagnosis of epilepsy and cerebral tumours in the 1930s and, after the Second War, a formally constituted Department of Electro-Encephalography was established by Dr Samuel Last, later with the assistance of Leo Honigsberger, who had an interest in epilepsy monitoring,. Donald Scott developed this department with Pamela Prior from the early 1960s. Electromyography and nerve conduction studies were provided by Kit Wynn-Parry in the Department of Physical Medicine. Later, as this specialty developed, these investigations joined EEG in the Department of Clinical Neurophysiology. Radiotherapy was in active use before the Second War, and radioisotope brain scanning preceded the advent of CT and then MR brain imaging in the 1970s and 1980s respectively. Rehabilitative services were provided in collaboration with the relevant related specialties beginning in the nineteenth century.
Acknowledgement: I thank Jonathan Evans in the Royal London Hospital Archives Centre for his invaluable help.
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