Abstract
Is it worthwhile still, in times of quick downloads and fake news, when people in highest administrative positions who declare not to be reading at all and that they do not need facts because they know the truth…is it worth to buy a book nowadays for 49£ with 563 pages and 120 mainly black and white illustrations or to lend it from a library in order to read about what happened in a Hospital and its adjacent Institute in London’s Bloomsbury over the last 160 years? In the actual case of this book on the National Hospital of Neurology and Neurosurgery (or ‘Neurocare’?) and its Institute of Neurology, the answer to the question whether it is worthwhile to read is an absolutely convincing and convinced, unconditioned: yes! It’s a must!
When the adage in neurology is still ‘If you believe you have discovered something new, first look it up in Gowers’, then certainly, if we consider ourselves to have unearthed something new regarding historical aspects of the history of neurology in general and at Queen Square in particular or have questions related to these details, we will do well to look it up in Shorvon’s and Compston’s book: or, as Confucius said: ‘he who puts in front of his eyes the old again in order to understand the new – he may be a teacher to others’. The Editors with this monumental book have proved themselves to be great teachers of the history of neurology and its development that sets a new standard and is unlikely to be surpassed, on this scale, for some time. Even in his darker moods, the German poet and historian Friedrich Schiller, who had asked in his habilitation lecture on ‘Why and to what end does one study history’? 1 would undoubtedly not have contemplated ascribing the misdemeanours of the professional scholar to them: rather he would surely have elevated this work to the upper house of the true philosophical mind – where the passions are the questions, even if the soothing answers to many difficult problems of neurology remain stubbornly enigmatic.
In 14 chapters, the story is told in much detail and in superbly mastered language how ‘The National Hospital for the Relief and Cure of Paralysis and Epilepsy’, as it was first officially named, was founded in November 1859 and opened in 1860 as the first specialist Neurological hospital in the world. It is so convincingly described how and why this institution quickly gained a reputation as the ‘Mecca of neurology’ and soon became (and remained to these days) a place of pilgrimage for neurologists from many countries.
The reputation of the hospital (of any hospital!) to a great extent depends on the quality of the clinical and academic work of individuals on its consultant staff. The consultant body’s power over, and influence on, hospital policy are (or used to be) important ingredients in any hospital’s success. This influence was predominant in earlier times (as described in the story of the first 100 years at Queen Square) but progressively weakened (everywhere) in the later 20th century. At Queen Square, the consultant body was small and highly selected, at least until recent times, and this conferred an elite status. ‘Elite’ is defined by the Cambridge Dictionary as ‘those people or organizations that are considered the best, or a small group of most powerful people compared to others of a similar type who hold a disproportionate amount of wealth, privilege, (political) power, or skill in a society’.
When we read in the Introduction to the book: we deliberately steered away from the temptation of being overly biographical or adopting the Carlylian method of viewing historical record simply as the sum of the deeds of exceptional people…tried to avoid excessive hagiography in telling the story of Queen Square which has often been accused of endlessly polishing its own halo…(p. 1) You must admit that the genesis of a great man depends on the long series of complex influences which has produced the race in which he appears, and the social state into which that race has slowly grown…Before he can remake his society, his society must make him. (Herbert Spencer, The Study of Sociology)
The history is told from varying perspectives against the backdrop of the evolution of British clinical neuroscience, the special position of London medicine, and the influence of world wars and is set in the context of modern British social history.
A broadly chronological approach is adopted in the narrative, divided into three distinctive periods: 1859–1902, 1903–1945 and 1946–1997. The authors also revisit certain themes throughout the book to show that these have on repeated occasions influenced the course of the history of the hospital and its reciprocal engagement with the wider national and international community. There are prominent themes in the hospital’s history: for example, The Tripartite Role: The provision of a clinical service, research and training. Their relative importance changed over time and over-neglect of or over-focus on one or another injured the hospital’s prospects at various periods in its historical trajectory. The Struggle to Maintain Independence: The hospital was, until 1948, a ‘voluntary’ – that is, a charitable foundation with independent governance, mainly on the basis of initiatives of the Chandler sisters – a ward in the actual hospital still bears their name. The mentality behind this foundation is discussed under the heading ‘The age of equipoise’ (p. 7): describing carefully the political context of that brief period of relative social harmony, peace, security and growing prosperity. The English landed aristocracy was enjoying unbridled social influence, political power and economic prosperity…Not all of this wealth was channelled into the more usual forms of conspicuous consumption and, as a result, medical philanthropy flourished…charity became a powerful and passionate impulse for many, giving meaning to a pious life and gratifying the Victorian sense of responsibility and muscular [sic!] citizenship.
However, the Institution became increasingly reliant financially on the State. By the end of the 19th century, the purely philanthropic, voluntary source of funding was proving inadequate, and financial crises dogged the hospital throughout the early 20th century.Despite initial hopes, the crises continued even after incorporation into the National Health Service (NHS) in 1948 as social mores and conditions changed, causing friction and argument. The hospital’s finances became intimately bound up with national policy and fortune and it often attempted solo performances, and its ambitions for retaining independence and self-governance within a centralized system caused continued difficulties. There was often an explosive conflict between medical staff and administration over issues that were nationally debated, and resolved with victory for the medical staff…The hospital administration found itself often snow-blind in a blizzard of bureaucracy, trekking Sisyphus-like up and down rock faces with little onward purpose, and occupied by what with benefit of hindsight, was largely useless expenditure of energy. (p. 2) The Context of British Social and Political History: The hospital’s role and position have been determined to a large extent by the social and political course of the country. Although often overlooked internally, these forces frequently trumped any attempt at autonomy and proved impossible to resist.
An enduring legacy of Queen Square has been the written academic contributions of its staff to the practice and scientific basis of clinical neurology and related disciplines and the evolution of the hospital’s clinical method. Both senior authors of the present masterpiece, Professors Simon Shorvon and Alastair Compston, are Editors of major influential textbooks: (Charles Clarke, Robin Howard, Martin Rossor, Simon Shorvon (eds) (2016) Neurology. A Queen Square textbook. 2nd ed. Wiley-Blackwell; and Alastair Compston et al. (eds) (2005) McAlpine’s Multiple Sclerosis. 4th ed. Churchill Livingstone).
Chapter 4 deals with carefully described, very detailed biographical essays of four of the prominent neurologists of the earlier years at Queen Square: the ‘Quadrumvirate’. John Hughlings Jackson deserves (among many) a longish footnote (p. 130) on whether to use his name hypheneated or not and comes to the conclusion after careful consideration of several arguments from different sources: ‘it is to be hoped that the hyphenated name will not be introduced in the future in printed matters’. Apart from references to the best-known biographies, always crafted according to the authors’ own enormously profound knowledge of the matter (both neurological/medical and literary and historical), there can also be found in this rich treasure trove footnotes such as the funny discussion (p. 133), for example, in the West Ridings Lunatic Asylum Report (Vol. III, 1873) on: Why does Dr Jackson deal so profusely with italics? No young lady in her teens writing to her dearest friend could be more liberal in underlyning words and sentences. As an observer there is no one for whom we have greater respect than for Dr Jackson, but as a writer he drives us to despair…he proceeds cruelly to pelt us with…as a literary canon: that a writer who has clearly conceived his ideas, and who has acquired the power to expressing them, may presume the existence of sufficient intelligence in his readers to render it unnecessary for him ever to use italics.
Queen Square (fortunately) always tried to maintain dominance in Neurology and to establish and to keep a prominent position within the wider context of British neurology and internationally throughout its history. By monopolizing national teaching and professional policy-making bodies, its staff worked to maintain an elite position that did not always make for friendships everywhere but, by any objective analysis, was never seriously challenged.
The National Hospital was (and is) a leader in developing specialism and, later, subspecialization of neurology, and this is the single most important justification for its existence as an independent hospital. As neurology became divided along disease lines into subspecialties, its relationship with general (internal) medicine and psychiatry became difficult and they continue to be discussed (sometimes fiercely). Ultimately there are differences in policy and attitudes. Throughout the 20th century, the difficult personal relationships between neurologists and physicians and psychiatrists contributed to a schism between the disciplines which could not be resolved (as yet).
The attitude of the hospital physicians to neurosurgery, after the death of Victor Horsley, resulted in loss of leadership in the subject, at least for a while. This threatened the hospital’s position when, stimulated by events in the Second World War, neurosurgery led the development of services outside London, and neurology followed. In more recent times, neurosurgery has grown at the expense of neurology – clinically, if not academically – and the relationship between the disciplines remains uncertain.
The limitations of space in Queen Square have been an important factor in determining the course of the hospital. Much management time and effort were expended on property and estate development. The Queen Square ‘brand’ has always been dependent on its location, and repeated proposals to move the hospital or its Institute (fortunately) failed once the co-location of the National Hospital and its Institute in Queen Square, central to its success, had been recognized. That is meant by Genius loci: In classical Roman religion, it was the protective spirit of a place, and Alexander Pope (1688–1744), the second most quoted English poet, describes it on the metaphor of garden and landscape design – which would be an appropriate metaphor for Queen Square and its history – with the following lines (from Epistle IV, to Richard Boyle, Earl of Burlington):