The challenges facing neurology, neurosurgery, and the neurosciences

Neurology as a distinct specialty is relatively new in the history of medicine. Beginning with Charcot, who built his neurology on a firm phenomenologic basis, the specialty of neurology was developed rapidly by such outstanding clinicians as Babinski, Duchenne, Erb, Marie,and Hughlings Jackson. In the 19th century, clinical observations increasingly were linked to neuroanatomical substrates. At the turn of the century, neuropathology gained a foothold, and clinical methods were developed further by such luminaries as Ramón y Cajal. Primitive laboratory procedures began to relate spinal fluid and brain electrical changes to human disease. A cadre of superb clinicians emerged, and neurology departments began to appear at medical schools, where residents were taught to interpret signs and symptoms carefully at the bedside. Mentored by superb clinicians, but lacking definitive laboratory and imaging procedures, these young neurologists continued the tradition of a specialty renowned for deductive reasoning. Neurologists were able to predict things other physicians could not, often with startling accuracy. But the specialty was plagued by lack of definitive studies to confirm clinical impressions, and an even more pervasive paucity of treatments for most neurologic conditions which exacted such a heavy human toll. Crude laboratory and radiologic tests, including angiography, were the only tools available. The clinicopathologic conference was in its heyday, and unexpected and startling revelations frequently were made at the autopsy table.