on 30 december 1919 , the american surgeon harvey cushing , who had limited his practice to 
 brain surgery since the turn of the century , drafted a statement which he intended to send 
 to a number of north american surgeons .
he was formalising the suggestion  made by a number 
 of persons whose primary interest lies in the surgery of the nervous system , that a 
 neuro - surgical interurban club be established. cushing expressed a hope  that in this way those interested in this 
 special field might be brought together for an exchange of opinion and with the hope of more 
 rapidly advancing the subject, a clear articulation of the belief that within such a social 
 space specialist knowledge could be better articulated .
a first draft of this statement was sent to ernest sachs , who had occupied , since 1911 , a 
 position in surgery at washington university in st .
conscious of the fact that the 
 general surgeon who is interested primarily in neuro - surgical technique does not 
 talk our language , but it may be necessary to have him included. sachs responded that  you and i , i think , 
 are the only ones who are doing that exclusively, and he quipped that a society made up of 
 the two of them , as the only properly qualified members , might lack in excitement :  though i 
 should like your company , i do nt know whether i would be too monotonous for you! the allusion to a shared language was a nod 
 towards the experimental work that formed the basis of the two surgeons practice and that 
 elevated them to an elite rank of the profession . especially as it was practised by the elites , the surgery of the turn of the century had 
 strong ties to the laboratory , coinciding with the rise of experimental medicine and forging 
 a strong relationship between surgical intervention and knowledge production . the historian thomas schlich has shown that 
 as surgery became  a scientific research discipline at the university , elite surgeons such 
 as theodor kocher emphasised repeatedly that  only scientific respectability guaranteed the 
 status of the field and its practitioners , thus anchoring surgical epistemology in experimental physiology and 
 animal experimentation .
both cushing and sachs were part of this tradition . during his 
 european wanderjahr ( 19001901 ) , cushing trained with kocher , in whose 
 laboratory in berne he studied experimentally the relationship between blood pressure and 
 intracranial pressure .
he continued this work in turin with the physiologist angelo mosso , 
 and he brought back from italy the riva - rocci cuff  an instrument for measuring blood 
 pressure quantitatively , which allowed him to chart blood pressure during surgery .
cushing viewed his ongoing experimental 
 work on animals at the hunterian laboratory at johns hopkins as very important , arguing that 
  for the development of surgical technic no place is comparable to the experimental 
 laboratory , and that  every young surgeon should begin to acquire his operative training in 
 a series of operations on the lower animals. while , especially later in his career , he did criticise the crude 
 reduction of medicine to laboratory science , cushing did believe that only an experimental setting allowed 
 surgeons - in - training to safely practise their surgical technique , while also having  the 
 double advantage of giving them a sufficient laboratory experience to enable them 
 subsequently to pursue to the only place where they are likely to be solved some of the many 
 problems which  arise. sachs had enjoyed 
 a similar educational trajectory , having trained with the british surgeon victor horsley 
 both in the operating room and the experimental laboratory , where he conducted numerous 
 experiments to probe the structure and functions of the thalamus in monkeys and cats .
ironically , despite the fact that the conversation had started from the premise that 
 cushing and sachs spoke a unique language and were therefore fit only for each other s 
 company , it was evident that there were enough american surgeons with relevant education , 
 interests and experience , because the conversation quickly turned to an issue that would 
 become a perennial concern for the members of the society in the coming years  that of 
 limiting membership .
would go a step further and only 
 take a very few men for the first meeting : [ the new york surgeon charles ] elsberg , [ the philadelphia surgeon charles ] frazier , 
 [ the baltimore surgeon charles ] bagley , [ walter ] dandy [ from johns hopkins ] , dean lewis 
 [ from chicago ] , and [ the rochester , mn surgeon alfred ] adson with ourselves as a 
 starter .
that will make a sufficient number of pioneer members , and we can add the 
 others more safely later on .
i can invite [ jason ] mixter and [ gilbert ] horrax [ both from 
 boston ] to help out in the meeting here though not as members .
[ the new york surgeon charles ] elsberg , [ the philadelphia surgeon charles ] frazier , 
 [ the baltimore surgeon charles ] bagley , [ walter ] dandy [ from johns hopkins ] , dean lewis 
 [ from chicago ] , and [ the rochester , mn surgeon alfred ] adson with ourselves as a 
 starter .
that will make a sufficient number of pioneer members , and we can add the 
 others more safely later on .
i can invite [ jason ] mixter and [ gilbert ] horrax [ both from 
 boston ] to help out in the meeting here though not as members .
this exchange of letters shows the extent to which an ethos of selectivity and exclusion 
 was an important aspect of the beginnings of neurosurgery as a medical specialty .
the goal 
 was not to seek the company of many of the surgeons who were interested in and skillful 
 enough to perform operations on the nervous system ; rather the idea was to put together a 
 select group of surgeons with distinct profiles , with specific professional and moral 
 qualities .
both cushing and sachs seemed aware of the historical weight of their role as 
 
pioneer members of such a select club , cushing going as far as suggesting that mixter and 
 horrax were not yet senior enough to be worthy of the title , despite being good enough to 
  help out during the first meeting .
this exclusionist ethos privileged academically 
 oriented surgeons like alfred taylor , who was on the faculty of the cornell medical college 
 and practised at the new york neurological institute , or dean lewis , who was a well - respected surgeon and anatomist at 
 the university of chicago , and who resigned two years later probably because his interests 
 were not confined to the narrow field of neurological surgery . beyond the provisions of an epistemology anchored in experiment ,
along with factors such as 
 seniority and academic standing , the exclusion of william sharpe in particular reveals some 
 of the moral values upon which the sns and the persona of this new specialist were built . 

one of the first men to train in 
 neurosurgery with cushing at the hunterian laboratory at johns hopkins , he had attended 
 harvard medical school , where he attained notoriety  and financial success  by tutoring 
 his fellow students .
sharpe developed an interest in neurological surgery after an initial 
 six - month internship with cushing , and in 1911 he returned to hopkins as cushing s assistant 
 resident after a two - year surgical internship at the roosevelt hospital in new york .
a year 
 later , harvard s president offered him an appointment as the first professor of surgery at 
 the newly established harvard medical school of china in shanghai .
sharpe wrote in his 
 autobiography that cushing had discouraged him from accepting this position because  i would 
 be  throwing myself away  as far as my development in neurosurgery was concerned .
besides , 
 the lack of rigid asepsis , inadequate hospital facilities , and other unfavorable conditions 
 in china would prove an insuperable barrier to competent surgical work , and as a result my 
 surgical discipline would rapidly deteriorate. for cushing surgical practice and skill could only 
 flourish under  surgical discipline , which in turn only the most controlled and select 
 environment would encourage .
despite cushing s explicit disapproval , sharpe accepted the position and arrived in 
 shanghai at the beginning of 1912 .
he spent an adventurous year in china , gaining 
 considerable fame by treating the head injury of the president s son .
when sharpe returned 
 to new york , he obtained a job as night resident in a private hospital and an appointment as 
 clinical assistant at the new york neurological institute .
a year later he joined the new 
 york polyclinic medical school and hospital , running a neurosurgical clinic in the 
 dispensary .
his voluminous 1920 book 
 diagnosis and treatment of brain injuries listed his professional title 
 as  professor of neurologic surgery and  consulting neurologic surgeon. as a practical 
 text , richly illustrated and detailing the hundreds of cases that sharpe had treated between 
 1913 and 1918 , the book s purpose was to  be of service to the general practitioner and to 
 the general surgeon , and in the cases of brain injuries in newborn babies and children to 
 the obstetrician and to the pediatrician , goals that cushing himself had thought important .
sharpe was particularly insistent on the need for 
 checking intracranial pressure and alleviating it .
relief could be achieved through a 
 temporal ( or subtemporal ) decompression , a procedure he had learnt from cushing and which consisted in the removal of an 
 area of bone in the temporal or subtemporal region to give the brain room to swell .
cushing 
 and other surgeons saw this procedure as a useful palliative measure for inoperable tumours , 
 but sharpe extended its use to spastic paralysis .
sharpe  as well as other surgeons who restricted their practice to the nervous system but 
 who were never considered for sns membership , such as his brother norman sharpe and karl 
 ney , another new york surgeon
 worked in crowded city hospitals or private practice and did 
 not engage in laboratory work .
but apart from these differences , sharpe was seen to have 
 committed a serious professional sin when he appeared to court the press .
his academy 
 presentation  in which he exhibited , paraded , and made the children perform their newly 
 refined bodily and mental skills  ended up in the newspapers , his name indelibly linked to 
 the promise of a radical and curative operation .
the neurosurgeons who came together in the 
 early 1920s for the purpose of creating a professional community did not sanction this kind 
 of public spectacle .
sharpe s name was all over the 
 newspapers again when he operated on a wealthy young man on trial for stealing platinum from 
 ( and then burning down ) the chemical laboratory at the university of virginia at 
 charlottesville .
sharpe testified that his patient s criminal behaviour was due to a brain 
 condition for which the surgeon performed a decompression and subsequently secured the man s 

sharpe s tendency to place himself in the public sphere had disastrous consequences for his 
 inclusion in the new society .
cushing s 1919 letter to sachs , in which he had outlined a 
 list of possible candidates for the neurosurgical club , included sharpe s name followed by a 
 question mark .
aware that sharpe s practice was devoted exclusively to neurological surgery , 
 cushing had at least entertained the idea of including him .
i question very much whether we ought to include sharpe , he wrote to 
 cushing .  i know he is only doing neuro - surgical work , but it seems to me he is 
i am taking the liberty of enclosing an item which appeared in 
 pierson s [ sic ] magazine several years ago and which i have kept for just 
 such an occasion. an article in 
 hearst s magazine published around the same time extols sharpe s surgical 
 method and describes at length 
the most remarkable feats of very recent surgery which is 
 transforming  feeble - minded , crippled children into relatively normal individuals. the first page features pictures of 
 children in before and after poses , and although the surgeon s name is not explicitly linked 
 to the patients , it was likely sharpe who provided the photographs . as mentioned at the beginning of this article , in 1914 

after a turbulent 
 period in which the code of ethics had been under sustained attack ( the advertising clause 
 included ) , the 1910s were a period in which the ama took a  laissez - faire approach to 
 medical ethics , and sharpe does not 
 seem to have suffered from his conduct .
but the surgeons who were laying the foundations for 
 neurosurgery as a surgical specialty saw themselves beholden to a stricter moral code than 
 the general profession as a whole . and
thus , despite the fact that he practised well within 
 mainstream medicine and achieved recognition both nationally and internationally , sharpe was not seen as morally worthy of 
 belonging to the sns .
he was not an academic surgeon with interests in laboratory 
 experiments , he espoused values that were at odds with those of elite surgeons , and , most 
 damningly , he appeared too eager to engage in flashy performances in the public arena . 

when , in 1988 , the 
 american neurosurgeon eben alexander came across sharpe s 1952 autobiography ( pointedly 
 entitled brain surgeon ) he marvelled :  how can a neurosurgeon who trained 
 at harvard and johns hopkins and studied under cushing and elsberg , who practised in new 
 york city during most of the first half of the twentieth century , and who was the author of 
 three books be virtually unknown to the present generation of neurosurgeons? the answer lies in the deliberate 
 marginalisation of sharpe , and others like him , by the group of surgeons who in the 1920s 
 sought to define the identity of the neurosurgeon and thereby overdetermined the history of 
 the specialty .
the concern with the moral character of the neurosurgeon , which prompted the close scrutiny 
 to which sachs and cushing had subjected sharpe , occurred in a specific cultural milieu and 
 can be explained by the particular challenges that surgery faced at the time . in the first 
 decades of the twentieth century , some surgeons began to express an urgent desire to 
 differentiate their practice from those of whom they disapproved .
the establishment of the 
 american college of surgeons ( acs ) in 1913 , with its dual mission of standardising surgical 
 practice and marginalising surgeons who were performing unnecessary procedures , was part of 
 this endeavour . in this context ,
character became ubiquitous . in 1919 , william mayo declared in 
 his presidential address that in the adoption of standards or requirements for admission into the american college of 
 surgeons , character should be first considered .
the dishonest , 
 conscienceless man who has surgical skill is most dangerous in any 
 community .
unnecessary operations , even when performed with a high order of 
 technical ability , are the bane of present - day surgery , but , owing largely to 
 the american college of surgeons , such practices are markedly on the wane . in the adoption of standards or requirements for admission into the american college of 
 surgeons ,
the dishonest , 
 conscienceless man who has surgical skill is most dangerous in any 
 community .
unnecessary operations , even when performed with a high order of 
 technical ability , are the bane of present - day surgery , but , owing largely to 
 the american college of surgeons , such practices are markedly on the wane .
the acs saw itself from the beginning as fulfilling the important task of being a moral 
 arbiter , formally requiring that its fellows not engage in practices such as 
 fee - splitting . by 1924 , charles mayo 
 was able to note the decline of this practice , reaffirming in his presidential address that 
  one of the aims of the college is to smoke these offenders out into the open. the following year , president rudolph matas 
 decried the surgeon who brought disrepute to surgery  no longer  the ordinary gross , 
 vulgar , ignorant and grotesque quack who was so familiar in past generations  
but rather a 
  more subtle type of quack   because they live in the fold and are not easy to recognize as 
 they are disguised in our own garb. 
 these surgeons , motivated by money or  insanely ambitious for reputation and prestige as 
 marvelous operators , allow their vanity and their reason to out - strip their morals by 
 performing unnecessary surgery . according to matas ,
the college stimulated  the cultivation 
 of a surgical conscience , a crucial attribute for a surgeon because : when a man has neither conscience nor character he can not be a good man , and if he is 
 not a good man he can not be a good surgeon .
and no matter how skillfully he may take out 
 appendices , gall bladders , resect stomachs , do hernias , and other fine jobs in surgery , 
 we do nt want him , and he need not apply for fellowship in the 
 american college of surgeons . when a man has neither conscience nor character he can not be a good man , and if he is 
 not a good man he can not be a good surgeon .
and no matter how skillfully he may take out 
 appendices , gall bladders , resect stomachs , do hernias , and other fine jobs in surgery , 
 we do nt want him , and he need not apply for fellowship in the 
 american college of surgeons .
this preoccupation with character , with the potentially problematic tension between 
 surgical skill and surgical judgement which only character could arbitrate successfully , 
 defined the mission of the acs , and along with the question of formal examination , it led to 
 disagreements about the stringency of admission criteria .
a 1924 petition , for instance , demanded that  more rigid tests 
 could be made as to the character , training and intelligence of candidates .
although it took a particular form for the surgeons of the beginning of the twentieth 
 century , a concern with character and integrity was evidently not novel in the medical 
 community .
as the historian christopher lawrence has shown , for an elite group of british 
 physicians in the second half of the nineteenth century ,  only the gentleman , broadly 
 educated , and soundly read in the classics , could be equipped for the practice of medicine . 

the equation almost ran : perfect gentlemen alone made great clinicians. these physicians believed that  
character  might matter 
 as much in medicine as it did in the church. character , in this instance , was linked to a particular kind of 
 gentlemanly culture . across the 
 atlantic , as john harley warner has shown ,
an ideal of science in the medicine of the second 
 half of the nineteenth century reordered the professional identity of doctors and  bound 
 together questions of medical epistemology with those of integrity. in the 1880s , some physicians challenged the ama code of 
 ethics because they believed science to be the ultimate arbiter of correct conduct 
no 
 codes of ethics were needed , in these doctors opinion , to prohibit consultation with 
 non - orthodox doctors such as homeopaths  while those who upheld the old code disagreed that 
 science could fulfil this role .
some early twentieth - century surgeons did not believe that education , surgical skill and 
 science would necessarily guarantee proper surgical conduct ; testimony from trustworthy 
 peers was also necessary in order to assess the character of the surgeon .
in fact , as the 
 acs presidents speeches indicate , skill could actually be a liability .
this belief was 
 partly informed by the particular pitfalls that surgery was seen to engender : unnecessary 
 operations and desire for fame and fortune .
for this reason , the historically contingent 
 relationship between character , professional identity , and medical practice found a 
 particular expression among the first generation of neurosurgeons , some of whom were deeply 
 involved with the acs and who reflected and attempted to shape its organisational concerns . 

one of these concerns  which had a direct bearing on the moral pitfalls mentioned above  
 was the surgeon s relationship with the lay press .
cushing was elected president of the acs in 1922 , and although he first rejected the 
 appointment , he eventually relented .
as 
 the historian michael bliss has noted , one of cushing s objections had been precisely the 
 fact that the press was allowed to cover the surgical clinics that were part of the congress 
 meetings .
cushing wrote to the founder 
 of the college that  [ o]ne of the very great , if not the greatest , evil that i see in 
 connection with the college is its publicity , and at the time of the meetings what i regard 
 the exploitation of patients on the part of many members of the college as a part of this 
 publicity .
it was to me the greatest evil of the original congress of surgeons , as great an 
 evil , indeed , as that of fee - splitting. 
 cushing s position reflected not only a concern for the patients .
he noted that although the 
 publications of the clinics were censored when the congress had met in boston ,  the papers 
 were full   of reports which were damaging to the profession as a whole and to individual 
 members of the profession .
after giving a simple 
 clinic. in his presidential address , cushing argued that because  surgery has become the chief 
 therapeutic resource of the profession, it lent itself to  commercializing opportunities 
 and temptations. he declared that  an 
 objectionable degree of publicity has been a distinct evil of former meetings of the 
 congress , and he drew a direct parallel between the moral qualities of a surgeon , his 
 surgical skill , and his desire for publicity :  as a rule , the better the surgeon the more 
 unassuming he is and the more he abhors seeing reference to his work in the lay press . 

certainly the college can not wish to foster the mere spectacularization of surgery , so 
 prevalent in days gone by. a few years 
 later , he told the boston globe that  a doctor should keep his name out of 
 the newspapers and remain unequivocably [ sic ] above any possible suggestion 
 of lending himself to  
publicity. while the ama had retained its prohibition of advertising in the wake of the late 
 nineteenth - century contentious debates about its code of ethics , the acs was in a more 
 complicated position as far as the press was concerned , since public education was one of 
 its mandates .
the ama actually attacked the college for its involvement with the public and 
 sought to punish those who courted too much attention .
loyal davis , a second - generation 
 neurosurgeon , wrote in his history of the acs that  [ john b. ] murphy [ 18571916 ] of chicago 
 and [ john b. ] deaver [ 18551931 ] of philadelphia , both with strong , forceful personalities 
 and a flair for the dramatic , were called 
publicity seekers. they were stimulating , 
 experienced teachers and their clinics were the most popular. murphy ,  a past ama president , was disciplined for 
 advertising by the ama s judicial council in 1916 .
the engagement of surgeons in public spectacles has a long history . as late as the second half of the nineteenth century 
 grand amphitheatres with ample seating for
both students and visitors were still being 
 built , but a change occurred in the early twentieth century when , gradually , surgical 
 operating rooms became smaller and were not designed to accommodate a large number of 
 spectators .
as thomas schlich shows , the ideals that defined the practice of 
 surgery underwent a generational shift : if in the 1880s the spectacular individual 
 performances of celebrated pioneers epitomised the best in surgery , over the following decades surgery began to be conceived 
 in a more communitarian way that emphasised standardised and teachable routines and 
 techniques . for cushing ,
the engagement of surgeons with the press seemed to evoke the public spectacle 
 of surgery s past , the spectre of quackery , and the general moral failure of vanity .
he was 
 advocating a movement away from large audiences , not only public but also professional ones . 
 in his presidential talk ,
apart from decrying the evils of engaging with the press , he 
 highlighted the 
temptations and  distractions that might cause a surgeon to make serious 
 mistakes when he was in charge of  the entertainment of , and provision for , a large number 
 of guests. surgical demonstrations 
 during the well - attended congress meetings were thus not profitable : there is no doubt but that one craftsman profits by seeing another craftsman at work , 
 but if a few hundred artists should stand at the elbow of mr john sargent while he is in 
 the process of painting a portrait , it would in all likelihood so modify his customary 
 performance that the sitter might with very good reason be dissatisfied with what may be 
 spoken of in surgical parlance as the end - result .
there is unquestionably a great deal 
 of artistry about a well - conducted operation , but surely as surgeons we are not content 
 to be mere manipulators and piece - workers  more interested in the technique 
 than in the portrait .
the important thing in surgery is not operative 
 dexterity but what the patient looks like after you and i have removed our 
 gloves , and what he is subsequently able to do with what we have left of him .
there is no doubt but that one craftsman profits by seeing another craftsman at work , 
 but if a few hundred artists should stand at the elbow of mr john sargent while he is in 
 the process of painting a portrait , it would in all likelihood so modify his customary 
 performance that the sitter might with very good reason be dissatisfied with what may be 
 spoken of in surgical parlance as the end - result .
there is unquestionably a great deal 
 of artistry about a well - conducted operation , but surely as surgeons we are not content 
 to be mere manipulators and piece - workers  more interested in the technique 
 than in the portrait .
the important thing in surgery is not operative 
 dexterity but what the patient looks like after you and i have removed our 
 gloves , and what he is subsequently able to do with what we have left of him .
but while large audiences were to be discouraged for these reasons , the small , select 
 audience of hand - picked colleagues was essential for the progress of surgery , and this was 
 precisely the kind of society of neurological surgeons that cushing was organising and which 
 was closed to morally suspicious surgeons like sharpe . the moral anxiety over the 
 spectacularisation of surgery was thus operating on multiple fronts : it signified an 
 engagement with the public by means of the press ,
too the neurosurgeons concern with the character of the 
 skilful but ambitious surgeon of questionable character found a particular expression in a 
 disapproval of spectacular performances and pitted flashy operative dexterity against 
 surgical judgement .
cushing articulated the potentially problematic relationship between skill and judgement in 
 a 1920 address to the cleveland academy of medicine , in which he explained the principles of 
 brain surgery .
he argued that the most dangerous surgeons were not those with mediocre skill 
  the  somewhat awkward craftsmen  but rather those  whose operative technic exceeds their 
 judgment as to when it should be put to use. cushing envisioned the operation as a theatrical performance : the patient , unfortunately , though he pays admission , has not the privilege of viewing 
 the performance , else he might like to see his appendix removed with a flourish , and to 
 applause .
his active interest begins when the curtain falls and he is then apt to find 
 himself more comfortable if the audience thought it a tedious and dull show .
the patient , unfortunately , though he pays admission , has not the privilege of viewing 
 the performance , else he might like to see his appendix removed with a flourish , and to 
 applause .
his active interest begins when the curtain falls and he is then apt to find 
 himself more comfortable if the audience thought it a tedious and dull show . in cushing s
vision the best brain surgeon had to aspire to put on  a tedious and dull 
 show in the operating room , a slow and careful performance whose aim was to lead to the 
 best result for the patient rather than to a dazzling show that nourished the surgeon s 
 vanity .
skill , if corrupted by vanity , could , in fact , become a liability .
thus for cushing , 
 the surgeon s work  an alchemy of judgement , knowledge , and skill  had this crucial moral 
 dimension that rested on the character of the surgeon , who had to refrain from spectacular 
 performances not only on the public stage , but also in the operating room . by rejecting 
 those like sharpe who were judged to fall short on this metric , the founders of the society 
 implicitly sanctioned a particular moral economy for the specialty .
although cushing s 
 initial defence of surgical specialisation was inflected by a belief that one day 
 specialties would return to general medicine , as a professional body the society became extremely important in the 
 specialty s development and organisation , and it was soon evident that neurosurgery would 
 enjoy a secure position as a medical specialty .
cushing and sachs had vetted nine surgeons , and they first met on 19 march 1920 in boston 
 at the peter bent brigham hospital .
other such travelling surgical clubs existed ( cushing 
 himself had been part of a travelling general surgery society ) , and while more work needs to 
 be done to understand the history , culture and function of these clubs , it is clear that 
 their existence represented an acknowledgement that , as the historian sally wilde has put 
 it ,  not everything necessary for the successful performance of a procedure could be 
 specified in a written text. cushing s 
 and sachs plan to establish a society for neurosurgeons was a reflection of this wider 
 trend in the culture of early twentieth - century surgery , embodying in part an expression of 
 these surgeons belief in the importance of tacit knowledge in surgical training and 
 practice . the first draft of the constitution of the society specified that
 formal papers 
 or written communications are to be discouraged. surgical clinics were the main focus of the sns meetings , which opened with the host 
 neurosurgeon performing an operation in the presence of his guests .
these performances , 
 followed by extensive discussions , were designed to negotiate particular norms , to 
 standardise surgical procedures , and to demonstrate the skill and judgement of the 
 neurosurgeon . in the second meeting , for instance ,
the secretary noted that  [ f]ollowing the operation the merits of 
 the intracranial approach and the transphenoidal [ sic ] route were 
 discussed. at the second meeting 
 there was a heated debate about the proper technique and the merits of ventriculography , a 
 new diagnostic procedure based on x - rays , and at the june 1931 meeting , c.c . 
coleman performed a surgical 
 procedure he had devised for mnire s disease in which the eighth cranial nerve was 
 cut .
the discussions following the surgical demonstrations allowed the neurosurgeons to create a 
 common repertoire of therapeutic procedures as well as to standardise both the techniques 
 and the instruments . in the third 
 meeting , following an operation at the university hospital in philadelphia , francis grant 
 led the surgeons into a discussion about atypical trigeminal neuralgia and the 
  standardization of technic of alcohol injections. at the same meeting , there were demonstrations followed by a long 
 debate about treating brain tumours with radium , which led to the consensus that  as yet 
 nothing positive could be stated as to the effect of radium , since a conclusion was made 
 difficult by the impossibility of telling  how much the relief of symptoms may be attributed 
 to the decompression and how much to the radium therapy. cushing had noted that  [ t]hey are ticklish performances , these operations for tumor , and 
 demand not only a rigorous regard for detail , such as the patient s position on the table 
 and the choice of anesthetic   but also a thorough knowledge of the diverse tricks of 
 controlling hemorrhage from scalp , meninges and brain. even the seemingly straightforward task of using a gigli saw could 
 be tricky , since the instrument could get caught in the dura .
 tricks like these were traded and negotiated in the professional 
 meetings that set the stage for surgical performances .
it was here that certain routines , 
 technical values and procedures , technologies , habits of mind and body became sanctioned 
 while others were discouraged .
historians of surgery drawing on the work of michel foucault have emphasised the 
 technologies of control that came into play in the operating room towards the end of the 
 nineteenth century .
the architecture of surgical theatres changed as surgeons demanded more 
 control over the environment as well as the body of the patient through technologies such as 
 anaesthesia or asepsis .
but there was 
 also another type of control that has been emphasised less  the surgeon s control over his 
 own body and gestures , the role this control played in the formation of a collective 
 surgical identity , and the technologies that made it possible .
the surgical performances that neurosurgeons put on for 
 each other fulfilled this crucial role by legitimating particular communal habits of the 
 body , and it can be useful to think of 
 these performances as a kind of technology of the self  a technology that helped the 
 neurosurgeon effect a change on the individual self in such a way as to help align him to a 
 community .
historians have highlighted 
 both the importance of shared cultural practices and spaces in the creation of a collective 
 identity , as well as the fact that 
 personal identity can not be made without the cooperation of others .
the neurosurgeons surgical performances in front of a 
 select audience were a means through which they affirmed interest in a shared practice and 
 sought to align their self to that of the entire specialist group .
for the first generation of neurosurgeons , these communally sanctioned surgical techniques 
 were underwritten by moral values such as self - control . during the first meeting of the 
 society ,
sachs noted that  dr cushing started a temporal lobe case which we had seen the day 
 before . the anesthetic was taken badly , so he removed fluid from the hernia , but then 
 postponed the operation , not thinking it wise to go on. sachs thought cushing s decision not to operate  was a hard 
 decision to make , but it made a profound impression upon me and , i am sure , upon the others . 

it seemed to me to show superlative judgment and self - control. self - control meant the ability of the surgeon to suppress his emotions as well as his 
 impulses , and it could be observed most clearly in action in the operating room . reflecting 
 on the establishment of the specialty board that began to certify neurosurgeons in the 
 1940s
, sachs made explicit the importance that early neurosurgeons attached both to 
 self - control and to the ability of the community to watch the prospective member in order to 
 determine if the surgeon possessed the proper technique , judgement and character .
he decried 
 the suggestion that this examination not be oral because observing a surgeon s reaction to a 
 problem  gave me a reasonably good idea of his ability to cope with a given situation .
on 
 the other hand , some men become speechless in an oral examination ; yet is this not in itself 
 significant ?
one wonders how such a man would react when faced with an emergency at the 
 operating table. an emphasis on self - control translated into a particular kind of neurosurgical practice  

conservative , careful , painstaking , slow , fastidious , tedious , dull  all descriptors that 
 the first generation of neurosurgeons used to characterise their 
technic. this kind of 
 surgery , its proponents argued , was different from the quick , bloody surgery of the end of 
 the nineteenth century .
a former 
 resident described the routine pantomime in the surgical theatre :  cushing s operating room 
 was a silent place .
he used a set of hand signals to indicate the instrument he wanted , the 
 thumb and forefinger pinched for a scalpel , an open palm with a twist of the wrist for the 
 needle holder , rapid motion of two fingers for scissors , and so forth. certainly , this kind of slow , careful surgery did not 
 originate with cushing himself , nor was it limited to neurosurgery .
william stewart halsted , 
 under whom cushing trained , had endorsed similar techniques in the late nineteenth century , 
 and the entire hopkins school of surgery relied on this approach .
some european surgeons had adopted similar practices . 
 when halsted visited kocher in 1899 , he was pleased to remark on the similarities between 
 their techniques .
such slow , exacting 
 practices had been made possible by new technologies such as anaesthesia and asepsis , and , 
 for neurosurgery , cushing s silver clips ( which allowed the surgeon to stem blood loss ) and 
 the charting of blood pressure during the surgical procedure ( which constituted a way of 
 monitoring intracranial pressure ) nevertheless , despite the fact that many of these 
 techniques were practised more widely by elite surgeons from the end of the nineteenth 
 century , an attention to detail , a slow meticulous surgery , an intolerance of both blood 
 loss and the sacrifice of healthy tissue and the prescribed steps to open and close the 
 skull became known as  the cushing ritual , or , as one of his students had described it , 
  the fastidious ritual of the cushing school. on this point neurosurgery was special , because , cushing had 
 argued , there was  no field of surgery in which fastidiousness is more essential to 
 success.
the meetings of the first neurosurgical society staged a critical encounter between the 
 host neurosurgeon and the society s members and guests who watched him perform surgery . 

these technical performances in the operating theatre , followed by discussions , were 
 designed equally to encourage particular norms , to negotiate surgical knowledge , and to 
 demonstrate the skills and character of the neurosurgeon .
the performances acted as a 
 technology of the self that at once aligned the operator to a community and helped that 
 community refine its norms of surgical conduct . in less than a decade these men spoke 
 confidently for the new specialty ; no outsider could compete .
sharpe himself was taught this 
 lesson when a scathing anonymous reviewer of his 1928 book neurosurgery : principles , 
 diagnosis and treatment declared that  the surgical course advocated and the 
 measures indicated are not in accord with the procedure of the leading neurologic surgeons 
 of this country. the founding members of the society had sought a small group of elite surgeons with 
 superior professional and moral qualities .
their concern about the skilful but ambitious 
 surgeon of questionable character developed in a context in which many north american 
 surgeons worried about unethical behaviour , from fee - splitting to the performance of 
 unnecessary operations .
as the presidents of the acs ( cushing among them ) had argued , the 
 community had to be vigilant about the character of its members because too often the 
 objectionable surgeon was  disguised in our own garb. surgical skill , if not balanced by judgement , and in conjunction 
 with vanity , ambition , or a commercialising impulse , could be very dangerous . when cushing 
 and sachs objected to sharpe s flair for the dramatic and the appearance that he was 
 courting the press , they were doing so out of a moral anxiety over the spectacularisation of 
 surgery , which could manifest on two different fronts : in the public arena through 
 advertising or the public intimation of radical cures , as well as in the operating room 
 through flashy surgical performances calibrated to showcase skill and dexterity and to stoke 
 the vanity of the operator . for the first generation of neurosurgeons
similar moral values , 
 such as self - control , underlined both the embrace of a conservative surgery and a distrust 
 of publicity .
this case study illustrates the historically contingent connection between surgical skill 
 and professional judgement , a relationship that reflects the broader concerns that animate 
 the medical community at a given time . in the first decades of the twentieth century ,
a 
 group of elite surgeons saw skill as a desirable but potentially problematic attribute that 
 had to be kept in check .
the first generation of neurosurgeons believed that an awkward 
 surgeon with inferior technical ability was preferable to the brilliant and vain operator 
 who lacked the capacity to judge when he should not call on his spectacular 
 skills .
 historical contingency complicates a reading of skill as a self - explanatory and always 
 positive attribute . by focusing on the attempts of the first generation of neurosurgeons 
 to build a community and fashion a collective neurosurgical self , 
 this article highlights 
 the extent to which the relationship between surgical skill and professional judgement is 
 reflected in broader concerns that shape the landscape of medicine at a given time . 
 some 
 early twentieth - century surgeons expressed concern about the spectacularisation of surgery 
 and the skilful but problematic work of  
 brilliant operators. the neurosurgeons policies 
 of inclusion and exclusion show that in the process of fashioning a neurosurgical persona , 
 this first generation sanctioned specific norms of conduct underwritten by similar moral 
 imperatives , such as self - control . 
 these norms governed the doctors work both in the 
 operating room and on the public stage ( in their engagement with the press ) . 
 the meetings 
 of the first neurosurgical society staged a critical encounter between the host 
 neurosurgeon and the members who watched him perform surgery . 
 these technical performances 
 in the operating theatre , followed by discussions , were designed to encourage particular 
 norms , to negotiate surgical knowledge , and to demonstrate the skills and character of the 
 neurosurgeon . 
 the performances acted as a technology of the self that aligned the operator 
 to a community and helped that community refine its norms of surgical conduct . 
 the awkward 
 surgeon with inferior technical ability was preferable to the brilliant but vain operator 
 who lacked the capacity to judge when he should not deploy his spectacular skills . 
The First Neurosurgical Society and the Exclusion of William Sharpe
Character and the Early Twentieth-Century Surgeon
Self-Control in the Surgical Theatre
Conclusion