• Political

By any metric, we have become a closed society.

We have our own scientific meetings. We have our own journal. We have our own (quite distinctive) name. We have remarkably difficult and demanding criteria for entry into our group. We have finally achieved credibility, acceptance by other specialties, and most importantly for our own members, respectability. We have become—during our most difficult but interesting journey—a closed society.

Before going any further, let me tell you how I define a closed society. They are, first, a group of individuals with similar backgrounds, skills and goals. But there is usually more to the situation. A closed society has its own—usually cryptic—language, its own customs, and, importantly, quite difficult requirements for entry. An almost inevitable corollary is the development of a vigorous and effective self-protective behavior. The SNIS satisfies those criteria on all counts.

What happens to closed societies? In particular, where do we go from here?

Historians often begin their books with Shakespeare's quote: “What's pass't is prologue”. There is certainly a valid reason: fail to learn from the past and we are doomed to repeat our ancestors' errors. So a primary question at this early moment in our existence is whether we can learn from the past so we do not make the same mistakes other closed societies have. Thus my title.

Perhaps we can develop some insight into this question by an examination of three cases—and an analysis of a story.

The patient shown in fig 1 was referred to me for retreatment about 20 years following Luessenhop and Spence's treatment of his brain arteriovenous malformation (AVM).¹ That initial treatment was carried out by cutting down on the internal carotid artery, then manually introducing handmade methacrylate spheres, allowing the sump effect of the malformation to flow the spheres into the …