The debt of neurosurgery to William Stewart Halsted (1852-1922)

From the Historical Examples of Drs. Osler, Cushing, and Van Wagenen: Lessons on the Importance of Mentorship in Contemporary Neurosurgery

Although the historical relationships between William Osler, Harvey Williams Cushing, and William Perine Van Wagenen are well known in the neurosurgical world, the nature of the mentor-mentee relationships that existed between these historical giants is not widely appreciated. In this historical vignette, we describe and exemplify such relationships, while at the same time extract important and applicable principles from them. We reviewed relevant primary and secondary sources that documented the interactions between Cushing, Osler, and Van Wagenen. In founding the field of neurological surgery, the brilliant yet volatile Dr. Harvey Cushing received guidance from his mentor, Dr. William Osler. Through our review, it is undeniable that Dr. Osler's personal and professional guidance was vital to young Dr. Cushing's success as the founder of modern neurosurgery. Likewise, Cushing's tutelage of Van Wagenen enabled Van Wagenen to become a leader of a second generation of neurosurgeons, thereby perpetuating the existence of Cushing's high neurosurgical standards. These historical mentor-mentee relationships were built on 4 primary components: accurate recognition of talent, guidance, arrangement of opportunity, and sustenance of mentorship-actions that are commonly implicated in effective mentorship in contemporary studies. Proper mentorship remains indispensable for the success of neurosurgical trainees.

Harvey Cushing, the spine surgeon: the surgical treatment of Pott disease

STUDY DESIGN

Review of historical archival records.

OBJECTIVE

Describe Harvey Cushing's patients with spinal pathology.

SUMMARY OF BACKGROUND DATA

Harvey Cushing was a pioneer of modern surgery but his work on spine remains largely unknown.

METHODS

Review of the Chesney Medical Archives of the Johns Hopkins Hospital from 1896 to 1912.

RESULTS

This is the first time that Cushing's spinal cases while he was at the Johns Hopkins Hospital, including those with Pott disease, have been described.Cushing treated three young men with psoas abscesses secondary to Pott disease during his residency: he drained the abscesses, debrided any accompanying necrotic vertebral bodies, irrigated the cavity with salt, and left the incision open to close by secondary intention. Although Cushing used Koch's "tuberculin therapy" (of intravenous administration of isolated tubercular bacilli) in one patient, he did not do so in the other two, likely because of the poor response of this first patient. Later in his tenure, Cushing performed a laminectomy on a patient with kyphosis and paraplegia secondary to Pott disease.

CONCLUSION

These cases provide a view of Cushing early in his career, pointing to the extraordinary degree of independence that he had during his residency under William Steward Halsted; these cases may have been important in the surgical upbringing both of Cushing and his coresident, William Stevenson Baer, who became the first professor of Orthopedics at Johns Hopkins Hospital. At the turn of the last century, Pott disease was primarily treated by immobilization with bed rest, braces, and plaster-of-paris jackets; some surgeons also employed gradual correction of the deformity by hyperextension. Patients who failed a trial of conservative therapy (of months to years) were treated with a laminectomy. However, the limitations of these strategies led to the development of techniques that form the basis of contemporary spine surgery-instrumentation and fusion.

"Fulfilling the chief of his duties as a physician": Harvey Cushing, selective dorsal rhizotomy and elective spine surgery for quality of life

At the beginning of the 20th century, the development of safer anesthesia, antiseptic techniques, and meticulous surgical dissection led to a substantial decrease in operative risk. In turn, the scope of surgery expanded to include elective procedures performed with the intention of improving the quality of life of patients. Between 1908 and 1912, Harvey Cushing performed 3 dorsal rhizotomies to improve the quality of life of 3 patients with debilitating neuralgia: a 54-year-old man with "lightning" radicular pain from tabes dorsalis, a 12-year-old boy cutaneous hyperesthesia and spasticity in his hemiplegic arm, and a 61-year-old man with postamputation neuropathic pain. Symptomatic improvement was seen postoperatively in the first 2 cases, although the third patient continued to have severe pain. Cushing also removed a prominent spinous process from each of 2 patients with debilitating headaches; both patients, however, experienced only minimal postoperative improvement. These cases, which have not been previously published, highlight Cushing's views on the role of surgery and illustrate the broader movement that occurred in surgery at the time, whereby elective procedures for quality of life became performed and accepted.

William S. Halsted and Harvey W. Cushing: reflections on their complex association

William Stewart Halsted, the father of modern surgery, and Harvey Williams Cushing, the father of neurosurgery, are remembered for their countless innovations and contributions to the discipline of surgery. Between 1896 and 1912, they worked together at Johns Hopkins Hospital making many of their respective achievements possible. In the later years, their complex relationship, somewhat strained during Cushing's residency, grew into a mutual respect and deep appreciation for one another. In this offering, the authors attempt to elucidate the evolution of this complex relationship.

Transcranial surgery for pituitary tumors performed by Sir Victor Horsley

OBJECTIVE

To describe the clinical details and the operative method used in pituitary tumors by Sir Victor Horsley (1857-1916), which represent the earliest attempts at pituitary surgery.

METHODS

Horsley's case books and postmortem records, archived at the National Hospital, Queen Square, London, were studied for patients with a primary diagnosis of a pituitary tumor admitted during the period 1886 to 1916 who were treated surgically. Contemporary records of nonpituitary cases were also examined to study aspects of Horsley's operative method.

RESULTS

Four patients (three men and one woman) underwent craniectomy for removal of a pituitary tumor via the subtemporal approach between 1904 and 1907. All four patients experienced significant impairments of visual fields or visual acuity; one patient had severe trigeminal neuralgia. Evidence of acutely raised intracranial pressure was present in one patient. All patients underwent craniectomy under chloroform anesthesia. One patient died on the day of surgery, and the postmortem findings are presented. In the other three patients, neurological morbidity was recorded in the postoperative period in the form of new cranial nerve deficits, monoparesis with dysphasia, and seizures. The patient with trigeminal neuralgia experienced partial relief and was readmitted later for reexploration and Gasserian ganglionectomy via the same route. Four contemporary nonoperative cases of pituitary tumor are also presented.

CONCLUSION

These cases provide insight into the presentation and operative treatment of pituitary tumors during the pre-Halsted era.