Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (33 page)

CHAPTER TWENTY-FIVE
Harvey Cushing

IN 1910, MAJOR GENERAL
Leonard Wood was about as distinguished a military man as could be found in the United States. Among his other accomplishments he commanded Theodore Roosevelt’s Rough Riders, was military governor of Cuba and later military governor of the Philippines, and on top of it all he was a physician interested in public health. His energetic exploits had made him a household name, and he was next in line to become army chief of staff. As his fame and military importance were growing, so too was a large, nearly half-pound, tumor in his brain.

Harvey Cushing had been at Johns Hopkins for 14 years. He had performed hundreds of craniotomies, usually to release pressure on the brain and relieve symptoms. He had removed brain tumors as well, but with very limited success. Still, he was the most experienced man in a field of general surgeons with an interest in neurological surgery. No one specialized in neurosurgery, because little was known about surgery of the brain, and the results of meddling were consistently bad. Prior to Cushing taking up the task, postoperative infection killed the patients that the operation hadn’t. Finding one’s way into and out of the brain was difficult enough; achieving tangible improvement for the patient was nothing short of a miracle.

Wood’s left-sided weakness and seizures had become too severe to ignore. After years of procrastinating, he found himself on Cushing’s operating table. Cushing followed his routine and personally shaved the general’s head, just as he would the head of an indigent ward patient. He had already proven that the skull and brain were insensitive to pain and planned to do the surgery under local anesthetic, using a dilute cocaine solution to numb the scalp. Patients could lie comfortably awake for hours, chatting away, as the surgeon dug into the recesses of their brains. After preparing the scalp with antiseptic, Cushing draped the area with sterile towels, in much the same manner he had been taught by Halsted to do in general surgery. Then Cushing changed his mind, and Wood was anesthetized with chloroform. He cut through the skin of the scalp to the richly vascular loose connective beneath it. He applied pressure to the scalp beyond the incision, thereby controlling bleeding, and applied fine Halsted clamps to the blood vessels. When the field was dry, he incised the deepest layers of connective tissue, the galea and periosteum, and exposed the bone of the skull. The next, brutal, step was to drill holes through the skull with a hand-powered trephine. A wire blade, called a gigli saw, was threaded from hole to hole and the saw pulled back and forth until the skull between the holes was opened. This then could be lifted out like the lid of a jack-o’-lantern, or left partially hinged to the scalp. It was a bloody and time-consuming procedure.

Cushing looked beneath the flap and encountered a very large, superficial mass. Calculating the difficulties already incurred in simply trying to control bleeding, he opted to withdraw, close the skull flap, and begin again another day.

Several days later, this time with the patient under local anesthesia, Cushing lifted the skull cap and faced the pulsating mass. Cushing thought the better of having Wood awake for the struggle, and he was given chloroform once again. It was an enormous and daunting tumor. Cushing began digging. The tumor appeared to be
a meningioma, originating from the fibrous layers covering the brain. It had pushed into the soft substance of the cerebral cortex, causing symptoms by its space-occupying mass, but was not actually invading the brain. After hours of painstaking dissection separating the benign meningioma from the normal brain surrounding it, Cushing believed he had removed the entire tumor, or as much as could be seen. The challenging task of controlling bleeding was time-consuming as well, but that, too, went Cushing’s way. The operation was completed by reversing the steps made to enter. The dura was sutured closed, the skull cap replaced, and the galea and scalp sutured in place.

General Wood recovered quickly and fully, and Harvey Cushing became a national hero.

AFTER INITIALLY PLANNING
to study medicine with Osler, Cushing switched gears and spent a year as a surgical intern at Massachusetts General Hospital. By all measure the ablest and most ambitious intern in the group, the obvious thing for him to do was to head for Baltimore and study the new surgery with Halsted. After an unsuccessful attempt to secure a position at Hopkins, Cushing was preparing to leave for a year of European study when an assistant residency became available. In September 1896, Cushing arrived in Baltimore ready to work.

Harvey Cushing wasn’t the usual self-effacing junior resident reporting for duty. This one arrived with his wardrobe, his books, and the first X-ray machine ever seen at The Johns Hopkins Hospital. In Wurtzburg, Germany, Wilhelm Roentgen had recently passed a highvoltage electric current through a vacuum tube and noted an odd form of light that was not absorbed by a screen, but instead was projected across the room. On November 8, 1895, Roentgen used the apparatus to produce an image of his wife Bertha’s hand. It clearly showed her bones as well as the wedding band on her ring finger—the first X-ray picture. The implications were enormous, and Cushing leapt into the fray. He, and others, at the Massachusetts General Hospital experimented a
bit, then purchased a tube and a hand-cranked static electricity generating device, and began taking X-rays of fractured bones. Cushing provided most of the money to purchase the device and after some wrangling took it with him to Baltimore.

The first X-ray ever taken at The Johns Hopkins Hospital was a dramatic image of a bullet lodged in a woman’s spine. Taking the X-ray was a tedious 45-minute affair, particularly for Joe Mitchell, who had to crank the generating apparatus while Cushing adjusted and readjusted the exposure. Cushing had arrived in a blaze of glory, bringing with him the newest and most obviously useful medical device. He continued to do all the X-ray work for the hospital until he became resident the following year.

Massachusetts General Hospital was very large and very busy, and Cushing was both surprised by the comparatively slow pace of Johns Hopkins and disappointed by the boring, backward city that Baltimore was at the time. In Boston the volume of surgical work had been great. Speed and technique were of the essence, and the idea of surgeons wearing rubber gloves was laughable. There was “No encouragement to follow-up a bad result, whether to its home or to the dead house.”

This was the difference between the Halsted system and all the others. For Halsted every case, every patient, and every manifestation of disease had to be carefully studied before surgery, meticulously executed at surgery, and examined for lessons learned after surgery. Results were analyzed and methods continually changed, in the constant search for better solutions.

Cushing had no prior experience with laboratory tests, bacteriology, or surgical pathology. His learning curve was labor intensive, but he recognized the value of the work and was soon publishing papers on various laboratory-based topics. He wrote:

The talk was of pathology and bacteriology, of which I knew so little that much of my time the first few months was passed alone at night in the room devoted to surgical pathology … looking at specimens with a German text book at hand…. It was most dis-concerting to me, after the hurly-burly of Massachusetts General Hospital, to have my new Chief come into Ward G; ask if he might be allowed to examine a particular patient; to have him spend an hour fiddling over a patient with cancer of the breast … if he were sufficiently interested he might ask that he be permitted to do the operation; and if he came and did operate, so soon as the breast was removed leaving the huge closure and skin graft to Bloodgood, he would depart with the tissues.

Cushing was the most impressive and possibly the most able and ambitious of the 17 Halsted residents. He was the first to utilize local anesthesia in hernia repair, the first to operate on the pituitary gland, the first to routinely open the skull to decompress the brain, the innovator of numerous neurological techniques, and the developer of prototypes for exactly how neurological operations should be performed. Simply put, he invented neurosurgery. All this transpired while Cushing worked as Halsted’s assistant in the department of surgery. Cushing was an able and enthusiastic teacher, and in the laboratory he directed a team of assistants on research projects, increasingly involving the pituitary gland. In his spare time he performed the bulk of Halsted’s surgery.

Halsted’s legacy was built on two equally potent, unimpeachably world-altering platforms. The first was the establishment of the school of scientific, safe, and anatomically correct surgery; the second, a working environment that shaped the education of generations of surgeons and propelled American surgery to its preeminent position in the world. The former brought about an undeniable surgical revolution, proven by consistently superior results; the latter was a more complicated and personal equation, and Harvey Cushing was the perfect case in point.

Cushing came to Hopkins with curiosity, intelligence, and intensity. There he found the proper environment for his talents to prosper. He was neither groomed nor nurtured, but was allowed to take from the environment everything he needed to excel. He was the first to carry the Halsted tradition to greater heights, and he became far better known than The Professor himself. Cushing was the product of the scientifically enriched surgical environment created by Halsted. He fully utilized the Halsted springboard to realize his ambition of greatness, but he was the least vocal of disciples in praise of his chief.

Shortly after being named resident in 1897, Cushing became ill with abdominal pain, which he initially blamed on bad food. William MacCallum, a fourth-year medical student who had uncovered the physical properties of the parasite that caused malaria, was assigned by Cushing to repeatedly perform a count of the leukocytes in his blood. The white count, elevated at the outset, rapidly rose to a level indicative of active, acute infection. The professors were called in. Both Osler and Halsted adopted a wait-and-see posture, though it remains unclear what they were waiting for. The JHH experience with appendicitis was growing, and early intervention, before rupture, had finally become the rule.

IN 90 CASES OF
appendicitis treated since the hospital had opened, the mortality rate was about 25 percent. Cushing didn’t want to be among them, and he pushed for the surgery. Halsted, Finney, and Bloodgood were all in on the operation the following day. Cushing was anesthetized with chloroform, and by his own account, “all six hands were inside of me at once—and big hands at that.” Nonetheless, the surgery was uneventful. The early postoperative course was smooth, but just when it seemed his problems were over, a wound infection developed. It was the first in a summer-long record of 200 consecutive cases without wound infection. Though Cushing recovered fully, he complained about the silver wires buried in his abdominal wall whenever anyone would listen.

When Cushing fully assumed the responsibilities of resident, he became more acutely aware of Halsted’s absence. He wrote home, “The chief rarely operates. Today I did all of his private cases ….” Gradually, Cushing became disenchanted with his chief. He respected Halsted for all he had accomplished, but was outspoken about finding him both difficult and odd. At times he seemed to be compiling a dossier on what he considered Halsted’s dereliction of duty; at others he was happy for the opportunity to assume responsibility and garner experience.

This, in fact, became the conundrum of the Halsted method of teaching. Had negligence and dodging of duty facilitated the graduated assumption of responsibility by the resident, or was all this according to plan? Cushing thought the worse of it in the early going, and the better of it in retrospect. Most residents shared the latter opinion. There can be little doubt that it was not a black-and-white issue. With increasing frequency, Halsted missed lectures, failed to appear at surgery, and did not follow up on research projects. There is no precise information on the extent of his drug use at the time, but things were getting worse.

HALSTED AND CUSHING
had more in common than the single-minded pursuit of their goals. Both were Yale men; both had been athletes at college, and neither could brag about having spent any time in the Yale library. Halsted was impressed by Cushing during his first year at Johns Hopkins and chose him above senior men as resident. Cushing was ambidextrous and was a skillful operator from the start. This he credited to his earlier training in Boston, where so much emphasis was placed on technique. When lecturing, he would write on the chalkboard with both hands simultaneously. He was a competent representational artist and illustrated his charts with drawings of each operation. The drawings became part of the Cushing legend, and a useful device adopted by many surgeons to come.

Cushing worked tirelessly and was as demanding of assistant residents, nurses, and ancillary staff. On one occasion he so humiliated a junior resident that the man cornered him in the changing room, locked the door behind them, and threatened to give him the beating of his life unless he apologized. Cushing backed off but didn’t change.

A perfectionist, he was rigid in his rules both inside the operating room and out, sometimes obsessively so. Samuel Crowe recounts that Cushing insisted his patients be fed soft-boiled eggs, bacon, and toast with bitter orange marmalade for breakfast, pureed spinach for lunch, and a list that went on and on. Hearing that Crowe forgot to order pureed spinach for a patient, Cushing flew into a rage, again nearly precipitating a physical clash.

But Cushing was just as hard on himself. When he lost a patient his first inclination was to blame himself, and in those early days he often complained to his wife that everyone he touched died. As he began to explore the uncharted world of brain surgery, failures far exceeded successes, and the self-flagellation became so intense that it almost smothered his enthusiasm. By 1899, he had already thrown himself into the deep water, achieving great success in an operation to control the debilitating pain of trigeminal neuralgia. Commonly known as tic douloureux, it is a life-altering affliction involving the sensory component of the fifth cranial nerve. Patients were known to kill themselves rather than endure the pain, and all prior efforts had failed for anatomical or technical reasons. Cushing was trained to become expert in the anatomy. He was technically proficient and he had great surgical courage, a combination that would lead him from success to success.