Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (34 page)

AFTER COMPLETING HIS
residency in May 1900, Cushing set off for his first European tour. He observed the state of European neurosurgery, made a number of cultural side trips, and generally enjoyed the experience. He had already written numerous papers and was well known,
and received job offers from hospitals in Boston, Philadelphia, and New York, eager to install a famous, young Halsted-trained surgeon. The most comfortable possibility was going home to Cleveland, where his father practiced, and set up as a surgeon. But everything considered, the future of medicine still resided at Johns Hopkins.

It was difficult to negotiate with Halsted. He either ignored the situation or refused to make a decision, but he wanted Cushing to return. Part of the inducement to draw him back to Hopkins was allowing him to take over the operative surgery course for third-year students, which occupied Friday afternoons, and the lectures on surgical anatomy two afternoons a week. Mornings were reserved for learning everything he could of neurology. He attended at the dispensary daily and did whatever operative neurology cases he could find on Friday mornings. For the first few years he saw private general surgery patients each afternoon from 2:00 to 3:00, in a small office in his home at 3 West Franklin Street. Throughout, he continued his work in the research lab.

Cushing restructured the operative surgery course, giving students roles in the care of the “patient” that mimicked human medical practice: family doctor, surgeon, assistants, and anesthetist. They dressed for surgery, observed proper aseptic technique, cared for the canine patient with a charted “history,” and kept anesthetic and surgical records. One of the rules of the laboratory was, “An autopsy shall be performed in all cases of death occurring in the laboratory. These autopsies shall be conducted with the same respect and formality in the pathological department of the hospital and the findings shall be recorded in the laboratory record.”

All this brought with it the feelings of joy and despair attendant upon any surgeon in the care of patients.

Halsted appreciated the improvement in the course he had created. Under Cushing it became the highlight of the student experience in surgery, and the envy of other medical schools. Halsted later wrote Welch, “I embrace this opportunity to express my indebtedness to
Harvey Cushing, for thirteen years my brilliant assistant, for his zeal in elaborating these courses and placing them on such a substantial basis that they are now regarded as one of the dominant features of the surgical curriculum for the third year medical students at the Johns Hopkins University and are being adopted by other medical schools of this country.”

CUSHING SHARED THE
rented house on West Franklin with two other young Hopkins doctors. Their neighbors at Number One were none other than the William Oslers. The relationship between Cushing and Osler had been excellent from the start, and it grew closer and more familial with the years. Osler welcomed the young men to the neighborhood with wine and cigars. An open-door policy, or at least an exchange of keys, was established, which was quickly dubbed the “latch key club.” Cushing and the others often spent the late evening in the Osler library, working or socializing. The relationship became closer still when Cushing and his new bride, Kate, took over the house. Cushing, always a bibliophile, regretted the absence of a fine library and loved spending time among Osler’s wide variety of well-bound editions. The Oslers adopted Kate as well, and the arrangement seemed to suit both families perfectly.

Osler was the glue between the volatile Cushing and the enigmatic Halsted. The 33-year-old Cushing was intemperate, at best, and the string of people he casually insulted gradually enveloped him and threatened to strangle his career. Rumors of his bad behavior spread beyond the Hopkins medical community. After one incident Osler called Cushing out for deprecating remarks he made about colleagues, which had found their way back from New York. Osler finished with the advice, “Keep your mouth.”

Cushing also confessed to his wife, Kate, of being rude to Halsted: “Sorry, but I couldn’t help it. Some day I will tell him I don’t like him and pack up my duds and go home and bury my head in your lap.”

A destructive pattern of behavior had developed. If Cushing did somehow learn to hold his tongue, much of the credit belonged to Osler. Beyond his father, there were few people who could influence Harvey Cushing. Years later he would win the 1926 Pulitzer Prize for his book
The Life of Sir William Osler
.

LITTLE OF WHAT
irritated Cushing about Halsted was untrue. He was often absent from surgery, he did miss lectures, he did not communicate with medical students, and he was away from the hospital for almost half the year, and worked at home or in the experimental lab for a good deal of the time that he was present. He was, unintentionally or otherwise, oblivious to the feelings and the needs of those working for him, critical in a quiet and diminishing manner, and certainly niggardly with his compliments.

Cushing’s negative attitude toward Halsted was evident during his residency, but The Professor’s delinquencies had provided more opportunity and experience for him, and he was mollified by his own profit. Later his anger jelled around the difficulties in extracting a clear delineation of his position should he choose to return to Hopkins after the European tour. After a stimulating year “opening the box,” as he referred to brain surgery, he had every intention of making a career of neurosurgery. Halsted had written him and offered such a position in the department of surgery. Later, Halsted suffered recriminations, thought there wouldn’t be enough work, and made other suggestions unacceptable to Cushing, among them adding orthopedic surgery to his responsibilities. Tempers flared, or at least Cushing’s did. Halsted said nothing. He backtracked and procrastinated, and was unable to make a decision. Finally, with some urging from others, the deal was struck and Cushing won all his points, but lost respect for The Professor.

For his part, Halsted recognized the unique talents before him and allowed them to blossom. He believed himself to be both
encouraging and appreciative, and was apparently unaware of the animosity the young neurosurgeon harbored toward him. As early as 1899, Halsted wrote him, “If you should break down I would be in my grave in a month.” There is no evidence of Halsted believing their relationship was anything but mutually beneficial and friendly, and later Cushing may have been the only former resident that Halsted treated like an equal.

It was Halsted who suggested Cushing pursue the exploration of pituitary function, which later resulted in his greatest scientific breakthrough, and it was he who allowed him the latitude to develop neurosurgery. As death and disappointment followed Cushing’s every step forward, Halsted was said to have quipped that he didn’t know whether to say “poor Cushing’s patients, or Cushing’s poor patients,” but he was always supportive and never interfered.

Opening the skull was a daunting enterprise. It was approached infrequently, and the demise of the patient was the most frequent outcome. Intraoperative death was usually related to bleeding, and postoperative death the result of swelling of the brain and infection. X-rays could not differentiate brain tumors from the surrounding soft tissue, and tumors were therefore difficult to localize. Neurological examination and past experience could indicate the general location of a lesion, but finding it within the substance of the brain was fraught with disaster. One could not dissect indiscriminately through the substance of the brain without expecting to pay a dear price in neurological deficit.

The pressure of expanding tumors causes swelling and fluid accumulation, and pushes the brain against the skull. This results in seizures and a whole range of neurological deficits. Cushing reasoned that even if he couldn’t localize the tumor and remove it, he could drain fluid and blood, and offer temporary relief until the tumor increased in size. It would be palliative at worst. He applied the lessons learned from Halsted; rigid asepsis and scrupulous hemostasis were
the rule.
¹
The towels draping the head should be as free of bloodstains and spatter at the conclusion of the operation as they had been at the start. Time-consuming and precise, the preparations made further exploration feasible, in a controlled environment.

The infection rate in Cushing’s cases plummeted. His subtemporal skull flap provided both adequate decompression and a strong muscular layer to keep the brain from herniating through the trapdoor in the skull when the cover was not replaced. A year after devising the approach, he had performed more than two dozen successful decompressions. Cushing took his show on the road, and was harsh with surgeons who advocated surgery only when the tumor could be localized. With better technique and a more aggressive attitude toward palliation, his reputation grew, and along with it the courage for wider exploration and tumor removal. But he was still groping in the dark.

The popular course in operative surgery was held in cramped and inadequate quarters on the ground floor of the old anatomical building. Cushing, MacCallum, and a group of students successfully petitioned the trustees for a larger space. The resulting effort was called the Hunterian Laboratory of Experimental Medicine, after the pioneering British anatomist and surgeon John Hunter. Built in 1905 at a cost of $15,000, the new building housed laboratories for surgery
and pathology. Cushing favored naming it for the 19th-century French physiologist François Magendie, a particularly insensitive choice. Magendie made great contributions to the knowledge of neuroanatomy, which accounted for Cushing’s interest, but he was a well-known vivisectionist, who caused great outrage in the United Kingdom with his thoughtless dissections of live animals. In a particularly revolting demonstration, he nailed an unanesthetized greyhound to a board and demonstrated the nerves of its face by dissecting it live. The direct result of this was the English laws banning cruelty to animals.

“The antivivisection group in Baltimore were very active at the time and Magendie’s name was anathema to them, so at the suggestion of Dr. Welch we thought we should use John Hunter’s name instead,” Cushing wrote. “It was not a bad solution, for it mystified a good many people who thought the term had something to do with a pointer or a setter, and after all we did have something to do with them for we began to have a good deal of veterinary work.”

Averting the public relations disaster was wise. Wiser still was the service rendered to the community. With their wide knowledge of animal diseases and their unheard-of facilities for care, Halsted and his staff treated many local pet dogs, saved many canine lives, and won over the community.

The Hunterian was the site of great experimental activity. Halsted was working on surgery of the thyroid gland, arterial aneurisms, and his eternal search for the best method for end-to-end intestinal anastomoses. Cushing had begun work on the pituitary, soon to be known as the “master gland.”

Cushing began writing and speaking about diagnosing brain tumors by examining the retina. Increased pressure from tumors put pressure on the retinal nerve, resulting in an easily visualized sign called a “choked disc.” His fame spread, and brain tumor patients came to Johns Hopkins for surgery by Cushing in the same way that breast cancer and hernia patients sought out Halsted. Revolutionary
work and frequent publications got the word out, and in 1909 and 1910, Cushing operated on more than 100 suspected brain tumor patients. In the
Bulletin
he reported an apparent cure of 30 of the last 100 patients, with a “complete absence of the old-time post operative complications. A meningitis or fungus cerebri [infection] is almost inexcusable today.”

Tumor cases were carefully followed, and Cushing, ever creative, had all patients write him on their birthday. If they didn’t write, he contacted them or their families. In this manner a great deal of information was amassed on the natural history of brain tumors, which helped direct efforts in the future. He was thoroughly devoted to his patients, and they to him. Though his energy, enthusiasm, and difficult temperament were pillars of his personality, he was socially charming, and always so with his patients. He was willing to go where others had declined to venture, and his patients and their families accepted the risks and felt his concern for them.

Cushing passed on his teaching responsibilities to others. He performed increasing numbers of long, tedious operations and had begun his work on the pituitary in earnest. He had his own assistants and staff, and an average census of 40 patients in the hospital, including many private patients. A legion of medical students and assistants worked with him on the wards and in the Hunterian Laboratory, and he had risen to associate professor at the medical school.

BY THE TURN OF
the century there was a general awareness of the importance of the strange, ductless glands like the thyroid and the parathyroid. Halsted was at the forefront of examining the function and malfunction of both. The adrenal glands, ovaries, testes, thymus, and pancreas are also ductless glands, a category that came to be called endocrine glands. These glands somehow delivered regulating substances to the body, not through a connection or duct, but directly into the bloodstream. Whether these glands were interconnected was unclear. What was clear was that animals without thyroid glands
could not survive. Animals without parathyroid glands perished as well. The pituitary gland is a small, bilobed, pea-sized structure sitting at the bottom of the brain in a bony saddle called the sella turcica. The position of the gland made it uniquely accessible to surgery, and Cushing assigned three medical students—Lewis Redford, Samuel Crowe, and John Homans—to remove the pituitaries of a series of dogs.

After 100 procedures it became clear that the dogs would die without the gland—often slowly, but they would die. The next step was to see whether the two lobes, the anterior and posterior, had separate functions. Most of the dogs that lost most or all of the anterior lobe died. In one of the surviving dogs, Cushing noted a loss of energy, lack of growth, asexuality, and a fatty slothfulness reminiscent of the symptoms of Frohlich’s syndrome, an enigmatic state linked to atrophy of the optic nerve, which happened to be in direct proximity to the pituitary. Cushing surmised that if lack of pituitary secretion, or hypopituitarism, was responsible for the condition, perhaps tumors of the pituitary could cause hyperpituitarism. The symptoms of hyperpituitarism were well known, and termed acromegaly. They included gigantism, thickened bones, large hands, protruding jaw, and vascular defects.