The Pharos - Alpha Omega Alpha

The making of a neurosurgeon
Cushing’s original illustration of the repair of a left-sided inguinal hernia, which he operated on at the same time as Halsted
worked to repair a right-sided inguinal hernia on the patient. Labels from left to right and top to bottom read: “testicle,” split
aponeurosis,” “thin fibers of int. oblique,” “upper limit of lower sac,” “cord showing [illegible] sac,” “opened lower sac.”
Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions.
Halsted had trained. 1,7 When Cushing returned to Baltimore
in 1901, his future at Hopkins remained uncertain until the
late fall, when he obtained an associate position within the
hospital, and received Halsted’s blessing to pursue neurosurgery
at least one day each week. Beginning in September 1901,
Cushing expanded his surgical repertoire to include operative
interventions for epilepsy, cerebral palsy, spina bifida, and
trigeminal neuralgia. Even though these operations were a far
cry from the general surgical procedures he had performed
during his training with Halsted, Cushing’s neurosurgery at
Hopkins owed a tremendous debt to the meticulous operative
techniques he learned from Halsted.
The personal and professional relationship between
Cushing and Halsted was stormy at best, 1,9 but it cannot
be doubted that Cushing had confidence in Halsted’s surgical
practices; after all, Halsted had successfully removed
Cushing’s appendix in 1897, following an episode of appendicitis.
This faith in his mentor is perhaps underscored by
the fact that, before his own bout with appendicitis, Cushing
had performed an appendectomy on a patient who died after
the operation. 9 Cushing thus understandably integrated the
surgical and academic techniques of his mentor into his own
practice.
The importance Cushing placed on accurate wound approximation
with minimal tension through the use of multilayered
closures, an integral part of Halstedian technique, 6,7 is
reflected in Cushing’s decision to use three to four layered closures
in five of his ten operative interventions for the repair of
spinal dysraphism. 12 The technique had been previously used
in Europe, but did not become popular in the United States
until 1918, following the publication of Charles Frazier’s book
on operations of the spine. 14 The mortality rate for these patients
remained high, but Cushing’s application of Halstedian
principles led to long-term improvement in two patients 12 at a
time when operating was considered largely futile.
Cushing’s operative notes show his attention to hemostasis,
albeit through somewhat unconventional means, as in a right
subtemporal decompression from 1912:
14 The Pharos/Autumn 2012