The Pharos - Alpha Omega Alpha

The making of a neurosurgeon
of the toes and foot. Only on using stronger currents could
any movements be produced in the head or arm areas which
were exposed. (Note that the leg area was not exposed in the
wound at all.) These movements of arm and face were very
slight even with the strongest currents and it was impossible
to carry them on to an epileptic seizure. The closure of the
jaw, shrugging of the shoulder and slight movements of the
arm were all that were elicited.
In this case, and many others, Cushing used the information
gleaned from intra-operative motor mapping to guide his
attempted surgical cure of epilepsy. “From the area which gave
movements of the arm a piece of the cortex was extirpated
measuring about 1 x 1½ cm. in its surface extent.” This patient
was discharged in improved condition, and her parents sent a
note two months after the operation saying that she had experienced
no more seizures.
Through his synthesis of Halsted’s vision of a physicianscientist
with his own clinical observation, laboratory investigations,
and surgical techniques, Cushing devised novel
operative treatments for trigeminal neuralgia, 1,17 hydrocephalus,
15 and hypopituitarism, 1,18,19 among other maladies.
The four years Cushing spent learning general surgery from
Halsted proved invaluable to his later work. He credited a
strong understanding of general surgery as the foundation on
which all further knowledge was built.
Today’s neurosurgical residents spend six months to a year
on general surgery training. While such abbreviated training
allows residents to pursue research and rotations through the
neurosurgical residency (which Cushing would undoubtedly
have supported 2–4 ) it focuses on specialization at the expense
of breadth of experience. Cushing spent the equivalent of
over half a contemporary residency period performing nonneurosurgical
procedures.
Cushing’s thoughts on general training for the subspecialist
are clear in his papers on neurological surgery: 2–4
those who can best take advantage of existing opportunities,
or can originate others, not only must have had a good
general training in clinical medicine and surgery, but must
have been thoroughly schooled in the fundamental subjects
. . . for without this knowledge any special branch is supported
by a root lodged in sand which does not long survive
overloading. 4pp605–06
Cushing’s extensive experience in general surgery, with
Halsted’s emphasis on operative technique, provided him with
the meticulous surgical skills necessary to transform neurological
surgery from a fool’s errand into a flourishing subspecialty
within the span of a decade.
References
1. Bliss M. Harvey Cushing: A Life in Surgery. New York: Oxford
University Press; 2005.
2. Cushing H. The special field of neurological surgery. Bull
Johns Hopkins Hosp 1905; 16: 77–87.
3. Cushing H. The special field of neurological surgery: Five
years later. Bull Johns Hopkins Hosp 1910; 21: 325–29.
4. Cushing H. The special field of neurological surgery after
another interval. Arch Neurol Psychiatry 1920; 4: 603–37.
5. Franzese CB, Stringer SP. The evolution of surgical training:
Perspectives on educational models from the past to the future.
Otolaryngol Clin N Am 2007; 40: 1227–35.
6. Cameron JL. William Stewart Halsted: Our surgical heritage.
Ann Surg 1997; 225: 445–58.
7. Halsted WS. The training of the surgeon. Bull Johns Hopkins
Hosp 1904; 15: 267–75.
8. Pellegrini CA. Surgical education in the United States: Navigating
the white waters. Ann Surg 2006; 244: 335–42.
9. Fulton JF. Harvey Cushing: A Biography. Springfield (IL): C.
C. Thomas; 1946.
10. Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg
2000; 87: 28–37.
11. Canale DJ. William Osler and “the special field of neurological
surgery.” J Neurosurg 1989; 70: 759–66.
12. Pendleton C, Ahn ES, Jallo GI, Quiñones-Hinojosa A. Harvey
Cushing and early spinal dysraphism repair at Johns Hopkins
Hospital. J Neurosurg Pediatrics 2011: 7: 47–51.
13. Frazier CH. Surgery of the Spine and Spinal Cord. New York:
D. Appleton; 1918.
14. Crowe SJ, Cushing H, Homans J. Effects of hypophyseal
transplantation following total hypophysectomy in the canine. Q J
Exper Physiol 1909; 2: 389–400.
15. McClure RD. Hydrocephalus treated by drainage into a vein
in the neck. Bull Johns Hopkins Hosp 1909; 20: 110-113.
16. Feindel W. Osler vindicated. Glioma of the leg center with
Jacksonian epilepsy; removal and cure, with a 50-year follow-up. J
Neurosurg 2009; 111: 293–300.
17. Cushing H. A method of total extirpation of the Gasserian
ganglion for trigeminal neuralgia. JAMA 1900; 34: 1035–41.
18. Cushing H. The hypophysis cerebri: Clinical aspects of
hyperpituitarism and of hypopituitarism. JAMA 1909; 53: 249–55.
19. Cushing H. The Pituitary Body and Its Disorders: Clinical
States Produced by Disorders of the Hypophysis Cerebri. Philadelphia:
J. B. Lippincott; 1910.
Address correspondence to:
Alfredo Quiñones-Hinojosa, MD
1550 Orleans Street
Cancer Research Building II Room 253
Baltimore, Maryland 21231
E-mail: aquinon2@jhmi.edu or courtney.pendleton@gmail.com
16 The Pharos/Autumn 2012