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of work can be avoided, if we wish more surely and progressively
to advance our manipulative therapy. 2
Thus it may be said that the clinical training and emphasis on
the concept of the physician-scientist that Cushing received
during his four years with Halsted undoubtedly provided him
with the skills necessary to pursue any surgical endeavor, and
certainly contributed to the success of his chosen field of neurological
surgery.
Following approval from our institutional review board, and
through the courtesy of the Alan Mason Chesney Archives, we
reviewed the surgical cases from Cushing’s year as Halsted’s
assistant surgical resident (1896–1897), as well as cases conducted
during his time as Halsted’s senior surgical resident
(1897–1900) and those conducted as a young attending specializing
in neurosurgery (1901–1912). Except where otherwise
indicated, quotations regarding these cases are taken verbatim
from Cushing’s original unpublished surgical notes. These files
document the apprentice model of training proposed by Osler
and Halsted, 5,6,7,10 and illustrate the role that general surgical
experience played in Cushing’s development as a surgical
trainee and physician-scientist.
Only the lead surgeon was recorded consistently in the
surgical record operative notes, with the first assistant or
resident in attendance only sporadically documented. The
hospital records thus do not thoroughly document Cushing’s
early presence in the operating room under Halsted’s supervision.
The earliest record of Cushing as a participant is
dated November 27, 1896.
At this time, a twenty-twoyear-old
woman presented
with tuberculosis of the
skin along her jaw. Cushing
is listed as the surgeon of
record, and the brief operative
note describes the procedure,
conducted under
local cocaine anesthesia:
lead surgeon, the operative note refers to Cushing by name.
Although the majority of the roughly 1100 operative notes
reviewed were written in the third person, Cushing typically
omitted agency or referred to himself as “the operator.” This is
the only note in which he refers to himself by name. Operative
notes were not customarily typewritten before about 1900.
Thus a comparison of handwritten notes initialed by Cushing
with the operative note for this particular case shows that
it was written by Cushing rather than Halsted. The unusual
reference to himself as operator may reflect pride at being the
lead surgeon for the first time, months of previous experience
documenting operations conducted by other surgeons, or
close supervision in this case by Halsted, both in the operating
theater and in post-operative chart documentation.
Cushing quickly progressed to more complex cases. On
December 13, 1896, a sixteen-year-old woman employed in
a shirt factory presented with “ingrowing toenails.” She was
brought to the operating room on December 14, 1896, where
Cushing excised the toenails. His hand-drawn illustration
from the surgical chart and the detailed operative note document
the procedure:
A double cutting done on the left, the bad toe, nail not
removed. A generous slice of tissue removed. On the right
foot a simple excision of granulating area, removing ⅛˝ of
the nail and matrix back to the neighborhood of the distal
joint. Wound closed.
The ulcerated area excised
by Dr. Cushing. It
was quite superficial apparently.
Facial artery [. . .]
tied c [illegible] during
removal. Wound closed c
interrupted silver suture.
Cocaine.
The patient was discharged
on December 1, 1896; no further
follow-up was available.
It is interesting that here,
in Cushing’s first case as the
Cushing’s original illustration of an ingrown left toenail, his second operative procedure during his
year as assistant surgical resident under Halsted.
Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions.
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