The Pharos - Alpha Omega Alpha

The making of a neurosurgeon
The post-operative chart documentation is in Cushing’s
handwriting, and indicates that he performed his own dressing
changes. This is not surprising given Halsted’s expectations
for the residents, 6,7 as well as Cushing’s own dissatisfaction
with the surgical staff’s attention to detail. 1 Shortly after the
operation, Cushing documented marked improvement in the
patient’s condition: “Toes doing well —Been up and walking
about for 48º [sic: minutes] s discomfort.” This rather simple
procedure was Cushing’s second performance as a resident
operating independently, and would certainly have been a
source of pride for the young surgeon.
Halsted was not the type of mentor to allow trainees to rest
on their laurels. Cushing would have been expected to expand
his experience to include increasingly complex cases, as well
as schedule more time for surgery. On December 26, 1896,
less than a month after his first experience as a lead surgeon,
Cushing performed two separate operations, each significantly
more complex than the preceding ones.
On December 21, 1896, a twenty-three-year-old African
American man presented with osteomyelitis at the lower end
of his femur. Cushing operated on the patient on December 23,
1896. His operative note describes the procedure:
Incision 15 cm long over internal condyle and above.
Sinus excised to point of entrance into bone. An opening at
about site of adduction tubercle leads through about an inch
and a half of eburnated periosteal (?) bone to a cavity in the
end probably of the diaphysis. Here some dead bone can be
felt. The sinus leading to it lined by flabby gray granulations.
The bone chiseled away till would have held a hen’s egg.
A flat sequestrum size diagram removed. Cavity curetted—
irrigated with HgCl 2 . Iodaform powder introduced. Wound
closed c silver over large blood clot. Dressing.
There appeared to be no extension of granulation along
the medullary cavity, which in fact seemed completely
walled off from the cavity . . . Apparently 4.5 cm of sclerosed
bone chiseled through before reaching the sequestrum.
The tone of the operative note, with its parenthetical question
mark and conditional wording, may indicate self-doubt and a
tendency to over-analyze, marking the transition from supervised
resident to independent operator. In his later operative
notes, Cushing continued to employ these occasional indicators
of uncertainty, transforming the worries of a young resident
into the hallmarks of a thorough and introspective attending
surgeon. As Cushing matured as an attending, his operative
notes reflected on similarities between the operation being
conducted and other operative procedures. He referenced other
cases where errors were made, and described his attempts to
avoid those adverse outcomes in subsequent operations.
Despite the doubts reflected in this early operative note,
and the apparent amazement at the defect created intraoperatively,
the patient had an uneventful post-operative
course. His final outcome remains unknown, as on February
6, 1897, following a forty-six-day hospital stay, the patient was
“discharged by Dr. Hurd for bad conduct.” No details regarding
the patient’s behavior were documented, and given the race
of the patient in a segregated hospital in the South only a few
years after the end of post-Civil War Reconstruction and the
enactment of the Jim Crow laws, it is not possible to speculate
profitably. From the post-operative documentation at the time
of the patient’s discharge, Cushing would have seen the operation
as a successful intervention.
Cushing’s second case on December 23, 1896, had a very
different outcome. The patient was a fifty-six-year-old African
American man who presented with hemorrhoids on December
16, 1896. The patient was brought to the operating room for
what Cushing described as an “excision of unilateral prolapse
of bowel. Whitehead method. Prolapse covered c verrucous
growths.” Cushing’s operative note documents the procedure:
Cushing’s original illustration of his excision of osteomyelitis of the femur during his internship year. The note in Cushing’s handwriting
reads: “The bone chiseled away till would have held a hen’s egg.”
Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions.
12 The Pharos/Autumn 2012