Experiment at Bedside : Harvey Cushing’S Neurophysiological Research*

醫史學 제18권 제2호(통권 제35호) 2009년 12월 Korean J Med Hist 18ː205-222 Dec. 2009 醫史學 제18권 제2호(통권 제35호) 2009년 12월 Korean J Med Hist 18ː89106 Dec. 2009 ISSN 1225-505X ⒸⒸ大韓醫史學會大韓醫史學會 ISSN 1225-505X

Experiment at Bedside : Harvey Cushing’s Neurophysiological Research*

Ock-Joo KIM**

Table of content

1. Cushing and surgical experimentalism 2. Innovative experimental operation on the pituitary 3. Experiment inseparable from treatment: trigeminal nerve experiment 4. Experiment on the operating table – localization of the sensory cortex 5. Identity, ethos, and human experimentation

Often regarded as the founder of neurosurgery in stood at the center of the twentieth-century America, Harvey Cushing developed neurosurgery transformation of American medicine. Born in as a specialty during the early twentieth century.1) Cleveland, Ohio in 1869, Cushing received his A product of the reform of medical education medical education at the Harvard Medical School, during the late nineteenth century in America, he from 1891 to 1896.2) He then began a residency at

* This work was supported by the Korea Research Foundation Grant funded by the Korean Government (KRF-2009-371-E00001). ** Department of History of Medicine and Medical Humanities, Seoul National University College of Medicine 1) Cushing has been commemorated as the pioneer of neurosurgery in America. For the life of Harvey Cushing, see E. R. Laws, Jr. Neurosurgery's Man of the Century: Harvey Cushing – the man and his legacy. Neurosurgery 1999;45:977-82; S. I. Savitz. The pivotal role of Harvey Cushing in the birth of modern neurosurgery. the Journal of the American Medical Association (JAMA) 1997;278:1119; R. G. Ojemann. The tradition of Harvey Cushing commemorated by a stamp in the Great American stamp series. The 1987 AANS (American Association of Neurological Surgeons) presidential address [published erratum appears in Journal of Neurosurgery 1988;68:502]. Journal of Neurosurgery 1987;67:631-42; W. F. Meacham. The neurosurgical legacy of Harvey Cushing. Surgery, Gynecology, and Obstetrics 1969;128:1066; Editorial, Harvey Cushing: great pioneer. British Medical Journal 1969;2:3-4; Editorial, Harvey Cushing, a surgical mastermind. Journal of Indiana Medical Association 1969;53:307-8. 2) John F. Fulton. Harvey Cushing: A Biography. Springfield Illinois: Charles C. Thomas, 1946; Elizabeth H. Thomson. Harvey Cushing: Surgeon, Author, Artist. New York: Neal Watson Academic Publications Inc.; 1981. Fulton was Cushing's student and one of the founding members of the Harvey Cushing Society. He reconstructed Cushing's life as much detail as possible, drawing upon voluminous primary sources such as Cushing's and his

- 205 - 醫史學 제18권 제2호(통권 제35호) 205-222, 2009년 12월 the Johns Hopkins Hospital under the noted had operated on more than 2,000 brain tumors, surgeon William Stewart Halsted. In 1900, his steadily lowering his surgical mortality rate. He residency completed, Cushing traveled to Europe to was honored as a surgeon, a physiologist, and a spend fourteen months in experimental study with man of letters.4) On his retirement from Harvard Charles Sherrington and Theodor Kocher. After in 1932, he served as a professor of neurology at returning to Johns Hopkins Hospital in 1901, Yale University until he died of myocardial Cushing established a center for experimental infarction in 1939. research in surgery, the Hunterian Laboratory of During the period from 1896 to 1912 when Cushing Experimental Medicine in 1905.3) Cushing had established himself as a neurosurgeon at Johns become interested in neurosurgery during his Hopkins Hospital, he also pursued neurophysiology. residency at Johns Hopkins, and began to develop Along with William Stewart Halsted’s experimental his neurosurgical skills. By 1908, he possessed a studies on surgery, Cushing’s neurophysiological national reputation as a "brain surgeon"; patients work has been praised as a breakthrough in modern came to him steadily from throughout the country. neurosurgery.5) In pursuing physiological questions, In 1912, Harvey Cushing moved from Baltimore Cushing relied not only on laboratory experiments but to Boston, to become Moseley Professor of also on clinical observation and surgical experiments Surgery at the Harvard Medical School and upon his patients. As an elite academic surgeon at Surgeon-in-Chief at the newly- built Peter Bent a teaching hospital, Cushing played a dual role as a Brigham Hospital. At the Brigham Hospital, he scientist and a clinician and freely crossed over the established a resident system, laboratories, an boundary between therapeutic and non-therapeutic operating system, and post-mortem examinations. experiments. Cushing’s case shows that a clear-cut At Harvard, Cushing established neurosurgery as a boundary between therapeutic and non-therapeutic medical specialty, educating medical students and experiments, which was demarcated after the World training surgical residents who came from all over War Ⅱ, did not exist in the early twentieth century the world to work with him. By 1931, Cushing America. This paper seeks to analyze the context of

contemporaries' correspondence, papers and speeches. Thomson’s biography of Cushing is less voluminous and more interpretative than Fulton’s. 3) Harvey Cushing, Instruction in operative medicine. With the description of a course given in the Hunterian Laboratory of Experimental Medicine. Johns Hopkins Hospital Bulletin 1906;17:123-34. For a short history of the Hunterian Laboratory, see P. Sampath, D. M. Long, and H. Brem. The Hunterian Neurosurgical Laboratory: the First 100 Years of Neurosurgical Research. Neurosurgery 2000;46:184-94; discussion 94-5. 4) For example, see S. K. Pandya. Harvey Cushing: The man and his literary contributions. Neurology of Indiana 1969;17:164-71; L. M. Davey. Harvey Cushing and the humanities in medicine. Journal of the History of Medicine and Allied Sciences 1969;24:119-24; W. H. Sweet. Harvey Cushing: author, investigator, neurologist, neurosurgeon. Journal of Neurosurgery 1979;50:5-12; E. Rossitch, Jr., and S. Khoshbin. Harvey Cushing as Medical Artist. Surgical Neurology 1989;32:237-40; N. H. Horwitz. Library: Historical Perspective. Harvey Cushing (1869-1939). Neurosurgery 1996;39:1062-7. 5) N. P. Christy. Harvey Cushing as Clinical Investigator and Laboratory Worker. American Journal of Medical Sciences 1981;281:79-96; S. H. Greenblatt. The Crucial Decade: Modern Neurosurgery's Definitive Development in Harvey Cushing's Early Research and Practice, 1900 to 1910. Journal of Neurosurgery 1997;87:964-71.

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Cushing’s experiment upon his patients. I will employ networks through journals and conferences, united by Cushing’s case to examine how the surgical their strong advocacy of experiment. Cushing’s call experimentalism, surgical practice, and professional for the specialization of neurosurgery in 1905 was identity were interconnected in performing surgical based on an ideology of experimentation shared research in early twentieth-century America. among elite medical scientists. Like his teachers, preceptors, and colleagues, 1. Cushing and surgical experimentalism Cushing interpreted history of medicine as a progressive achievement enlightened by experimentation. Although With his education at Yale, Harvard, and Johns they all placed a highly value on experimentation, the Hopkins, and European universities, and with his term “experiment” was used in different ways by various training both at the bedside and in the laboratory, groups. First, basic medical scientists who underwent Cushing helped to create a new profession in the professionalization earlier than clinical scientists argued United State, that of the clinical scientist. In the late that experimentation in the laboratory should be the nineteenth century, inspired by the successes of foundation of the modern medicine. William Henry German scientific medicine, American physicians Welch and Lewellys Barker, for example, believed founded full-time appointments for basic medical that only laboratory-based medical education could sciences in the medical schools of major universitie make good physicians, among whom the highest noble s.6) The opening of the Johns Hopkins Hospital in minds would become experimenters to produce valuable 1889 and the Medical School in 1893 were part of knowledge of human kind.7) Second, while approving a broad reformation in American medical education. of laboratory experimentation as a historical necessity Reformers advocated university-based medical for medical progress, physician William Osler education, with a strong emphasis on laboratory emphasized the importance of clinical observation on teaching and research. The professionalization of the patients and of clinical studies that incorporated basic medical sciences and the establishment of the experimentation upon patients.8) Since disease was the laboratory medical teaching created young doctors very experiment of the Nature, meticulous clinical skilled both in science and in clinical medicine. studies on patients would reveal the hidden secrets Scientifically oriented doctors established their own of the human body. To Osler, the bedside was the

6) Bruce Fye. The Development of American Physiology: Scientific Medicine in the Nineteenth Century. Baltimore and London: The Johns Hopkins Univ. Press; 1987; Kenneth M. Ludmerer. Learning to Heal: The Development of American Medical Education. New York: Basic Books, Inc.; 1985; idem. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. Oxford, New York: Oxford University Press; 1999; Paul Starr. The Transformation of American Medicine. New York: Basic; 1982; William G. Rothstein. Physicians in the Nineteenth Century: From Sects to Science. Baltimore: Johns Hopkins Univ. Press; 1972. For the comparative studies on medical education, Thomas N. Bonner. Becoming a Physician: Medical Education in Britain, France, Germany, and the United States, 1750-1945. New York, Oxford: Oxford University Press; 1995. 7) Lewelleys Barker. Medical laboratories: their relation to medical practice and medical discovery. Science 1908. 8) William Osler. The historical development and relative value of laboratory and clinical method in diagnosis: the evolution of the idea of experiment in medicine. Transactions of the Congress of American Physicians and Surgeons 1907;7:1-8.

- 207 - 醫史學 제18권 제2호(통권 제35호) 205-222, 2009년 12월 laboratory of the physician. Neither an experimenter while he was working at the Johns Hopkins Hospital. in the laboratory nor an ordinary practitioner could Trained in this interactive complexity, Cushing solve imminent problems posed at the bedside. As the embodied these different meanings of experiments in historian Gerald Geison has pointed out, there was his various activities while at Johns Hopkins.11) a creative tension that included elements of both cooperation and competition between basic scientists 2. Innovative experimental operation on the and clinical scientists in the early decades of the pituitary twentieth century.9) Third, the leading surgeons including William Stewart Halsted and William Cushing’s well–known experimental studies on Williams Keen stressed contemporary surgery’s the pituitary gland characterized his mind-set as well interdependence upon experimental sciences since the as the experimental spirit dominant at Johns advent of elective surgery brought by antiseptics and Hopkins in the early decades of the twentieth anesthesia.10) With direct accessibility to the inside century. Since 1901 when he first saw a pituitary of the human body, these pioneering surgeons tumor patient, he became interested in pituitary experimented upon their patients with new surgical diseases, puzzled by their various manifestations. techniques. From their surgical experiments, the Questions posed at the bedside about pituitary gland surgeons tried to produce practicable knowledge for were moved to laboratories at the Hunterian saving patients’ lives as well as physiological Laboratory for Experimental Medicine, a place for knowledge. They shared the surgical experimentalism: pursuit of basic research with clinical relevance. the surgeon’s moral obligation to perform With the help of John Homans and Samuel J, experimentation. These three groups exerted a great Crowe, Cushing removed the pituitary glands of one influence on Cushing personally as well as academically hundred dogs to understand the function of the

9) Gerald L. Geison. Divided we stand: physiologists and clinicians in the American context. edited by Morris J. Vogel and Charles E. Rosenberg. The Therapeutic Revolution: Essays in the Social History of American Medicine. University of Pennsylvania Press; 1979. p.67-90. Also see Russel C. Maulitz. 'Physician versus Bacteriologist': the ideology of science in clinical medicine. Ibid.. p.91-107. 10) William W. Keen. Animal Experimentation and Medical Progress. Boston; 1914; William Stewart Halsted. The training of the surgeon. Surgical Papers. 1904. Vol.Ⅱ. p.513. 11) While working at the Johns Hopkins Hospital, Cushing, with the experimentalist’s spirit, performed various activities in relation to experimentation, medical practice and medical education. His bacteriological and physiological experiments at the laboratory were published as Harvey Cushing. A comparative study of some members of a pathogenic group of bacilli of the Hog Cholera or Bac. Enteritidis (Gartner) Type, Intermediate between the typhoid and colon groups. With the report of a case resembling typhoid, in which there occurred a post-febrile osteomyelitis due to such an intermediate bacillus. Johns Hopkins Hospital Bulletin. 1900;11:156-70; Concerning a definite regulatory mechanism of the vasomotor centre which controls blood pressure during cerebral compression. The Johns Hopkins Hospital Bulletin 1901;12:1-8; Concerning the poisonous effect of pure sodium chloride solutions upon the nerve-muscle preparation. American Journal of Physiology 1901;6:77-90. He also made Oslerian clinical observation at the bedside and produced clinical knowledge. For example, see Harvey Cushing. Perineal zoster, with notes upon cutaneous segmentation post-axial to the lower limb. American Journal of Medical Sciences 1904;37:375-91. For an example of surgical experiment, see Harvey Cushing, Samual Crowe, and John Homans. Experimental hypophysectomy. Johns Hopkins Hospital Bulletin. 1910;21:127-69.

- 208 - Ock-Joo KimːExperiment at Bedside: Harvey Cushing’s Neurophysiological Research gland. The stark similarities in appearance between opportunity than physiologists in the laboratory to animals with a partially removed pituitary gland and produce physiological knowledge.12) Cushing attacked his patients with pituitary diseases spurred Cushing the questions which neurophysiologists working with to further studies on the pituitary gland clinically animals could not easily solve - the sensory function and experimentally. Inventing new operative of the nervous system. While operating upon twenty techniques, Cushing attempted surgical cure of patients suffering from trigeminal neuralgia from pituitary diseases. His pituitary operations served 1899 to 1905, Cushing concurrently performed two-folded experiments: therapeutic experiments of physiological experiments, in order to elucidate the the pituitary diseases and pathophysiological sensory function of the nerve.13) Treatment and experiments on the effect of surgical extirpation of experiment were interdependent and inseparable. the gland. His innovative operations upon patients A typical trigeminal neuralgia patient whom with pituitary diseases were experimental in nature Cushing operated on had the following history. In because no proven therapy had been established yet. August 1899, a sixty-three-year-old man, formerly a At the same time, the surgical extirpation of the prosperous sea captain, came to Cushing for surgical gland granted Cushing to observe the symptoms of treatment. Suffering from trigeminal neuralgia for depletion of the gland. From the integration of nine years, the patient spent all his life savings to meticulous pre- and post-operative observations of obtain relief from the constant, unbearable pain in patients and animal experimentation, Cushing his face that frequently intensified into paroxysms. produced comprehensive knowledge on pituitary The areas of the face and mouth cavity, supplied by endocrinology. This work was often regarded as the the three branches of the trigeminal nerve, were culmination of his Johns Hopkins years. very sensitive to stimulation. Unable to speak or to swallow food, the patient weighed only ninety 3. Experiment inseparable from treatment: pounds. The intractable pain deprived him of sleep. trigeminal nerve experiment He had undergone extraction of all of his teeth and three operations of peripheral neurectomy, which had given him only temporary relief. When he came While physiologists worked with animals most of to the hospital, he was so desperate that, without the time, Cushing studied physiology also from the relief from the pain, he was considering suicide, bedside and the operating table. As a surgeon with something not uncommon among this kind of legitimate access to the inside of the human body, patient. Such patients sometimes looked insane: Cushing was well aware that he had a better screaming loudly and constantly, with emaciated,

12) Harvey Cushing. The surgical aspects of major neuralgia of the trigeminal nerve. A report of twenty cases of operation on the Gasserian ganglion, with anatomic and physiologic notes on the consequences of its removal. the Journal of the American Medical Association (JAMA) 1905;44:773-778; 860-865; 920-929; 1002-1008; 1088-1093. 13) Harvey Cushing. On preservation of the nerve supply to the brow, in the operative approach to the Gasserian ganglion. Annals of Surgery 1906;43:1-4; idem. Remarks on some further modifications in the Gasserian ganglion operation for trigeminal neuralgia (sensory-root evulsion). Transactions of the Southern Surgical and Gynecological Association 1907;19:480-485.

- 209 - 醫史學 제18권 제2호(통권 제35호) 205-222, 2009년 12월 dirty, and hairy faces that they could not bear to governed by the trigeminal nerve. In his papers, touch even lightly, for fear of exacerbating the pain. Cushing included post-operative photographs of his After Cushing succeeded in excising the ganglion patients with the anesthetized areas marked with and sensory root of the patient’s trigeminal nerve, black lines on their faces. Accompanied by the patient slept eight hours without interruption. detailed and vivid case histories of the patients, The next morning, he said that it was his “first long the photographs illustrated the areas of sensation sleep in nine years.” Nine months after the innervated by the trigeminal nerve. Cushing found operation, he had gained forty pounds, to restore his that the sensory distribution of the trigeminal usual weight. Four years later, the patient reported nerve possessed a distinct shape. The anterior line to Cushing that he remained free from symptoms: of the area anesthetized after Gasserian ganglion “My face has not given me any trouble whatever extirpation was the median-longitudinal line of the since the operation was performed... My general scalp and face, where all sensations of touch, health is good and I have a splendid appetite.”14) temperature, and pain disappeared. The posterior The twenty patients with this desperate neuralgia line was irregular and varied among individuals. were the subjects of Cushing’s physiological Invariably, however, the posterior line of tactile inquiries. With a clear design for research, and thermal anesthesia enclosed the tragus, and Cushing made thorough pre-operative tests of upper and anterior wall of the external auditory sensations of touch, temperature, pain, and taste canal.15) with various stimuli in order to establish the Cushing took full advantage of being a surgeon, patient’s equation. A few elderly patients had when he drew a final conclusion about the already lost their sense of taste before the relationship between the trigeminal nerve and the operation. The pre-operative tests also trained sensation of taste.16) The anatomist and the patients to identify different stimuli promptly. For physiologist failed to elucidate the route of the taste more than two to three weeks after extirpation of fiber. The clinical observations and interpretations the Gasserian ganglion, the root of the trigeminal were so contradictory that some concluded that the nerve, he examined the changes in the four route of taste fibers showed considerable individual sensations in the tongue, the skin of the face, and variation. Confused by the intricate phenomena of the mucous membrane of the mouth and throat disturbance in taste sensation caused by an everyday. Cushing was able to demarcate the intracranial lesion, for example, one physician said to sensory fields in the skin and mucous membrane, Cushing: “One feels inclined to think that there may

14) Harvey Cushing. The surgical aspects of major neuralgia of the trigeminal nerve. A report of twenty cases of operation on the Gasserian ganglion, with anatomic and physiologic notes on the consequences of its removal. the Journal of the American Medical Association (JAMA) 1905;44:773-778; 860-865; 920-929; 1002-1008; 1088-1093. For the citation, see p.864. 15) Harvey Cushing. The sensory distribution of the fifth cranial nerve. Johns Hopkins Hospital Bulletin 1904;15:213-232. 16) In December 1902, Cushing presented his findings before the American Physiological Society. Harvey Cushing. The taste fibres and their independence of the N. trigeminus. Deductions from thirteen cases of Gasserian ganglion extirpation. Johns Hopkins Hospital Bulletin 1903;14:71-78.

- 210 - Ock-Joo KimːExperiment at Bedside: Harvey Cushing’s Neurophysiological Research be individual variations in the proportion of taste Sherrington at Liverpool with whom he studied fibres present in the nervus intermedius and three years ago. In 1898 from an experiment with glossopharyngeal on the one hand, and in the fifth monkeys, Sherrington had concluded that section [the trigeminal nerve] on the other.”17) Cushing of the trigeminal nerve caused loss of the thought that such individual anatomical variations sensation of taste as well as general sensation.19) were improbable. In May 1903, in a rather apologetic tone After an operation, Cushing made regular Sherrington replied that the surgeon was in an examinations to see whether his patient had incomparably better position for the study of preserved or lost the sense of taste. For about ten sensation than the physiologist. days after an operation, patients could not recognize taste with the anterior two-thirds of the The “trigeminus” observations interest me tongue on the operated side. After a transient particularly. We have as physiologists much to hope period of one or two weeks, patients recovered from these observations by the surgeons, for “interrogation” is the only means of communication their entire sense of taste. General sensation of the that can deal adequately with the subtleties of anterior two-thirds of the tongue on the same side sensation: & this means of communication is barred as the operation remained anesthetized permanently to the physiologist even in dealing with his nearer after the operation. Most previous papers, which ancestry, the apes or even his grandmotherly had reported post-operative loss of taste sensation, anthropoids … Sensation can only be adequately had relied upon tests executed during the first two judged of as between man & man.20) or three weeks while the patient was hospitalized. From his systematic clinical observation of thirteen While studying the sense of taste in animal patients who had undergone Gasserian ganglion experiments, Sherrington said that he had not extirpation, Cushing concluded that the trigeminal realized that he had pushed animal physiology nerve “in all probability does not convey taste “beyond its legitimate capability.”21) fibres to the brain either from the anterior or Cushing’s research on trigeminal function posterior portion of the tongue.”18) embraced the tension of playing double roles both In April 1903, soon after publication of his as a scientist and as a healer. Given that previous paper on the independence of taste fibers from the studies employing occasional, short-term tests led trigeminal nerve, Cushing sent a copy to the to confusion about the path of taste sense, distinguished British neurophysiologist Charles Cushing made special efforts to perform rigorous

17) P. Stewart to Harvey Cushing. November 18, 1905. Harvey Cushing Papers. Microfilm Reel 127. Yale University. 18) Harvey Cushing. The taste fibres and their independence of the N. trigeminus. Deductions from thirteen cases of Gasserian ganglion extirpation. Johns Hopkins Hospital Bulletin 1903;14:71-78. 19) Charles Sherrington. Examination of the peripheral distribution of the fibres of the posterior roots of some spinal nerves. Philosophical Transactions of the Royal Society, Series B. 1898;190:45-186. 20) Charles Sherrington to Harvey Cushing. May 26, 1903. Harvey Cushing Papers. Microfilm Reel 127. Yale University. 21) Ibid.

- 211 - 醫史學 제18권 제2호(통권 제35호) 205-222, 2009년 12월 examinations upon patients. The patients were many years, felt obliged to accept his surgeon’s subjected to tedious and time-consuming daily solicitation. One patient resisted the test, claiming examinations for several weeks. The examination that Cushing had experimented on him with of sensation took much time, requiring great routine daily examination of his palate, sensation, patience on the part of subject, who after an and taste. Cushing described the patient in a operation easily became tired from the tests. In negative tone: the patient was a farmer, thereby these experiments, however, patients’ cooperation implying an “unintelligent patient” compared to a was essential. Obviously those examinations gave cooperative intelligent patient. He was a “habitual no benefit to patients; rather it gave them opium-eater,” who tried “to extort money from the discomfort. Judging by his description of patients’ hospital.” Despite the uncooperativeness of this records, Cushing did not always get permission patient, Cushing reproduced a picture of him in from his patients for their participation in research. his paper. While handling difficult patients was not To quote the historian Susan Lederer, “What easy, Cushing still managed to collect data from physicians understood by the words ‘full consent them.24) and understanding’ is less clear than the circumstances in which they solicited patient 4. Experiment on the operating table permission.”22) When admitted to the Johns － localization of the sensory cortex Hopkins Hospital, a teaching hospital with plenty of free beds, patients were considered as “clinical Trained himself as a surgeon-physiologist, material” for education and research.23) Some of Cushing capitalized on access to the human brain his patients, whom Cushing described as for his experiment on the localization of the “intelligent patients,” understood Cushing’s purpose human cortex. While performing brain surgery, he and helped him. In general patients participated in developed the technique of electrical stimulation of his experiments, because they believed that the the human cortex. After becoming familiar with tests were part of the procedure for their the methods of electrical stimulation of the brain treatment. Most of all, the environment of the at Sherrington’s laboratory in 1901, Cushing experiments compelled the patients to take part in systematically stimulated the motor cortex of more them. After the operation, the patient, relieved than fifty anesthetized patients during operations. from the severe pain that had afflicted them for Sherrington’s experiment in which Cushing

22) Susan Lederer. Subjected to Science: Human Experimentation in America before the Second World War. Baltimore: Johns Hopkins University Press; 1997. p.12. 23) Abraham Flexner reported that the Johns Hopkins Hospital had six public wards with 180 free beds and 85 paid beds, and two private wards with 84 paid beds. He also discussed the availability of “clinical material” for medical education at the hospital. From the report on the Johns Hopkins Medical School. p.8, 19-21. Harvey Cushing Paper. Yale University. 24) Harvey Cushing. The surgical aspects of major neuralgia of the trigeminal nerve. A report of twenty cases of operation on the Gasserian ganglion, with anatomic and physiologic notes on the consequences of its removal. the Journal of the American Medical Association (JAMA) 1905;44:773-778; 860-865; 920-929; 1002-1008; 1088-1093.

- 212 - Ock-Joo KimːExperiment at Bedside: Harvey Cushing’s Neurophysiological Research participated was to delineate functional areas in between experimenter and subject, which was the the motor cortex of chimpanzees and gorillas by most important method for obtaining reliable data. means of electrical stimulation. After returning to Illustrious as Hughlings and Broca’s cerebral Baltimore, Cushing tried to verify the motor cortex localization, clinical observation with its of the brain in man: “… for the past five years I concomitant postmortem findings needed first-hand have invariably put into practice whenever knowledge on the physiology of the human brain. stimulation of the cerebral hemisphere, exposed by What would happen if the human brain were operation or injury, has been needed for purposes electrically stimulated directly? Would the results of localization, or has seemed justified in the be similar to those from animal experiment? interests of physiological investigation.”25) While The lack of access to the human brain caused “the interest of physiological investigation” and physicians enthusiastic about stimulating the human “the purpose of localization” for treatment did not brain directly. In 1874 American physician Robert always come together, Cushing did not mention Bartholow electrically stimulated an Irish whether he received permission from patients to housemaid’s brain that had been exposed by electrical stimulation for “the interest of cancer erosion.26) The patient, Mary Rafferty, physiological investigation.” suffered from pain and convulsions, and eventually Questions of the cerebral localization in man died. Although severely condemned both by the intrigued neuroscientists for several decades in the medical profession and public, Bartholow’s late nineteenth century. Such British scholars as experiment was acknowledged as important for John Hughlings Jackson, David Ferrier, and later having demonstrated the relevance of cerebral Charles Sherrington as well as Germans such as localization in human already performed upon Edward Hitzig and Gustav Fritsch ardently pursued animals.27) Even in an article critical of the cruelty the topic, mainly employing clinical observation of Bartholow’s experiment, the author mentioned and animal experimentation. To neurosurgeons and that the results of the experiment with human neurologists, animal experimentation hardly brain corresponded to those of animal experiment resolved anatomical and physiological differences s.28) All the criticisms against the Bartholow among species. Most of all, approach of animal experiment never stopped physicians from trying to experiments were lacking verbal communication stimulate the human brain electrically. After 1882

25) Harvey Cushing. Surgery of the Head. 1908. p.166. 26) Bartholow’s experiments were reported in Roberts Bartholow. Experimental Investigations into the Functions of the human brain. American Journal of Medical Sciences 1874;76:305-13. For a historical study on Bartholow’s experiment, see James P. Morgan. The first electrical stimulation on the human brain. Journal of the History of Medicine and Allied Sciences 1982;37:51-64. 27) For criticism against Bartholow’s experiments, see Dr. Bartholow’s experiments. British Medical Journal 1874;1:723; Human vivisection. Cincinnati Medical News 1874;3:385; “Letter from a Hospital Patient Not of the Good Samaritan Hospital” Cincinnati Medical News 3. 1874:234-235. Bartholow replied to these criticism in his “Experiments on the Functions of the Human Brain.” British Medical Journal 1874;1:727; Experiments on the Functions of the Human Brain. London Medical Record 1874;1:727. 28) David Ferrier. Bartholow’s Experiments on the Human Brain. London Medical Record 1874;2:285-86.

- 213 - 醫史學 제18권 제2호(통권 제35호) 205-222, 2009년 12월 when Victor Horsley electrically stimulated the patients after opening their skulls and dura mater. brain of an epileptic patient, more physicians From electrical stimulation of the sensory cortex in followed his example. In 1893, John S. Pyle two patients suffering from epilepsy, he was able to emphasized the importance of access to a living map out the localization of the sensory cortex.31) In human brain for the development of neurosurgery 1907, Cushing operated upon a patient suffering and suggested that condemned criminals be used from a cystic tumor. Because the patient suffered for the study of brain localization.29) His proposal from pulmonary tuberculosis, Cushing had difficulties was rejected on ethical grounds, but scientific in administrating anesthesia to the patient. During doctors kept seeking access to the human brain, the fifth operation the patient, the patient became especially to solve the question of localization of unanesthetized and conscious, and chatted with the human cortex. Most neuroscientists agreed operators and explained what he sensed.32) After upon the location of the motor cortex located in the operation, Cushing greatly regretted that he the precentral gyrus, anterior to the central fissure. had not electrically stimulated the postcentral gyrus The question of the location of the sensory cortex, of the conscious patient. Through experience with however, divided experimentalists as well as the patient, however, Cushing saw the possibility clinical neurologists into opposing camps. Some to perform a surgical experiment upon thought that the precentral and postcentral gyri unanesthetized patients with electrical stimuli upon were sensori-motor areas, while others regarded the cerebral cortex. From then on, he looked for the postcentral gyrus, located posterior to the patients upon whom he could perform surgical central fissure, as the motor area. Experimental experiments on the sensory cortex. His first studies on sensory function in animals had serious experience of this kind came soon. On a patient limitations because the experimenter could not operated upon for decompression with temporal communicate verbally with animals. In Osler’s opening, Cushing performed an experiment: “without textbook in 1905, and again in Cushing’s an anesthetic, and the exposed temporal lobe was neurosurgical treatise in 1908, the location of the stimulated, giving the patient certain definite sensory cortex remained vague.30) auditory impression[s] which he clearly distinguished For delineation of the sensory cortex, Cushing from the “buzz” of the vibrator.”33) Only the temporal stimulated electrically the cortex of conscious lobe was involved; this case did not satisfy

29) John S. Pyle. A Plea for the Appropriation of Criminals, Condemned to Capital Punishment, to the Experimental Physiologist. Tri-State Medical Journal 1893-94;1:5-11. 30) Harvey Cushing. Diseases of the nervous system. William Osler. Principles and Practice of Medicine. New York & London: D. Appleton and Co.; 1905, the 6th, p.867-1110, 874; Harvey Cushing. Surgery of the head. 1908. p.154. 31) Harvey Cushing. A note upon the faradic stimulation of the post-central gyrus in conscious patients. Brain 1909;32:44-53. 32) Harvey Cushing. Removal of a subcortical cystic tumour at a second stage operation without anesthesia. the Journal of the American Medical Association (JAMA) 1908;50:847-856. 33) Harvey Cushing. A note upon the faradic stimulation of the post-central gyrus in conscious patients. Brain 1909;32:44-53. For the citation, see p.45, Note 2.

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Cushing. from which the sensory impressions had first been An opportunity for a better experiment came on obtained. Thus the crests of all of the exposed June 16, 1908, when Dr. H. M. Thomas, professor convolutions … were stimulated, with the of neurology at the Johns Hopkins Hospital elicitation of no sensory.”35) To Cushing’s referred to Cushing a fifteen-year-old epileptic boy. questions after electrical stimulation, he replied The first operation was performed on that day, that he felt, “as though someone had touched or since it was “the looked-for opportunity of making stroked the fingers.” By repetitions of the stimulus, further observations upon the sensory field.”34) At Cushing was able to confirm that the postcentral the first operation, he stimulated the motor area gyrus was the sensory area, and to map out the electrically, but failed to find the lesion. Twenty area of its function. days after the first operation, Cushing performed a Cushing’s study on human sensory cortex drew second operation. At this time, Cushing intended wide professional attention. It was lauded as a to stimulate the brain cortex after the patient scientific accomplishment proving the existence in recovered from the light anesthesia. After receiving man of a sensory cortex comparable to the motor morphine and chloroform, the boy promptly cortex. The author of a review of Cushing’s work in regained consciousness. With mild current Lancet wrote that his paper had a “modest title” and electricity, Cushing stimulated the sensory cortex. “may well prove to be epoch-making, both from the When Cushing stimulated the postcentral gyrus, the physiological and the surgical point of view.”36) patient, unaware of the application of the Cushing’s electrical stimulation of the motor cortex electrode, reported sensing touch in the hand, the in more than fifty anaesthetized patients was “of the arm, the tongue, and the fingers. deepest significance.” “By experiment on the human A second patient, aged forty-four, also came to cortex,” according to the same author, “the motor Cushing, complaining of epilepsy. At the second area has been exactly delimited and found to operation, the patient recovered promptly from the correspond strictly to the excitable motor area of the temporary narcotic effects of chloroform, and anthropoid ape.” While the need for experimentation regained consciousness. Since this patient was on animals was obvious, human experiment was cooperative, Cushing made a full electrical more satisfactory and easier. Using human subjects, navigation over the exposed area: “the outlying Cushing overcame the shortcomings of animal convolutions were “coursed” in order to see experimentation. In his Linacre Lecture, Victor whether any subjective sensations occurred from Horsley also proclaimed Cushing’s experiment as a stimulation of other than the postcentral gyrus breakthrough in neurophysiology.37) With Horsley

34) Ibid.:46. 35) Harvey Cushing. A note upon the faradic stimulation of the post-central gyrus in conscious patients. Brain 1909;32:44-53. For the citation, see p.51. 36) Annotations: Faradic stimulation of the cerebral cortex in conscious patients. The Lancet 1909;174:93-94. 37) Victor Horsley. Linacre Lecture: The Functions of the so-called mota area of the brain. The British Medical Journal 1909;2:121-32.

- 215 - 醫史學 제18권 제2호(통권 제35호) 205-222, 2009년 12월 and Fedor Krause, Cushing came to belong among stimulation? Cushing gave up stimulation on this pioneers of electrical stimulation of the human patient, resumed anesthesia, enlarged the skull cortex. 38) opening, and finally found the hidden irremovable However praiseworthy his work was on scientific lesion. grounds, Cushing’s human experimentation needed to be justified. The same author of the article in 5. Identity, ethos, and human experimentation Lancet tried to defend the experiments based upon several reasons. First, there was no harm; under Was the human experiment compatible with Cushing’s skillful hands, there was an “entire Cushing’s identity and ethical standards as a absence of any sort of pain or even of discomfort neurosurgeon? Of course, yes. Cushing, following on the part of the patient.”39) Second, the purpose examples of his preceptor Halsted, believed that of the experiment was to benefit the patients: “It nobody could be a good surgeon without the must be emphasized that Professor Cushing applied experimentalists’ ethos. Philadelphia surgeon William his electrode for the particular purpose of Williams Keen held the same view, saying, “The determining the localisation of the area of Age of Experiment is the Age of Progress,” and excitability producing his patients attacks, and for “Stop experiment and you stop progress.”40) The that purpose alone. The experiments were network of elite medical scientists in leading conducted from the patients standpoint.” Third, universities influenced Cushing’s enthusiasm of Cushing received cooperation from his patients. experiment. Sherrington, Kocher, Osler, Welch, Although Cushing was not clear for the case of Halsted, and Keen were all ardent proponents for the fifteen-year-old boy, he emphasized that he had experimental research, legitimating human informed the second epileptic patient and received experimentation in cases in which only a human his cooperation. What is not clear in his description could serve as a meaningful subject for the was the content of information given to the patient. experiment. Varied in their specialties and foci of Did Cushing fully reveal that the electrical emphases, they shared a common ethos and spirit: stimulation had multiple purposes, therapeutic as imperatives for medical experimentation. well as non-therapeutic? Again, Cushing highlighted Cushing’s identity as a neurosurgeon was closely that the cooperative patient was “intelligent.” Did interconnected with this experimentalists’ ethos. In the intelligent man understand why all of the his writing titled “Human Experimentation,” exposed area had been stimulated, and how he Cushing said, “As a matter of fact every surgical developed unexpected convulsions, cyanosis, and operation is vivisection,” and “most forms of protrusion of the cerebral cortex after repeated treatment are experimental in the full sense that

38) S. J. Franz. On the function of the post central convolutions. Journal of Comparative Neurology 1911;21:115; Otfrid Foerster. The cerebral cortex in man: Prof. Foerster’s Lectures. The Lancet 1931;218:309-312. 39) Annotations: Faradic stimulation of the cerebral cortex in conscious patients. The Lancet 1909:174;93-94. For the citation, see p.94. 40) W. W. Keen. Defense of Research Pamphlet. 1912, p.43.

- 216 - Ock-Joo KimːExperiment at Bedside: Harvey Cushing’s Neurophysiological Research antivivisectionist asks and not surgical treatment highly insulated and trained to exercise “doubling” alone but most medical care.”41) His surgical as healer and scientist. Conflicts of interests practice included not only therapeutic experiments scarcely became a problem to him. His ambition but also non-therapeutic ones. To Cushing armed as a scientist was supported by the conviction that with incomparable neurosurgical skill of his time, only the progress of medical knowledge could desperate patients came from all over the country eventually bring benefits to the suffering patients. to seek his care. Cushing made experiments upon Cushing’s success as a clinical scientist resulted the patients brought under his therapeutic umbrella. from his ability to mobilize his patients as human 42) Dedicated to alleviating his patients’ suffering, subjects. Yet, Cushing’s case was just the he freely experimented with physiological questions beginning of the story. Until 1979 when the as well as with surgical techniques. Cushing’s Belmont Report was published to distinguish willingness and capability to cross over the research from practice as one of the key features boundary between therapeutic and non-therapeutic of ethical guidelines for human experimentation, experiments were the essential characteristics of his the line between patient care and research had identity as an academic surgeon. often been blurred. Throughout the twentieth As a scientist at the bedside, Cushing played century, clinical research conducted upon the double roles as a healer and as an experimenter. patients increased rapidly. Cushing’s case signified For their part, Cushing’s patients became his the beginning of the emergence of clinical subjects as well. Communicating between the scientists who performed experiment at bedside in laboratory and bedside, he belonged to two the twentieth century. domains: the sphere of suffering and sphere of knowledge. In the sphere of suffering, he stood between patient and disease, commanding therapeutics to his patients; his patients and their Key Words : Harvey Cushing, Human experimenta families relied heavily upon his surgical judgment -tion, Neurosurgery, Neurophysiology, History of and techniques. In the sphere of knowledge, he Research Ethics. belonged to the network of clinical scientists,

41) Harvey Cushing Paper. Reel 152 Box 190 Folder 314. Yale University. 42) For the history of informed consent, see Ruth R. Faden, Tom L. Beauchamp, Nancy M.P. King. A History and Theory of Informed Consent. New York: Oxford University Press; 1986.

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Acknowledgement Special thanks are given to Dr. Toby Anita Appel at Harvey Cushing/John Hay Whitney Medical Library Yale University, who gave me a kind help in finding Cushing manuscript as well as in deciphering Harvey Cushing’s handwriting. I am also grateful to Professor Allan M. Brandt at the Department of the History of Science Harvard University for his insightful feedback to the early stage of this manuscript. Professor Susan E. Lederer at the Department of Medical History and Bioethics University of Wisconsin gave me valuable comments on this manuscript after I had read the paper at the annual conference of the American Association of History of Medicine in 2000.

투고일 2009. 10. 19. 심사일 2009. 10. 19. 게재확정일 2009. 11. 11.

참고 문헌

Barker, Lewelleys. Medical laboratories: their relation to medical practice and medical discovery. Science 1908. Bartholow, Roberts. Experimental Investigations into the Functions of the human brain. American Journal of Medical Sciences 1874;76. Cushing, Harvey. A comparative study of some members of a pathogenic group of bacilli of the Hog Cholera or Bac. Enteritidis (Gartner) Type, Intermediate between the typhoid and colon groups. Johns Hopkins Hospital Bulletin. 1900;11. Cushing, Harvey. Concerning a definite regulatory mechanism of the vasomotor centre which controls blood pressure during cerebral compression. The Johns Hopkins Hospital Bulletin 1901;12. Cushing, Harvey. Concerning the poisonous effect of pure sodium chloride solutions upon the nerve-muscle preparation. American Journal of Physiology 1901;6. Cushing, Harvey. The taste fibres and their independence of the N. trigeminus. Deductions from thirteen cases of Gasserian ganglion extirpation. Johns Hopkins Hospital Bulletin 1903;14. Cushing, Harvey. Perineal zoster, with notes upon cutaneous segmentation post-axial to the lower limb. American Journal of Medical Sciences 1904;37. Cushing, Harvey. The sensory distribution of the fifth cranial nerve. Johns Hopkins Hospital Bulletin 1904;15. Cushing, Harvey. The surgical aspects of major neuralgia of the trigeminal nerve. A report of twenty cases of operation on the Gasserian ganglion, with anatomic and physiologic notes on the consequences of its

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removal. the Journal of the American Medical Association (JAMA) 1905;44. Cushing, Harvey. Diseases of the nervous system. William Osler. Principles and Practice of Medicine. New York & London: D. Appleton and Co.; 1905. Cushing, Harvey. On preservation of the nerve supply to the brow, in the operative approach to the Gasserian ganglion. Annals of Surgery 1906;43. Cushing, Harvey. Instruction in operative medicine. With the description of a course given in the Hunterian Laboratory of Experimental Medicine. Johns Hopkins Hospital Bulletin 1906;17. Cushing, Harvey. Remarks on some further modifications in the Gasserian ganglion operation for trigeminal neuralgia (sensory-root evulsion). Transactions of the Southern Surgical and Gynecological Association 1907;19. Cushing, Harvey. Removal of a subcortical cystic tumour at a second stage operation without anesthesia. the Journal of the American Medical Association (JAMA) 1908;50. Cushing, Harvey. Surgery of the Head. 1908. Cushing, Harvey. A note upon the faradic stimulation of the post-central gyrus in conscious patients. Brain 1909;32. Cushing, Harvey, Samual Crowe, and John Homans. Experimental hypophysectomy. Johns Hopkins Hospital Bulletin 1910;21. Ferrier, David. Bartholow’s Experiments on the Human Brain, London Medical Record 1874;2. Foerster, Otfrid. The cerebral cortex in man: Prof. Foerster’s Lectures. The Lancet 1931;218. Franz, S. J. On the function of the post central convolutions. Journal of Comparative Neurology 1911;21. Fulton, John F.. Harvey Cushing: a Biography. Springfield Illinois: Charles C. Thomas; 1946. Halsted, William Stewart. The training of the surgeon. Surgical Papers. 1904. Vol.Ⅱ. Harvey Cushing Papers. Yale University. Horsley, Victor. Linacre Lecture: The Functions of the so-called mota area of the brain. The British Medical Journal 1909;2. Keen, William Williams. Animal Experimentation and Medical Progress. Boston; 1914.

Bonner, Thomas N. Becoming a Physician: Medical Education in Britain, France, Germany, and the United States, 1750-1945. New York, Oxford: Oxford University Press; 1995. Christy, N. P. Harvey Cushing as Clinical Investigator and Laboratory Worker. American Journal of Medical Sciences 1981;281. Davey, L. M. Harvey Cushing and the humanities in medicine. Journal of the History of Medicine and Allied Sciences 1969;24. Editorial, Harvey Cushing: great pioneer. British Medical Journal 1969;2. Editorial, Harvey Cushing, a surgical mastermind. Journal of Indiana Medical Association 1969;53. Faden, Ruth R., Beauchamp, Tom L., King, Nancy M.P. A History and Theory of Informed Consent. New York: Oxford University Press; 1986.

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Fye, Bruce. The Development of American Physiology: Scientific Medicine in the Nineteenth Century. Baltimore and London: The Johns Hopkins Univ. Press; 1987. Geison, Gerald L. Divided we stand: physiologists and clinicians in the American context. edited by Vogel, Morris J. and Rosenberg, Charles E.. The Therapeutic Revolution: Essays in the Social History of American Medicine. University of Pennsylvania Press; 1979. Greenblatt, S. H. The Crucial Decade: Modern Neurosurgery's Definitive Development in Harvey Cushing's Early Research and Practice, 1900 to 1910. Journal of Neurosurgery 1997;87. Horwitz, N. H. Library: Historical Perspective. Harvey Cushing (1869-1939). Neurosurgery 1996;39. Laws, E. R. Jr. Neurosurgery's Man of the Century: Harvey Cushing－the man and his legacy. Neurosurgery 1999;45. Lederer, Susan. Subjected to Science: Human Experimentation in America before the Second World War. Baltimore: Johns Hopkins University Press; 1997. Ludmerer, Kenneth M. Learning to Heal: The Development of American Medical Education. New York: Basic Books, Inc.; 1985. Ludmerer, Kenneth M. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. Oxford, New York: Oxford University Press; 1999. Maulitz, Russel C. 'Physician versus Bacteriologist': the ideology of science in clinical medicine. edited by Vogel, Morris J. and Rosenberg, Charles E. The Therapeutic Revolution: Essays in the Social History of American Medicine. University of Pennsylvania Press; 1979. Meacham, W. F. The neurosurgical legacy of Harvey Cushing. Surgery, Gynecology, and Obstetrics 1969;128 Morgan, James P. The first electrical stimulation on the human brain. Journal of the History of Medicine and Allied Sciences 1982;37. Ojemann, R. G. The tradition of Harvey Cushing commemorated by a stamp in the Great American stamp series. The 1987 AANS (American Association of Neurological Surgeons) presidential address [published erratum appears in Journal of Neurosurgery 1988;68:502]. Journal of Neurosurgery 1987;67. Osler, William. The historical development and relative value of laboratory and clinical method in diagnosis: the evolution of the idea of experiment in medicine. Transactions of the Congress of American Physicians and Surgeons 1907;7. Pandya, S. K. Harvey Cushing: The man and his literary contributions. Neurology of Indiana 1969;17. Pyle, John S. A Plea for the Appropriation of Criminals, Condemned to Capital Punishment, to the Experimental Physiologist. Tri-State Medical Journal 1893-94;1. Rossitch, E. Jr. and Khoshbin, S. Harvey Cushing as Medical Artist. Surgical Neurology 1989;32. Rothstein, William G. Physicians in the Nineteenth Century: From Sects to Science. Baltimore: Johns Hopkins Univ. Press; 1972. Sampath, P., Long, D. M., and Brem, H. The Hunterian Neurosurgical Laboratory: the First 100 Years of Neurosurgical Research. Neurosurgery 2000;46.

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Savitz, S. I., The pivotal role of Harvey Cushing in the birth of modern neurosurgery. the Journal of the American Medical Association (JAMA) 1997;278. Sherrington, Charles. Examination of the peripheral distribution of the fibres of the posterior roots of some spinal nerves. Philosophical Transactions of the Royal Society, Series B. 1898;190. Starr, Paul. The Transformation of American Medicine. New York: Basic; 1982. Sweet, W. H. Harvey Cushing: author, investigator, neurologist, neurosurgeon. Journal of Neurosurgery 1979;50. Thomson, Elizabeth H. Harvey Cushing: Surgeon, Author, Artist. New York: Neal Watson Academic Publications Inc.; 1981.

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= 초 록 =

임상에서의 실험 - 하비 쿠싱의 신경생리학 연구 Experiment at Bedside: Harvey Cushing’s Neurophysiological Research

김 옥 주*

이 논문은 하비 쿠싱(Harvey Cushing, 1869-1939)이 그의 환자를 대상으로 수행한 비 치료적인 실험 (non-therapeutic experiments)을 다룬다. 하비 쿠싱은 1896년부터 1912년까지 존스홉킨스 병원에서 신 경외과학 분야를 개척하는 동안 신경생리학 연구를 병행하였다. 쿠싱의 신경생리학 연구는 주로 그 의 환자들에 대한 임상관찰과 외과적인 실험에 의존하였다. 자신이 신경외과 의사로서 동물 대상으 로 연구하는 신경생리학자들보다 더 유리한 위치에 있다는 잘 알고 있는 쿠싱은 신경생리학자들이 쉽게 풀지 못하는 문제인 신경계의 감각 기능에 대해 연구하였다. 그의 연구방법은 수술을 하는 도 중 다양한 자극을 신경계에 주고 환자의 반응을 보는 것이었다. 대뇌의 운동 피질을 확인하기 위해 쿠싱은 수술 도중 50명 이상의 환자의 운동 피질에 체계적으로 전기자극을 주었다. 감각 피질을 구 분하기 위해서 쿠싱은 두개골과 경질막(dura mater)을 연 다음 의식이 있는 환자의 대뇌 피질을 전기 로 자극하며 감각에 대해 질문하여 감각피질 지도를 완성하였다. 이 논문은 쿠싱의 연구를 20세기 초반 미국의 임상연구의 맥락에서 살펴보았다. 왜 쿠싱의 환자들은 치료적 이익이 없는 쿠싱의 생리 학 연구에 참여하였는가? 쿠싱의 동료들은 그의 환자들을 대상으로 한 쿠싱의 실험에 어떻게 반응하 였는가? 쿠싱은 환자들에 대한 실험을 어떻게 정당화하였는가? 임상시험은 신경외과의사로서의 쿠싱 의 정체성과 윤리에 부합하였는가? 쿠싱은 항상 환자로부터 허락을 받고 환자들에게 실험을 한 것은 아니었지만, 이것은 그 자신에게나 사회적으로 거의 문제가 되지 않았다. 쿠싱은 그의 비치료적 실험 을 정당화할 수 있었다. 실험은 진단이나 치료의 부산물로 기술되었으며, 협조하지 않은 환자들을 그 는 “교육받지 않은,” 또는 “마약 중독자”로 기술되었다. 쿠싱의 환자들에 대한 비치료적 실험은 쿠싱 이 환자를 연구대상자로 모을 수 있는 능력이 있었기에 가능한 결과로서 생리학자들에게 과학적 성 취로 환영을 받았다. 쿠싱은 어느 누구와도 비교할 수 없는 신경외과학적 지식과 기술을 가지고 있 어 그에게 치료받고자 전국에서 환자들이 몰려왔다. 부권주의적인 의사이며 야망이 넘치는 과학자였 던 쿠싱은 환자들을 치료하는 동안 환자들을 대상으로 비치료적 연구를 수행하였던 것이다. 사람 대 상 연구의 윤리 원칙은 1970년대에 만들어지게 되는데, 그 이전까지는 치료와 연구의 구분은 명확하 지 않았다. 20세기 동안 환자를 대상으로 하는 임상연구는 급증하게 되는데, 쿠싱의 예는 20세기 임 상에서 실험을 하는 임상과학자들의 도래를 알리는 시작이었다.

색인어 : 하비 쿠싱, 인간대상실험, 신경외과학, 신경생리학, 연구윤리 역사

* 서울대학교 의과대학 의사학 교실

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