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Home , Emil Theodor Kocher, Harvey Cushing, William Stewart Halsted

The making of a neurosurgeon , Halstedian technique, and the birth of a specialty Courtney Pendleton, MD, and Alfredo Quiñones-Hinojosa, MD

Dr. William S. Halsted with present and former members of his staff at the twenty-fifth anniversary of the opening of the , October, 1914. Left to right, standing: Roy D. McClure, Hugh H. Young, Harvey Cushing, James F. Mitchell, Richard H. Follis, Robert T. Miller, Jr., John W. Churchman, George J. Heuer. Sitting: John M.T. Finney, William S. Halsted, Joseph C. Bloodgood. Courtesy of the National Library of .

8 The Pharos/Autumn 2012 The making of a neurosurgeon Harvey Cushing, Halstedian technique, and the birth of a specialty

Dr. Pendleton is a second-year resident in at Jefferson Medical College. Dr. Quiñones-Hinojosa (AΩA, University of California, San Francisco, 2004) is an associ- ate professor of Neurosurgery and Oncology and Director of the Pituitary Tumor Center at School of Medicine.

arvey Cushing, the founder of American neurosurgery, began his ca- reer as an assistant surgical resident Hand then as a senior surgical resident at the Johns Hopkins Hospital under the supervision of Dr. . Examination of Hopkins’ surgical files throughout Cushing’s four-year general surgical under Halsted shows how he developed the experi- ence, vision, and operative skills he needed to transform neurosurgery into a successful sub- specialty during the early twentieth century.1–4 As the demands of subspecialty surgical train- ing increase, and the length of general surgical training decreases, it is worthwhile to reflect on the important role of broad general surgical education in the early development of a surgical subspecialty in the United States. Structured surgical training programs grew out of an early desire to distinguish tradesmen barber- from academically trained pro- fessionals. In in the thirteenth century, the College de Saint Come identified the two groups by coat length, those with the most formal train- ing having the longest coats.5 This separation of trained versus untrained gave way to the establishment of formal apprenticeships in the sixteenth century.5 Apprenticeships provided

The Pharos/Autumn 2012 9 The making of a neurosurgeon

Dr. William Stewart Halsted, 1922. Photo by John H. Stocksdale. Courtesy of the National Library of Medicine.

hands-on training, with an experienced providing had extensive experience in the operating theater as well as longitudinal mentorship for the young apprentice, and in the wards, but its main drawback was that a percentage of many fundamental ways forms the basis for contemporary residents had to leave the program with too much training surgical residency training. to pursue an alternative career and not enough training to be In the late nineteenth and early twentieth centuries, as safe and successful practicing surgeons.8 hospitals established themselves as centralized sources of The Hopkins program placed strong emphasis on perform- medical care, the need for a more structured training system ing surgery safely, according to the Halstedian method.6 The grew. This new system was first proposed by Sir William Halstedian principles of aseptic operative technique, careful Osler at the Johns Hopkins Hospital,5 although it is William handling of delicate tissues, meticulous hemostasis, and ap- Stewart Halsted who is most often credited with its inception proximation of tissues with minimal tension using multi- at Hopkins in 1889 and its adoption throughout the United layered closures were thoroughly emphasized.5–7 States and Europe soon thereafter.5,6 Under Halsted’s guidance, Cushing learned the fundamen- Halsted’s residency training bore great similarities to tals for improving surgical outcomes, as well as the impor- the apprenticeship model. It was pyramidal, similar to the tance of thoughtful, evidence-based medicine.6,9 In his 1905 training programs in Germany where Halsted had studied.7 address on neurological surgery, Cushing offered his perspec- The program had as its hallmark stepped responsibility for tive on both the role of broad surgical training and the need the residents depending on both experience and successful for further specialization: performance of clinical tasks,5-7 and weeded out residents who did not continue to progress during training. This granting the wisdom and necessity of a general surgical structure ensured that residents continuing through training training beforehand, I do not see how such particularization

10 The Pharos/Autumn 2012 of work can be avoided, if we wish more surely and progres- lead surgeon, the operative note refers to Cushing by name. sively to advance our manipulative therapy.2 Although the majority of the roughly 1100 operative notes reviewed were written in the third person, Cushing typically Thus it may be said that the clinical training and emphasis on omitted agency or referred to himself as “the operator.” This is the concept of the physician-scientist that Cushing received the only note in which he refers to himself by name. Operative during his four years with Halsted undoubtedly provided him notes were not customarily typewritten before about 1900. with the skills necessary to pursue any surgical endeavor, and Thus a comparison of handwritten notes initialed by Cushing certainly contributed to the success of his chosen field of neu- with the operative note for this particular case shows that rological surgery. it was written by Cushing rather than Halsted. The unusual Following approval from our institutional review board, and reference to himself as operator may reflect pride at being the through the courtesy of the Alan Mason Chesney Archives, we lead surgeon for the first time, months of previous experience reviewed the surgical cases from Cushing’s year as Halsted’s documenting operations conducted by other surgeons, or assistant surgical resident (1896–1897), as well as cases con- close supervision in this case by Halsted, both in the operating ducted during his time as Halsted’s senior surgical resident theater and in post-operative chart documentation. (1897–1900) and those conducted as a young attending spe- Cushing quickly progressed to more complex cases. On cializing in neurosurgery (1901–1912). Except where otherwise December 13, 1896, a sixteen-year-old woman employed in indicated, quotations regarding these cases are taken verbatim a shirt factory presented with “ingrowing toenails.” She was from Cushing’s original unpublished surgical notes. These files brought to the operating room on December 14, 1896, where document the apprentice model of training proposed by Osler Cushing excised the toenails. His hand-drawn illustration and Halsted,5,6,7,10 and illustrate the role that general surgi- from the surgical chart and the detailed operative note docu- cal experience played in Cushing’s development as a surgical ment the procedure: trainee and physician-scientist. Only the lead surgeon was recorded consistently in the A double cutting done on the left, the bad toe, nail not surgical record operative notes, with the first assistant or removed. A generous slice of tissue removed. On the right resident in attendance only sporadically documented. The foot a simple excision of granulating area, removing ⅛˝ of hospital records thus do not thoroughly document Cushing’s the nail and matrix back to the neighborhood of the distal early presence in the operating room under Halsted’s su- joint. Wound closed. pervision. The earliest record of Cushing as a participant is dated November 27, 1896. At this time, a twenty-two- year-old woman presented with tuberculosis of the skin along her jaw. Cushing is listed as the surgeon of record, and the brief opera- tive note describes the pro- cedure, conducted under local :

The ulcerated area ex- cised by Dr. Cushing. It was quite superficial ap- parently. Facial artery [. . .] tied c [illegible] during removal. Wound closed c interrupted silver suture. Cocaine.

The patient was discharged on December 1, 1896; no fur- ther follow-up was available. Cushing’s original illustration of an ingrown left toenail, his second operative procedure during his It is interesting that here, year as assistant surgical resident under Halsted. in Cushing’s first case as the Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions.

The Pharos/Autumn 2012 11 The making of a neurosurgeon

The post-operative chart documentation is in Cushing’s walled off from the cavity . . . Apparently 4.5 cm of sclerosed handwriting, and indicates that he performed his own dressing bone chiseled through before reaching the sequestrum. changes. This is not surprising given Halsted’s expectations for the residents,6,7 as well as Cushing’s own dissatisfaction The tone of the operative note, with its parenthetical question with the surgical staff’s attention to detail.1 Shortly after the mark and conditional wording, may indicate self-doubt and a operation, Cushing documented marked improvement in the tendency to over-analyze, marking the transition from super- patient’s condition: “Toes doing well—Been­ up and walking vised resident to independent operator. In his later operative about for 48º [sic: minutes] s discomfort.” This rather simple notes, Cushing continued to employ these occasional indicators procedure was Cushing’s second performance as a resident of uncertainty, transforming the worries of a young resident operating independently, and would certainly have been a into the hallmarks of a thorough and introspective attending source of pride for the young surgeon. surgeon. As Cushing matured as an attending, his operative Halsted was not the type of mentor to allow trainees to rest notes reflected on similarities between the operation being on their laurels. Cushing would have been expected to expand conducted and other operative procedures. He referenced other his experience to include increasingly complex cases, as well cases where errors were made, and described his attempts to as schedule more time for surgery. On December 26, 1896, avoid those adverse outcomes in subsequent operations. less than a month after his first experience as a lead surgeon, Despite the doubts reflected in this early operative note, Cushing performed two separate operations, each significantly and the apparent amazement at the defect created intra- more complex than the preceding ones. operatively, the patient had an uneventful post-operative On December 21, 1896, a twenty-three-year-old African course. His final outcome remains unknown, as on February American man presented with osteomyelitis at the lower end 6, 1897, following a forty-six-day hospital stay, the patient was of his femur. Cushing operated on the patient on December 23, “discharged by Dr. Hurd for bad conduct.” No details regarding 1896. His operative note describes the procedure: the patient’s behavior were documented, and given the race of the patient in a segregated hospital in the South only a few Incision 15 cm long over internal condyle and above. years after the end of post-Civil War Reconstruction and the Sinus excised to point of entrance into bone. An opening at enactment of the Jim Crow laws, it is not possible to speculate about site of adduction tubercle leads through about an inch profitably. From the post-operative documentation at the time and a half of eburnated periosteal (?) bone to a cavity in the of the patient’s discharge, Cushing would have seen the opera- end probably of the diaphysis. Here some dead bone can be tion as a successful intervention. felt. The sinus leading to it lined by flabby gray granulations. Cushing’s second case on December 23, 1896, had a very The bone chiseled away till would have held a hen’s egg. different outcome. The patient was a fifty-six-year-old African A flat sequestrum size diagram removed. Cavity curetted— American man who presented with hemorrhoids on December irrigated with HgCl2. Iodaform powder introduced. Wound 16, 1896. The patient was brought to the operating room for closed c silver over large blood clot. Dressing. what Cushing described as an “excision of unilateral prolapse There appeared to be no extension of granulation along of bowel. Whitehead method. Prolapse covered c verrucous the medullary cavity, which in fact seemed completely growths.” Cushing’s operative note documents the procedure:

Cushing’s original illustration of his excision of osteomyelitis of the femur during his year. The note in Cushing’s hand- writing 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 A prolapse of right side of rectum. The prolapse covered senior surgical resident, the two men performed a simultane- with 8-10 pedunculated growths, about the size of a pea. ous repair of bilateral inguinal in a forty-one-year-old Above them the pedicle of the extruded gut caught by the man. Each surgeon dictated his own operative note, although sphincter. Sphincter dilated—Rest of bowel seems normal. both are in Cushing’s handwriting. One can imagine Halsted No similar growths seen. 6 small high internal hemorrhoids. conducting his operation on the right side, while supervis- Excision of prolapse by Whitehead method. One side only ing Cushing’s handiwork on the left. Cushing’s illustrations so treated. Closed c catgut. document the attention to detail throughout the operation, as well as the careful handling of the tissues. His note confirms The surgical file offers no information regarding the post- that “six retractors” were used to separate the tissue without operative management. The patient’s outcome at discharge damage and indicates a multilayered closure in line with the was documented as “dead,” and his date of discharge/death is Halstedian principles of careful tissue approximation and December 23, 1896. minimal tension along suture lines: Cushing had developed a reputation early in his career as a surgeon with high expectations for himself and those around [The rectus muscle transplant] were then closed with him,1 but in this case the operative note describes notable about six silver mattress sutures including aponeurosis . . . departures from Halstedian technique: Halsted used black silk The aponeurosis of the ext. oblique was then closed by in- suture or silver wire for tissue approximation and closure,1,7 terrupted silk sutures above the projecting muscle—silver while Cushing here used catgut, a thicker natural-fiber suture. wire for skin. (See page 14) While it is unlikely that the choice of suture material alone was a cause of mortality, coarse catgut suture provided inferior In April 1898, halfway through Cushing’s training period, wound closure, and may have contributed to wound dehis- he and Halsted scrubbed into a radical mastectomy for a forty- cence, infection, or sepsis, any of which may have caused the year-old woman with a tumor in her left breast. The operative patient’s death. Cushing used catgut suture in future hemor- note is in Cushing’s handwriting, and describes in detail the rhoid operations, but his later endeavors employed black silk removal of gross tumor, potentially infiltrated lymph nodes, suture layers in addition to this coarser suture material. The and surrounding tissue, the hallmarks of Halsted’s operation. chart does not provide insight into Cushing’s thoughts on the The Halstedian obsession with meticulous hemostasis is re- case, but the modification of his approach in future operations flected in Cushing’s note: “Vein exposed and dissected clean implies that he may have connected the death of the patient before the breast with pectorals was removed . . . Bleeding with his failure to follow Halsted’s technique. points tied c fine silk.” Cushing did not perform two cases in a day again until July During his tenure as Halsted’s senior surgical resident from 10, 1897. Given the apprentice model of training, it is probable 1897 through 1900, Cushing performed more than 200 general that this was a result of the outcome of the second December surgery cases. As a general surgical trainee, Cushing began 23 case, which had shown Cushing’s limits. The case load to explore the field of neurological surgery, which remained for young residents was always light,1 and this, coupled with fraught with difficulty and was yet to be developed as a truly Joseph Bloodgood’s extended presence as Halsted’s senior independent surgical specialty.2–4 Under Halsted’s tutelage, resident and Halsted’s intermittent absenteeism as a result of Cushing performed a wide variety of neurosurgical cases, his ongoing struggles with cocaine and morphine, may have beginning in 1897 with a craniotomy for an extra-dural ab- resulted in a dearth of cases for Cushing to pursue during the scess—these early cases encompassed the operative treatment latter half of his first year of residency. After the December of spinal cord and column , trauma, facial neuralgia, holidays, Cushing returned to the operating room as the sur- and the removal of components of the calvarium for treatment geon of record in an excision of a rectal abscess, with good of recurrent bony tumors. As Cushing’s interest in neurologi- results. Although Cushing’s case load remained light, the cal surgery increased during the latter half of his general sur- complexity of the cases he was given in the operating theater gical training, Osler’s interest in neurological disorders added increased, and he soon returned to the same operative proce- to Halsted’s influence on Cushing’s surgical technique.11 The dure involved in his first patient mortality as the surgeon of surgical records document physician referrals to Cushing from record. This time, Cushing used Halsted’s preferred black silk outside institutions, but do not provide a consistent record of sutures, as well as a second layer of catgut suture. The patient patients referred to Cushing’s service from Hopkins. A review was reported “cured” post-operatively. of referrals from clinics overseen by Osler would provide in- Throughout Cushing’s four years of surgical training un- sight into that relationship. der Halsted, the two men were co-lead surgeons in a hand- After Cushing completed his general surgical training ful of cases. These operations offer insight into the surgical under Halsted, he spent nearly a year in Europe observing techniques Cushing observed in his direct interactions with operative techniques and participating in clinical and research Halsted in the operating theater. endeavors with the brightest surgeons and physician-scientists In December 1897, with Cushing now serving as Halsted’s of the day, including , with whom

The Pharos/Autumn 2012 13 The making of a neurosurgeon

Cushing’s original illustration of the repair of a left-sided inguinal , which he operated on at the same time as Halsted worked to repair a right-sided 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 had performed an appendectomy on a patient who died after in 1901, his future at Hopkins remained uncertain until the the operation.9 Cushing thus understandably integrated the late fall, when he obtained an associate position within the surgical and academic techniques of his mentor into his own hospital, and received Halsted’s blessing to pursue neurosur- practice. gery at least one day each week. Beginning in September 1901, The importance Cushing placed on accurate wound ap- Cushing expanded his surgical repertoire to include operative proximation with minimal tension through the use of multi- interventions for , cerebral palsy, spina bifida, and layered closures, an integral part of Halstedian technique,6,7 is trigeminal neuralgia. Even though these operations were a far reflected in Cushing’s decision to use three to four layered clo- cry from the general surgical procedures he had performed sures in five of his ten operative interventions for the repair of during his training with Halsted, Cushing’s neurosurgery at spinal dysraphism.12 The technique had been previously used Hopkins owed a tremendous debt to the meticulous operative in Europe, but did not become popular in the United States techniques he learned from Halsted. until 1918, following the publication of Charles Frazier’s book The personal and professional relationship between on operations of the spine.14 The mortality rate for these pa- Cushing and Halsted was stormy at best,1,9 but it cannot tients remained high, but Cushing’s application of Halstedian be doubted that Cushing had confidence in Halsted’s surgi- principles led to long-term improvement in two patients12 at a cal practices; after all, Halsted had successfully removed time when operating was considered largely futile. Cushing’s appendix in 1897, following an episode of appen- Cushing’s operative notes show his attention to hemostasis, dicitis. This faith in his mentor is perhaps underscored by albeit through somewhat unconventional means, as in a right the fact that, before his own bout with appendicitis, Cushing subtemporal decompression from 1912:

14 The Pharos/Autumn 2012 injury to posterior branch of meningeal artery lead to tem- Beyond operative technique, Cushing learned from Halsted porary difficulties with an annoying hemorrhage. The vessel the importance of integrating laboratory research into his was definitely flattened with a spoon. clinical practice. In a 1904 address, Halsted gave an early de- scription of the physician-scientist:6 Although the cutlery method of hemostasis never caught on, Cushing devised silver clips for controlling hemorrhage After all, the hospital, the operating room and the wards that became widely used. His operative note from the same should be laboratories, laboratories of the highest order, and 1912 case documents their use: “many silver clips being ne- we know from experience that where this conception pre- cessitated owingto [sic] oozing points along the edge of the vails . . . the welfare of the patient is best promoted. . . . The dura.” Cushing also meticulously documented blood loss, and surgeon and the physician should be equipped and should expressed his frustration with operations muddled by vascular be expected to carry on work of research.7 oozing and frank hemorrhage because this interfered with his ability to maintain the nearly bloodless operative field so Cushing continued in this tradition, using cadaver models strongly endorsed by Halsted. to perfect novel operative approaches.1 A case of attempted Halsted further insisted on maintaining aseptic technique resection of a pituitary lesion from 1910 offers a detailed analy- in the operating theater.6,7 In his 1904 Annual Address in sis of the result laboratory-based cadaver experiments had on Medicine at , Halsted praised the German sur- actual operations: gical school for adopting antiseptic operative approaches, and lamented the limited foothold this theory had gained within After an experience on the cadaver the preceding day, it the United States.7 Cushing appears to have taken this lesson seemed feasible to approach the gland by an incision under to heart, and documented his patients’ surgical site infections the upper lip which opened into the nasal fossae and was possibly to guard against future mishaps. An operative note then conducted as follows: for a second stage operation on a ten-year-old patient with a It was a simple matter on the cadaver to remove the mu- suspected brain tumor, performed without anesthesia, shows cous membrane on each side of the vomer and then to insert Cushing’s introspective approach to his failures in aseptic the speculum on each side. The vomer was then removed in operative technique: one piece. . . . Difficulties were encountered in the operation which had Child in excellent condition, in spite of high temperature and not been present on the cadaver. . . . rapid pulse which I had taken to be from a central disturbance The patient’s anterior nares proved to be so small that rather than from any possible infection. When the dressing the same size speculum that had been used on the cadaver was removed the incision was found to be perfectly dry and did not enter well and consequently the exposure of the sella beautifully healed, so much so that I commented upon it. To tursica [sic] was less satisfactory than had been anticipated. my intense chagrin, on opening the incision, however, there poured out what seemed to be thick creamy pus. Cushing went beyond cadaver models, bringing clini- cal puzzles into the laboratory to search for answers within Cushing made notes for future improvement: animal models of disease.14,15 During his year of observator- ships and research in Europe, Cushing assisted Sir Charles I had no idea . . . that it could be otherwise than an infec- Scott Sherrington in his laboratory exploration of the motor tion and it was attributed to the technical slip at operation and sensory cortices in primate models.1,9,16 After returning I, namely, the withdrawal of the drainage tubes from outside to Baltimore, Cushing brought the laboratory technique of in, instead of by reopening the old wound and drawing them Faradic stimulation into the operating theater for treatment out through the scalp and draining so as to be sure that no of epilepsy, brain tumors, and trauma. The note accompany- infection could come from the small point of skin infection ing the surgical treatment in 1905 of a three-year-old boy for above mentioned [from prior operative note]. “Epilepsy, infantile convulsions,” illustrates Cushing’s attention to detail, as well as his attempts to thoroughly map the motor This early willingness to reflect on errors that may have led cortex: to poor results contributed to Cushing’s ability to perfect his aseptic technique in future. Within his series of transfacial It was quite easy to recognize the situation of the motor approaches to lesions of the skull base, as well as transnasal strip and efforts to obtain response by electrical stimula- approaches to the sella turcica and the pituitary gland, only tion met with most unaccountable results. Anywhere over rarely did surgical site infections or meningitis occur. For a the exposed part of the cortex movements of the right foot surgeon operating in the pre- era, this was certainly could be elicited, even with moderately slight currents. a hard-won achievement. These movements consisted of quick, sharp plantar flexion

The Pharos/Autumn 2012 15 The making of a neurosurgeon

of the toes and foot. Only on using stronger currents could ford University Press; 2005. any movements be produced in the head or arm areas which 2. Cushing H. The special field of neurological surgery. Bull were exposed. (Note that the leg area was not exposed in the Johns Hopkins Hosp 1905; 16: 77–87. wound at all.) These movements of arm and face were very 3. Cushing H. The special field of neurological surgery: Five slight even with the strongest currents and it was impossible years later. Bull Johns Hopkins Hosp 1910; 21: 325–29. to carry them on to an epileptic seizure. The closure of the 4. Cushing H. The special field of neurological surgery after jaw, shrugging of the shoulder and slight movements of the another interval. Arch Neurol Psychiatry 1920; 4: 603–37. arm were all that were elicited. 5. Franzese CB, Stringer SP. The evolution of surgical training: Perspectives on educational models from the past to the future. In this case, and many others, Cushing used the informa- Otolaryngol Clin N Am 2007; 40: 1227–35. tion gleaned from intra-operative motor mapping to guide his 6. Cameron JL. William Stewart Halsted: Our surgical heritage. attempted surgical cure of epilepsy. “From the area which gave Ann Surg 1997; 225: 445–58. movements of the arm a piece of the cortex was extirpated 7. Halsted WS. The training of the surgeon. Bull Johns Hopkins measuring about 1 x 1½ cm. in its surface extent.” This patient Hosp 1904; 15: 267–75. was discharged in improved condition, and her parents sent a 8. Pellegrini CA. Surgical education in the United States: Navi- note two months after the operation saying that she had expe- gating the white waters. Ann Surg 2006; 244: 335–42. rienced no more seizures. 9. Fulton JF. Harvey Cushing: A Biography. Springfield (IL): C. Through his synthesis of Halsted’s vision of a physician- C. Thomas; 1946. scientist with his own clinical observation, laboratory inves- 10. Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg tigations, and surgical techniques, Cushing devised novel 2000; 87: 28–37. operative treatments for trigeminal neuralgia,1,17 hydrocepha- 11. Canale DJ. and “the special field of neurologi- lus,15 and hypopituitarism,1,18,19 among other maladies. cal surgery.” J Neurosurg 1989; 70: 759–66. The four years Cushing spent learning general surgery from 12. Pendleton C, Ahn ES, Jallo GI, Quiñones-Hinojosa A. Har- Halsted proved invaluable to his later work. He credited a vey Cushing and early spinal dysraphism repair at Johns Hopkins strong understanding of general surgery as the foundation on Hospital. J Neurosurg Pediatrics 2011: 7: 47–51. which all further knowledge was built. 13. Frazier CH. Surgery of the Spine and Spinal Cord. New York: Today’s neurosurgical residents spend six months to a year D. Appleton; 1918. on general surgery training. While such abbreviated training 14. Crowe SJ, Cushing H, Homans J. Effects of hypophyseal allows residents to pursue research and rotations through the transplantation following total hypophysectomy in the canine. Q J neurosurgical residency (which Cushing would undoubtedly Exper Physiol 1909; 2: 389–400. have supported2–4) it focuses on specialization at the expense 15. McClure RD. Hydrocephalus treated by drainage into a vein of breadth of experience. Cushing spent the equivalent of in the neck. Bull Johns Hopkins Hosp 1909; 20: 110-113. over half a contemporary residency period performing non- 16. Feindel W. Osler vindicated. Glioma of the leg center with neurosurgical procedures. Jacksonian epilepsy; removal and cure, with a 50-year follow-up. J Cushing’s thoughts on general training for the subspecialist Neurosurg 2009; 111: 293–300. are clear in his papers on neurological surgery:2–4 17. Cushing H. A method of total extirpation of the Gasserian ganglion for trigeminal neuralgia. JAMA 1900; 34: 1035–41. those who can best take advantage of existing opportuni- 18. Cushing H. The hypophysis cerebri: Clinical aspects of ties, or can originate others, not only must have had a good hyperpituitarism and of hypopituitarism. JAMA 1909; 53: 249–55. general training in clinical medicine and surgery, but must 19. Cushing H. The Pituitary Body and Its Disorders: Clinical have been thoroughly schooled in the fundamental subjects States Produced by Disorders of the Hypophysis Cerebri. Philadel- . . . for without this knowledge any special branch is sup- phia: J. B. Lippincott; 1910. ported by a root lodged in sand which does not long survive overloading.4pp605–06 Address correspondence to: Alfredo Quiñones-Hinojosa, MD Cushing’s extensive experience in general surgery, with 1550 Orleans Street Halsted’s emphasis on operative technique, provided him with Cancer Research Building II Room 253 the meticulous surgical skills necessary to transform neurolog- Baltimore, 21231 ical surgery from a fool’s errand into a flourishing subspecialty E-mail: [email protected] or [email protected] within the span of a decade.

References 1. Bliss M. Harvey Cushing: A Life in Surgery. New York: Ox-

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