HISTORICAL VIGNETTE J Neurosurg 135:205–213, 2021

Harvey Cushing’s international visitors

Eric Suero Molina, PD Dr med, MBA,1 Michael P. Catalino, MD, MSc,2,3 and Edward R. Laws, MD2

1Department of , University Hospital of Münster, Germany; 2Department of Neurosurgery, Brigham and Women’s Hospital, , Massachusetts; and 3Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina

Harvey Cushing is considered the father of neurosurgery, not just for his work within the United States, but also for his global influence through international visitors and trainees. Starting in 1920, the neurosurgical clinic at the Peter Bent Brigham Hospital in Boston, led by Cushing, trained surgeons from all over the globe, many of whom returned home to establish neurosurgical departments and become neurosurgical pioneers themselves. The objective of this vignette is to highlight the importance of Cushing’s international trainees, describe their contributions, and discuss how each had an impact on the development of the practice of neurosurgery worldwide. The authors demonstrate how Cushing provided the impetus for a movement that revolutionized and neurosurgery worldwide. Even today, international coop- eration continues to shape the success of our delicate specialty. https://thejns.org/doi/abs/10.3171/2020.5.JNS193386 KEYWORDS Harvey Cushing; training; mentorship; international visitors; history of neurosurgery

A doctor must be a traveler. International Influence on Cushing’s Early — Paracelsus (1493–1541) Career: Sir Victor Horsley (1857–1916) Harvey Cushing (1869–1939) dedicated most of his The international thread woven into the fabric of Cush- efforts to teaching during the period when ing’s early career served as a prominent feature coloring (WWI) had just ended, and the first meeting of the So- his role as a neurosurgical educator. The first international ciety of Neurological Surgeons had already occurred. In neurosurgeon to have an important influence on Cushing 1912, Cushing became chief of surgery at the new Peter did so indirectly: Sir Victor Horsley, a pioneering neuro- Bent Brigham Hospital (PBBH) in Boston, Massachusetts. surgeon in the United Kingdom. His global influence, however, was not established until The contributions to neurosurgery made by Horsley 1920, when he began encouraging international visitors are indisputable. He is credited with performing the first to PBBH, who themselves were essential in establishing a operations for spinal neoplasm, epilepsy, and pituitary pa- rapidly expanding global movement in neurosurgical edu- thology, and the first operation for a craniopharyngioma, cation. Many were actually voluntary graduate assistants.1 to name a few.2 Horsley pioneered the concept of stereo- There were at least 32 international visitors in total (Tables tactic techniques and presented the first homunculus of the 1 and 2), but many remain unknown. Most visitors were motor strip of an animal.2 In 1889, Horsley hosted Boston from the United Kingdom or Western Europe, but pio- surgeon John Wheelock Elliot of Massachusetts General neers from Eastern Europe, Canada, Scandinavia, Russia, Hospital (MGH), to whom Horsley demonstrated several and Australia were also included (Fig. 1). Cushing started of his neurosurgical procedures.3 a global initiative in neurosurgery that was uniquely car- It took Elliot about 5 years to perform neurosurgery ried home by each individual trainee. We contend that this himself at MGH. In the summer of 1895, he performed led to rapid global expansions of both neurology and neu- only three neurosurgical operations, and unfortunately, rosurgery by the middle of the 20th century. all 3 patients died. Elliot became discouraged and lost

ABBREVIATIONS PBBH = Peter Bent Brigham Hospital; WWI = World War I. SUBMITTED January 16, 2020. ACCEPTED May 11, 2020. INCLUDE WHEN CITING Published online August 21, 2020; DOI: 10.3171/2020.5.JNS193386.

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TABLE 1. Harvey Cushing’s notable international trainees and visitors Time w/ Name Lifetime Position Country Cushing Selected Achievements Sir Charles 1890– Prof of Neurology, Na- England 1920 Contributions to idiopathic intracranial hypertension, otitic hydrocephalus, Symonds 1978 tional Hospital, Queen cluster headache, & encephalitis lethargica Square Description of cause & clinical manifestations of SAH Frédéric 1892– Prof of General Pathol- Belgium 1920– Uncovered central origin of diabetes insipidus w/ Percival Bailey Bremer 1982 ogy, Brussels 1921 Pioneer in sleep research Paul Martin 1891– Prof of Neurosurgery, Belgium 1921– Neurosurgery pioneer in Belgium 1968 Brussels 1922 Advances in depicting intracranial masses w/ ventriculography, encephalogra- phy, electroencephalography, & angiography Cofounded Neurochirurgie journal Sir James 1895– Prof of Surgery, Univer- England 1922 President of Royal College of Surgeons of England (1957–1960) Paterson 1980 sity Ross Director of Surgery, St. Bartholomew’s Hospital Kenneth G. 1892– Prof of Neurosurgery, Canada 1919, First neurosurgeon in Canada McKenzie 1964 Toronto 1922– First neurosurgeon to treat Ménière syndrome by vestibular nerve division & 1923 posttraumatic intractable epilepsy by hemispherectomy Norman Dott 1897– Prof of Neurosurgery, Scotland 1923– Development of transsphenoidal surgery 1973 University of Edinburgh 1924, Establishment of first neurological surgery unit in Scotland 1929 First surgical treatment of a ruptured aneurysm Advances in surgery of cleft palate Sir Geoffrey 1886– Prof of Neurosurgery, England 1924 First prof of a neurological surgery chair in Britain Jefferson 1961 University of Man- Fellow of the Royal Society (1947) chester Classification of axis fracture named after him First successful embolectomy (brachial artery) in England Jean Morelle 1899– Prof of Neurosurgery, Belgium 1925 Created the first neurosurgery division w/in general surgery in Belgium 1983 Leuven Sir Hugh 1896– Prof of Neurosurgery, England 1926– Founder of modern British neurosurgery along w/ Norman Dott & Geoffrey William Bell 1952 Oxford 1927 Jefferson Cairns Teacher of Hugo Krayenbühl, pioneer of neurosurgery in Switzerland Clovis 1879– Prof of Neurosurgery, France 1927, Pioneer of French neurosurgery Vincent 1957 Paris 1930 First prof of neurosurgery in France Ignaz 1888– Prof of Neurosurgery, Nether- 1927– Pioneer of modern neurosurgery in the Netherlands Oljenick 1981 University of Amster- lands 1929 “Oljenick syndrome”: occipitalization of C1 dam Cofounder of Nederlandse Studieclub voor Neurochirurgie (Dutch Study Club for Neurosurgery) Dumitru 1893– Prof of Neurosurgery, Romania 1927– Founder of Romanian neurosurgery Bagdasar 1946 University of Bucharest 1929 Author of Traité de Neurochirurgie (1948), main training book for neurosurgeons in Romania for >25 yrs Minister of Health for the Romanian government Axel Herbert 1891– Prof of Neurosurgery, Sweden 1929 Founder of Swedish neurosurgery Olivecrona 1980 Royal Serafimer Hospi- Author of Handbuch of Neurochirurgie w/ Wilhelm Tönnis (1954–1974) tal, , First recipient of Fedor-Krause Medal from German Society of Neurosurgery Stockholm (1956) Daniel Petit- 1889– Prof of Neurosurgery, France 1930 First president of the Société de Neurochirurgie de Langue Française (1948) Dutaillis 1968 Paris Description of root compression by lumbar disc herniation causing radiculopathy Sir Leonard 1896– Prof of Neurosur- Australia 1929– Founding member of Neurosurgical Society of Australasia Charles Ed- 1978 gery, Royal Adelaide 1930 Honorary neurosurgeon of Royal Adelaide Hospital ward Lindon Hospital Pioneered founding & development of neurosurgery in his region Ferdinand 1902– Prof of Neurosurgery, Nether- 1932 Coeditor of Zentralblatt für Neurochirurgie (1936–1943) Verbeek 1958 University of Groningen lands Cofounder of Nederlandse Studieclub voor Neurochirurgie (Dutch Study Club for Neurosurgery) Eduard A. V. 1899– Prof of Neurosurgery, Denmark 1933 Founder of Danish Neurosurgery Busch 1982 Rigshospitalet, Copen- First prof of neurosurgery in Denmark hagen American Medal of Freedom United Nations Medal of Honor Prof = professor; SAH = subarachnoid hemorrhage.

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TABLE 2. Other known international trainees and visitors of his enthusiasm.3 However, for 8 weeks during that sum- Harvey Cushing mer Elliot was assisted by a Harvard medical student who Name Place of Work Time w/ Cushing witnessed the last two of these neurosurgical procedures, both the novel approaches and Elliot’s failures.3 That stu- Arthur van Dessel Louvain, Belgium 1925 dent was Harvey Williams Cushing. Cushing himself was Boris M. Fried Russia 1925 later quite critical of Horsley, especially after observing Walter Lehmann Göttingen, Germany 1926 his operations.2 Nevertheless, it appears that Cushing’s Georges Schaltenbrand Hamburg, Germany 1926–1927 first exposure to neurosurgery was borne out of the in- Alan C. Gairdner London, United Kingdom 1928–1929 ternational influence of Victor Horsley on the American surgeon John Elliot. Attracta Halpenny Dublin, Ireland 1929 F. A. R. Stammers Birmingham, England 1929 United Kingdom Gaston de Coppet Bern, Switzerland 1929–1930 Francois Ody Geneva, Switzerland 1930–1931 In addition to Horsley, there were numerous other as- piring in the United Kingdom, many of whom Johannes Rives Tartu, Estonia 1931 became acquainted early with the rise of modern neuro- Carl F. List Berlin, Germany 1931–1932 surgery through the work of Harvey Cushing. Benno Schlesinger Vienna, Austria 1931–1932 D. Vasiliu Bucharest, Romania 1932 Sir Charles Putnam Symonds (1890–1978) Arsit A. Stender Hamburg, Germany 1932 Sir Charles Symonds has been described as one of the Vittorio Putti Bologna, Italy 1932 most influential neurologists of the 20th century. Symonds left Guy’s Hospital, London, in 1920 to study with Har- vey Cushing under a traveling fellowship,4 during which

FIG. 1. Cushing’s international visitors organized by country and region. See the text for references on each visitor. For Benno Schlesinger, see Tschabitscher et al. Dr. Benno Schlesinger: neuroanatomist and neurosurgeon from Vienna, 1900–1983. Neuro- surgery. 2006;59(3):697–701. Figure is available in color online only.

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Symonds described the etiology of subarachnoid hemor- rhage in a patient with a ruptured aneurysm.5 After his return to the United Kingdom, Symonds worked at the National Hospital, Queen Square, London, and served as a professor of neurology. Symonds also studied encepha- litis lethargica, cluster headache, idiopathic intracranial hypertension, “otitic hydrocephalus,” epilepsy, and trau- matic brain injuries. He published a distillation of his most notable work (Studies in Neurology) in 1970.6

Sir James Paterson Ross (1895–1980) Sir James Paterson Ross was a distinguished surgeon and forensic medical scientist.7 In 1922, Ross began work under Cushing, a year that was notable for giving Ross much motivation and happiness8 as part of Cushing’s “family.” 7 Ross then returned to London, where he be- came the chair of general surgery at St. Bartholomew’s Hospital after its founder, George E. Gask (1875–1951), retired. Ross, interested in surgery of the sympathetic nervous system, treated King George VI with a lumbar sympathectomy. He was also appointed surgeon to Queen Elizabeth II.

Sir Geoffrey Jefferson (1886–1961) Sir Geoffrey Jefferson (Fig. 2) worked at an Anglo- Russian Hospital in Petrograd and later led a surgical unit west of Kiev.9 He learned neurosurgery autodidactically through Cushing’s writings, because there were no locally available clinical training programs at the time.9,10 After training with Cushing in 1924, Jefferson was appointed as a consultant surgeon in the Salford Royal Hospital in Manchester upon his return to the United Kingdom.10 Jefferson pioneered neurosurgery in Britain, driving the FIG. 2. Sir Geoffrey Jefferson (1886–1961). Reprinted from Guthkelch founding of the Society of British Neurological Surgeons AN. Geoffrey Jefferson (1886–1961), neurosurgeon, physiologist, phi- and introducing Cushing’s techniques.10 Jefferson became losopher. J Neurosurg. 1987;66(5):642–647. the first professor of neurological surgery in Manchester in 1939, 9 and he was named a fellow of the Royal Society. He gave a Hunterian lecture on fractures of the atlas and to the development of microsurgical minimally invasive axis, and the Jefferson classification of axis fractures is access to the skull base. Norman Dott personally inspired still used today. He published a collection of his personal the senior author of this article, as well as many other sur- favorite works in Selected Papers in 1960.11 geons who have continued to improve upon Dott’s legacy of transsphenoidal approaches to the skull base. Norman McOmish Dott (1897–1973) Given his prior research on the pituitary gland, Nor- Sir Hugh William Bell Cairns (1896–1952) man McOmish Dott, from Edinburgh, received a Rock- Sir Hugh William Bell Cairns, Australian by birth, efeller traveling fellowship, which enabled his appoint- was an athlete (rugby and lacrosse), scholar, and service- ment as a junior associate at PBBH from November 1923 man (Australian Army Medical Corps). Cairns was a born to June 1924. This position proved to be a pivotal step leader.14 He was a Rhodes Scholar under Charles Sher- in his career, and Dott was essential to the evolution of rington (Oxford 1920–1921),14 and in 1925, he met Cush- transsphenoidal surgery. After training with Cushing, ing in London. As Cushing’s assistant in 1926, Cairns’ first Dott continued using the transsphenoidal approach to the operation was also the first case in which Cushing used skull base, which was eventually abandoned by most oth- electrocautery, described in Fulton’s biography of Cushing ers, including Cushing.12 Dott enhanced this technique by as a “circus” (p. 537).15 Cairns claimed that his service in introducing a speculum incorporating fiber-optic lights to WWI prepared him for the hard work of neurosurgery but enhance the surgical view.12 It was not until 1956 that Dott that “Gallipoli and the Battle of the Marne were nothing introduced this surgical technique to Gerard Guiot, who compared with the physical stress of a year as Cushing’s later trained Jules Hardy.12,13 Both Guiot and Hardy were resident” (p. 539).15 Cairns came to the Brigham during the instrumental in the evolution of modern transsphenoidal most rigorous and productive period of Cushing’s career. surgery by applying intraoperative fluoroscopy and the By 1935, after returning to England, Cairns assumed the surgical microscope to this method.12 These advances led Nuffield Professorship in Surgery at Oxford while found-

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FIG. 3. Selection of physicians from Western Europe. Left: Clovis Vincent (1879–1947). Reprinted from Le Beau et al. J Neuro- surg. 1950;7(2):148–155. Right: Ignaz Oljenick (1888–1981). Reprinted from Kloet et al. J Neurosurg. 2008;109(2):348–355. ing the medical school there.15 Cairns trained numerous as the Tracy Cabot Fellow and spent another year at Har- neurosurgeons, including Hugo Krayenbühl, a founder of vard Medical School in 1929 as the chief of the labora- neurosurgery in Zürich, Switzerland.16 Cushing’s parting tory of experimental surgery.21 Martin studied the return advice to Cairns was the following: of tendon reflexes after surgical decompression of brain- stem tumors,22 as well as the clinical signs of fourth ven- Don’t imagine that you can learn everything about the surgery 23 of intracranial tumours in [12 months], and from having had tricle tumors, and contributed to the development of ven- a hand in dealing with one or two hundred cases, I have been triculography, encephalography, electroencephalography, in this business myself for a long time. After my first year and angiography.20 He cofounded the still-active journal or two, I thought I knew much more about the subject than I Neurochirurgie, the most important French neurosurgical now do after twenty-five years [p. 541].15 journal.20,21 Martin was a dedicated general surgeon and valued the contributions of both surgery and neurosurgi- 20 Western Europe cal specialization to the general field of medicine. Surgeons from Western European countries, includ- Jean Morelle (1899–1983) ing Belgium, Germany, France, and the Netherlands, were Jean Morelle of Leuven, Belgium, served as a volun- Cushing’s most frequent international visitors (13 in total). tary assistant with Harvey Cushing from 1925 to 1926. According to Fulton’s biography,15 in 1938, Arnold Klebs Frédéric Bremer (1892–1982) (1870–1943) referred to Morelle as one of “Harvey’s boys.” Frédéric Bremer was a voluntary graduate assistant After completing his training with Cushing, Morelle re- with Harvey Cushing in 1920.1 Bremer, a neurophysiolo- turned to Leuven University and started the “nucleus” of gist from Brussels, served in the Ocean Ambulance in a department of neurosurgery within the general surgery WWI.17 He began training in neurology in 1919 under service. He was instrumental in the development of neuro- Professor Pierre Marie at the Hôpital de la Salpêtrière surgery in Belgium.24 in Paris and then spent a year with Harvey Cushing be- fore working with Cushing’s former mentor, Sir Charles Clovis Vincent (1879–1957) 17 Sherrington, in Oxford. Bremer’s first scientific publi- Pupil and heir of the great neurologist Joseph Babinski cation, with Percival Bailey from Cushing’s laboratory, (1857–1932), Clovis Vincent’s (Fig. 3 left) legacy and im- uncovered the central origin of diabetes insipidus and the 18 mense contribution to French neurosurgery are undispu- “thirst” center of the hypothalamus. Bremer said, “What table. Vincent visited Cushing’s clinic in 1927, and at that could be more exalting in a man’s life than to try and lift time his scientific career was dedicated predominantly to the corner of the veil that hides from us the mystery of 19 neurology. Unfortunately, Vincent only spent a short time things?” Bremer became a pioneer in the neurophysiol- with Cushing, due to a language barrier, but he visited ogy of sleep and is best known for his integrity and com- 25,26 17,19 Cushing once again in 1930. Despite Vincent’s lack of mand of scientific language. prior surgical training, he employed Cushing’s techniques back home, igniting immense growth in French neuro- Paul Martin (1891–1968) surgery.27 Together with Thierry de Martel (1875–1947), Paul Martin was the founder of neurosurgery in Bel- Vincent laid the foundation for neurosurgery in France. gium (1948; Institut Heger-Bordet, the Universite libre de Cushing visited Vincent several times in Paris and was Bruxelles).20 He studied under Cushing from 1921 to 1922 impressed by his skills and competence.27 In 1938, neu-

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Unauthenticated | Downloaded 10/06/21 11:05 PM UTC Suero Molina et al. rosurgery was recognized as an independent specialty in as one of Cushing’s last visitors.32 Verbeek subsequently France. Vincent dedicated much of his time to research on pursued training at Johns Hopkins with Walter Dandy be- brain edema, temporal lobe function and pathology, cer- fore returning to the Netherlands. There, Verbeek worked ebellar herniation, and brain abscesses.28 Vincent trained at the University of Groningen, but because of difficulties Hami Dilek (1898–1985), who was the father of neurosur- expanding his practice, he settled at a private hospital, the gery in Turkey (1949).27 Roman Catholic Hospital in Groningen,31,32 and kept up close correspondence with Dandy more than Cushing. Daniel Petit-Dutaillis (1889–1968) Verbeek soon became respected among neurosurgeons in Daniel Petit-Dutaillis, a contemporary of Clovis Vin- Europe and was coeditor of one of the first national neuro- cent, is also considered a father of French neurosurgery. surgical journals, Zentralblatt für Neurochirurgie, found- After initially training as a general surgeon, Petit-Dutaillis ed in 1935 by Wilhelm Tönnis (1898–1978). acquired an interest in neurosurgery around 1923, and he worked with the neurologist Georges Guillain (1876– Eastern Europe 29 1961), who first described Guillain-Barré syndrome. In The origins of neurosurgery in Romania can be traced 1928, Petit-Dutaillis presented the outcomes of a series back to two important mentoring relationships that oc- of craniotomies he performed for traumatic brain injury. curred in France and the United States. Alexandru Moru- In 1929, he published one of the first reports of a case of 30 zzi, who was a student of Thierry de Martel in Paris, cauda equina syndrome. Petit-Dutaillis visited Cushing founded the first Romanian neurosurgical center. Another in 1934 and then, returning to France at a time when neu- neurosurgeon, Dumitru Bagdasar, studied for 2 years un- rosurgery was considered a subspecialty of neurology, he der the supervision of Harvey Cushing at the PBBH.33 extended the indications for neurosurgical procedures to traumatology, functional neurosurgery, and vascular sur- Dumitru Bagdasar (1893–1946) gery, as well as describing the first case of lumbar disc herniation causing radiculopathy.29 Petit-Dutaillis became Dumitru Bagdasar (Fig. 4) is considered the father of head of the neurosurgical department of La Pitié Hospital Romanian neurosurgery. After an educational hiatus due to WWI, he finished his studies by writing a thesis about in Paris in 1947 and is widely recognized for his global 34 contributions to neurosurgery.29 postencephalic parkinsonism. Bagdasar later trained as both a neurologist and general surgeon. Nicolae Paulescu Ignaz Oljenick (1888–1981) (1869–1931), a neurologist and highly regarded researcher of the hypophysis,33 nominated Bagdasar for a Fulbright Ignaz Oljenick (Fig. 3 right), born in 1888, was a gen- scholarship.35 Bagdasar trained for 2 years with Harvey eral surgeon in Amsterdam. He served in the Balkan War Cushing, starting in 1927, and published two papers, on in Montenegro in 1913 and with the Red Cross in the chordoblastoma and neurosyphilis, during this time.35 In Czech Republic and Vienna. He developed an interest in 1927, Cushing wrote: neurology after studying disorders following traumatic ce- rebral arterial lesions.31 Oljenick began a neurology resi- Doctor Bagdasar worked very closely with me and I’ve come to feel the highest esteem for his work, skill, and personality. dency, where he worked closely with Bernard Brouwer at … I have all the reasons to believe that he has the capacity the Hospital for Epilepsy and Organic Nervous Diseases to build a reputation for himself and for neurosurgery in his in Amsterdam. Neurosurgery finally emerged as an in- country.35 dependent specialty in the Netherlands in the 1930s.31 In 1927, Oljenick spent 2 years with Cushing and became the In 1931, Bagdasar became chief of neurology at the first fully trained neurosurgeon in his country.32 Upon his Cernauti Hospital, Romania, and contributed immensely to the operative, administrative, educational, and scien- return to Amsterdam, Oljenick established his practice at 33 the Neurological Institute at the “Wilhelmina Gasthuis” tific development of neurosurgery in Romania. His most of the University of Amsterdam. He kept in touch with important work was published after his death in 1948, , with whom he had crossed paths in Boston, the Traité de Neurochirurgie, which became the training 31 manual for Romanian neurosurgeons and remained so for for consultation on difficult cases. Oljenick’s surgical 33 skills and meticulous management of patients, which he more than 25 years. Finally, under Bagdasar’s supervi- learned from Cushing, contributed to his success and rap- sion, Sofia Ionescu, his trainee, performed her first sur- idly changed the perception of neurosurgery in the Neth- gery, saving the life of an 8-year-old child by evacuating erlands. Oljenick started training neurosurgeons, but after an epidural hematoma. Ionescu became the first woman the outbreak of WWII, and because of his Jewish ancestry, neurosurgeon in the world, as recognized by the World Federation of Neurosurgical Societies in the 2005 Annual he fled the country with his family and began a new life 36 in New York City, never again to practice neurosurgery Congress. or see his home country. He died in 1981 in Manhattan.32 Canada Ferdinand Verbeek (1902–1958) While modern neurosurgery had an earlier start in Eu- Ferdinand Verbeek emerged as a candidate from the rope and the United States, it did not take long before Ca- Department of Surgery at the University of Groningen, the nadian neurosurgeons developed a passion for this field. Netherlands, and then traveled to the United States to pur- Wilder Penfield, a global neurosurgical pioneer in his own sue training. In 1932, he began work with Harvey Cushing, right, was an American-Canadian surgeon whose relation-

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FIG. 5. Physicians from Scandinavia. Left: Axel Herbert Olivecrona (1891–1980). Accessed April 15, 2020. https://commons.wikimedia.org/. Public domain. Right: Eduard A. V. Busch (1899–1982). Reprinted from Taarnhøj P. J Neurosurg. 1983;58(3):313–314.

for the beginning of premodern neurosurgery there.40 However, two neurosurgical pioneers of Sweden and Den- mark, respectively, visited the PBBH and kept close rela- tionships with Harvey Cushing.

Axel Herbert Olivecrona (1891–1980) After finishing his medical education at the University of and at the Karolinska Institut in Stockholm, FIG. 4. Dumitru Bagdasar (1893–1946). Reprinted from Mohan et al. Sweden, in 1918, Axel Herbert Olivecrona (Fig. 5 left) Rom J Morphol Embryol. 2018;59(4):1299–1303. Public domain. worked as a surgical assistant in Leipzig, Germany, and at the Royal Serafimer Hospital in Sweden.41 He received a scholarship from the American-Swedish foundation, ship with Cushing is discussed in detail elsewhere.37 Har- and he traveled to the in Balti- vey Cushing trained the first full Canadian neurosurgeon. more to study under Prof. William Halsted (1852–1922) at the Hunterian Laboratory. Between animal experiments, Kenneth G. McKenzie (1892–1964) Halsted’s lectures, and observing surgical procedures, Kenneth G. McKenzie took a leave of absence from Olivecrona spent almost a full year in . Upon his work as an anatomy instructor to work as an assistant his return to Sweden, he continued his training as a surgi- resident with Cushing under the Mickle Fellowship (1922– cal resident at the Serafimer Hospital, eventually applying 1923). McKenzie was surgically sloppy at first, but Cushing for a yearlong stay at Cushing’s clinic. Cushing accepted 38 him as a foreign resident. However, due to financial issues, described him as willing to “work and learn.” McKenzie 41 eventually returned to Toronto and became Canada’s first Olivecrona’s plans fell through, until his return in 1929. neurosurgeon. McKenzie improved Cushing’s hemostatic Meanwhile, Olivecrona practiced neurosurgery in Swe- clip, and Cushing eventually adopted McKenzie’s innova- den, where he rapidly gained experience and recognition. tion.38 Fulton’s biography15 describes McKenzie as adding Based on his initial neurosurgical work, he published the book Die chirurgische Behandlung von Gehirntumoren comic relief after Cushing humbly accepted a “birthday 42 book” (the Festschrift) on the accomplishments of his (The Surgical Management of Brain Tumors) in 1927, “disciples.”39 McKenzie said he wanted to discover who which crystalized Olivecrona’s international credentials “selected [Harvey Cushing’s] neckties” because they had and established the momentum for the founding of neuro- “aroused the research instincts of others” (pp. 571–572).38 surgery in Sweden. Olivecrona was a pioneer in cerebro- vascular and acoustic neuroma surgery and is considered one of the earliest surgeons who aimed at preserving the Scandinavia facial nerve.43 The beginning of neurosurgery in the “Nordic” coun- Olivecrona was named assistant surgeon in chief in tries can be traced further back before the beginning of the 1930 at the Serafimer Hospital and later professor of neu- 20th century. Olof of Acrel, the father of Swedish surgery, rosurgery at the Karolinska Institute, where he stayed on operated on a young patient with a brain tumor in 1768.40 until his retirement in 1960. Among his renowned pupils Vilhelm Magnus from Oslo was trained by Victor Horsley were Wilhelm Tönnis, Eduard Busch, and Aarno Snell- and pioneered neurosurgery in Norway, setting the stage man, who contributed to the development of neurosurgery

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first holder of the chair for Danish neurosurgery. He con- tinued his work on sympathectomy and published articles about spinal cord tumors, tumor-associated epilepsy, and electroencephalography.44 He was an honorary member of several neurosurgical and neurological societies around the globe and received numerous honorary awards and doctoral degrees.44 Busch was the honored guest speaker at the meeting of the Congress of Neurological Surgeons in 1961.44 He will forever be remembered as the founder and father of Danish neurosurgery.

Australia Sir Leonard Charles Edward Lindon (1896–1978) Sir Leonard Lindon (Fig. 6) was one of the founding members of the Neurosurgical Society of Australasia and was instrumental in the advancement of neurosurgical ed- ucation. He led the neurosurgery department at the Royal Adelaide Hospital in South Australia from 1931 to 1951 after being the first neurosurgeon on the staff.45 In 1929, Lindon performed a career-shifting journey to at least nine specialized neurosurgical centers in Europe (where he met Dott, Olivecrona, Cairns, and Jefferson) and North America (where he met Penfield and McKenzie), includ- ing the PBBH, where he met Cushing. Lindon was deeply impressed by the meticulous and modern neurosurgical techniques he observed, but also by his observation that Cushing’s philosophy was already implemented by his FIG. 6. Sir Leonard Charles Edward Lindon (1896–1978). Reprinted 45 from Simpson D. ANZ J Surg. 2012;82(5):311–317. ©2012 The Author. pupils overseas. Lindon pioneered the development of a ANZ Journal of Surgery ©2012 Royal Australasian College of Surgeons. neurosurgical unit in Adelaide and contributed to the de- Published with permission. velopment of modern neurosurgery in his region.

Conclusions in their own countries, Germany, Denmark, and Finland, respectively. 41 One of Olivecrona’s most important Swed- Harvey Cushing influenced and inspired the careers ish pupils was (1907–1986), who revolution- of a global network of surgeons. Cushing’s mentorship ized stereotactic procedures and is considered the founder empowered these young physicians to join the challeng- of .41 The Herbert Olivecrona Award is one of ing new field of neurosurgery and build momentum for the most important awards within the international neuro- the establishment of departments of neurosurgery within surgery community. Professor Olivecrona died in January the hospitals and academic institutions of their respective 1980 at the age of 86. countries to provide state-of-the-art surgical treatment of neurological disorders. Each pioneer was an innovative Eduard A. V. Busch (1899–1982) thinker, an early adopter of new ideas and techniques, and creative. Inspired himself by global pioneers, Cushing was Eduard Busch (Fig. 5 right) began his medical stud- the primary provider of the impetus for a movement that ies in Denmark at the University of Copenhagen in 1924, revolutionized modern medicine around the world. Even which were followed by general surgery training un- 44 today, international cooperation, which has historically til 1932. He initially had no interest in neurosurgery, shaped the field of neurosurgery, is essential for the con- mainly due to its discouraging outcomes, but his doctoral tinuing success of our delicate specialty. thesis was on “periarterial sympathectomy,”44 a topic that he later studied with pioneer René Leriche (1879–1955) in Strasbourg. With increasing interest in neurosurgery, Acknowledgments 44 Busch worked with De Martel in Paris and then served We would like to acknowledge Gilles Reuter from the Uni- as Herbert Olivecrona’s first assistant in Sweden.41,44 In versity of Liege in Belgium for assisting us in translating French 1933, Busch worked with both Harvey Cushing and Wal- documents and describing the life of Daniel Petit-Dutaillis. ter Dandy. Upon his return to Denmark in March 1934, Busch was named neurosurgical assistant to the profes- sor of neurology at the Rigshospitalet in Copenhagen.44 In References 1934, he was responsible for 11 beds and 1 operating the- 1. Annual Report of the Peter Bent Brigham Hospital. Univer- ater within the neurological department of Viggo Chris- sity Press, Cambridge (Mass);​ 1915–1920. tiansen (1867–1939), and Busch became head of a fully 2. Lehner KR, Schulder M. American views of Sir Victor Hors- independent department in 1939. By 1948, he became the ley in the era of Cushing. J Neurosurg. 2019;​130(2):​337–673.

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Chirurgia article: all authors. Reviewed submitted version of manuscript: all (Bucur). 2011;106(5):​ 567–572.​ authors. Approved the final version of the manuscript on behalf of 26. Le Beau J. Clovis Vincent. Article in French. Neurochirurgie. all authors: Suero Molina. Administrative/technical/material sup- 1980;​26(5):​359–367. port: Catalino, Laws. Study supervision: Laws. 27. Elmaci I, Balak N. Pioneering Turkish neurosurgeon Hami Dilek and the traces of Harvey Cushing’s legacy in his work. Correspondence J Neurosurg. 2008;​108(4):​821–829. Eric Suero Molina: University Hospital of Münster, Germany. 28. Le Beau J, Tavernier J. Clovis Vincent: ​His life and main [email protected]. contributions to neurosurgery. J Neurosurg. 1950;​7(2):​148– 155.

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