HISTORICAL VIGNETTE J Neurosurg 125:1291–1300, 2016 New York City at the dawn of neurological surgery Robert A. Solomon, MD Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, New York Although there are many cities that can claim to have been the incubator of modern neurological surgery, the rise of this surgical subspecialty in New York City in the late 19th and early 20th century mirrors what was occurring around the world. The first confirmed brain tumor operation in the US was performed there in 1887. The author describes the role of several pioneers in the development of neurological surgery. Charles Elsberg was the first dedicated neurological sur- geon in New York City and was instrumental in the development of the Neurological Institute and the careers of several other notable neurosurgeons. http://thejns.org/doi/abs/10.3171/2015.7.JNS15732 KEY WORDS history; New York; brain tumor; Charles Elsberg; Byron Stookey; Tracy Putnam; Wilder Penfield; Leo Davidoff UMAN civilization began about 200,000 years ago, “On the invitation of Dr. Seguin I went to New York to yet the ability to perform neurological surgery has witness the first operation for a tumor of the brain by an evolved in just the last 150 years. Although there American Surgeon, Dr. Weir.”30 areH many cities that can claim to have been the incubator The surgery was performed on March 9, 1887, in the of modern neurological surgery, the rise of neurological presence of Drs. Birdsall and Séguin as neurological coun- surgery in New York City in the late 19th and early 20th sel. Also in attendance were several neurologists and sur- century mirrors what was occurring around the world in geons who, in later years, would become instrumental in the development of this marvelous surgical subspecialty. developing neurological surgery as a subspecialty. Among those observing were Charles Dana, the first professor of First Brain Tumor Operation in the US neurology at Cornell; Bernard Sachs, a neurology consul- tant at Mount Sinai Hospital; Allen Starr, professor of neu- The first reported brain tumor operation in the US was rology at Columbia University College of Physicians and performed in New York City in 1887 by Robert F. Weir, 4 Surgeons; Robert Abbe, a general surgeon at St. Luke’s a general surgeon at New York Hospital. The case was Hospital; and William T. Bull, chief of surgery at New reported by W. R. Birdsall, a neurologist on the faculty York Hospital. 26 of the College of Physicians and Surgeons, with Weir as Some descriptions of the operation are quoted and a coauthor. The patient was a 42-year-old man who was paraphrased as follows: initially diagnosed by Edward Constant Séguin, one of the most distinguished New York neurologists of the period. The head was shaved, and the scalp washed with green soap In November 1885, after 2 or 3 months of observation, Dr. and water, and then with ether, and subsequently covered Séguin recognized a hemianopic defect, gait imbalance, for several hours with carbolic cloths … a U-shaped flap and intermittent diplopia. The diagnosis was a tumor of the was made with the base upward… The trephine opening was made and the bone rongeured away… The dura mater, non- mesial aspect of the right occipital lobe, involving primar- pulsating, rose tensely in the space… On opening the dura, the ily the cuneus, extending downward toward the tentorium tumor at once rose into the bony opening. It was purplish-red cerebelli and perhaps also upward toward the paracentral color, like kidney structure, and was covered over by thin cel- lobule. Dr. Charles Mills, a prominent neurologist at the lular tissue, with large veins ramifying in it… The tumor was University of Pennsylvania, later wrote about the occasion: therefore incised, and some of its softened, granular, and fatty- SUBMITTED March 31, 2015. ACCEPTED July 29, 2015. INCLUDE WHEN CITING Published online January 22, 2016; DOI: 10.3171/2015.7.JNS15732. ©AANS, 2016 J Neurosurg Volume 125 • November 2016 1291 Unauthenticated | Downloaded 09/24/21 10:22 AM UTC R. A. Solomon looking contents forced out … and enabled the forefinger to be passed between the cranium and tumor … the delicate cel- lular attachments that held the mass in place were felt to yield easily... By drawing the finger gently toward the cranial open- ing, the tumor was torn nearly in two ... and withdrawn by the end of the finger-end and nail.... The operation was well borne until the final enucleation, when the pulse fell from loss of blood. The limbs were bandaged and whiskey given subcu- taneously ... pulse of 132... On coming out of ether he moved all his limbs... At six hours he was conscious but dull. He was given a salt transfusion ... but failed to respond and died shortly thereafter.4,26,31 (Fig. 1) By modern standards the procedure was a disaster, with a bone flap too small, no way to stop the bleeding scalp, no rubber gloves, inserting the finger to tear the tu- mor out of the brain, ripping bridging veins to the midline, and avulsing the arterial supply without the means to stop the bleeding. It is probably fortuitous that the patient died of massive blood loss before succumbing to sepsis, venous infarction, and brain swelling. Nonetheless, it was this pio- neering effort that gave rise to the first successful brain tumor removal later that same year in Philadelphia by Dr. William Keen.14 Origin of Neurosurgery in Neurology and General Surgery The origins of neurological surgery lie in the 1860s with the concept of cerebral localization and spinal physi- ology. Prior to the development of cerebral localization, the brain was considered like any other solid organ, func- FIG. 1. Figures from Birdsall and Weir’s article with original legends tioning as a unit. It is illustrative of the times to review the describing the first brain tumor operation performed in the US. Repro- vigorous debate being waged at a meeting of the Société duced from Birdsall WR, Weir RF: Medical News 50:424, 1887. Public d’Anthropologie in Paris in 1861. Louis Pierre Gratiolet, domain. opposing the theory of cerebral localization, declared: “I do not hesitate to conclude that all schemes of localiza- tion hitherto proposed are without foundation.”11 On the surgery of the central nervous system. Aggressive neurolo- other side of the argument was Ernest Auburtin,3 a faithful gists, emboldened by a new understanding of the function- disciple of Jean-Baptiste Bouillaud. Bouillaud had already al significance of structures in the central nervous system, concluded that a distinct and independent center respon- drove surgeons, now capable of more sophisticated surgi- sible for speech existed in the frontal lobe.27 cal techniques, to operate on the brain and spinal cord.9 Rather than argue the point, Auburtin proposed an ex- In New York this sentiment was reflected by R. W. periment. A dying patient on the service of Professor Paul Amidon who read a paper before the New York Academy Broca at the Hospital for Incurables had been diagnosed of Medicine in June 1884 urging heroic surgical inter- several years earlier with an expressive aphasia. He sug- vention for brain lesions: “… accessible neoplasms of the gested that when the patient died, an autopsy would reveal brain, which have resisted medicinal treatment, and which a lesion of the left frontal lobe. Broca, a general surgeon continue to grow … should be removed; for the reason that and anthropologist who had been reluctant to accept the they are generally single … and always kill by pressure.”2 doctrine of Bouillaud, became a devoted advocate of the These radical sentiments propelled New York general sur- concept when the autopsy confirmed a lesion in the third geons such as Robert Abbe, Robert Weir, Arpad Gerster, left frontal convolution.6 Bouillaud and Auburtin, not Charles McBurney, and others in cooperation with neu- Broca, were the first to recognize the importance of the rologists Edward Séguin, Allen Starr, Bernard Sachs, and left frontal lobe in motor speech. The work of these men Charles Dana to experiment with cranial surgery for mass gave credibility to the concept of cerebral localization and lesions, epilepsy, and pain.26 launched intensive research into this field. The first textbook on neurological surgery was in fact Of course the other landmark event that made neuro- written by the neurologist Moses Allen Starr. Working surgery possible was the development by Joseph Lister with Charles McBurney, a noted general surgeon at Roo- of the antiseptic principle of surgery in 1867.16 The pos- sevelt Hospital in the late 19th century, Starr is quoted as sibility of operating on the brain without the usually fatal stating that “one of the functions of the neurologist is to complications of meningitis, combined with the increasing superintend and direct operative procedures on the brain understanding of cerebral localization during the late 19th and spinal cord by surgeons.”26 Through their work at the century, allowed general surgeons to experiment with open Syms Operating Pavilion, a building that still stands today 1292 J Neurosurg Volume 125 • November 2016 Unauthenticated | Downloaded 09/24/21 10:22 AM UTC New York neurosurgery on the west side of Manhattan, Starr gained the experi- ence that led him to write Brain Surgery,25 a seminal work dealing with the status of brain surgery and its potential for treating intracranial tumors. It was the first real text- book of modern neurosurgery. The Rise of the Neurological Institute of New York Neurosurgery in New York City was incubated at the Mount Sinai Hospital.