HISTORICAL VIGNETTE J Neurosurg 127:927–940, 2017 Norman M. Dott, master of hypothalamic craniopharyngioma surgery: the decisive mentoring of Harvey Cushing and Percival Bailey at Peter Bent Brigham Hospital Ruth Prieto, MD, PhD,1 and José M. Pascual, MD, PhD2 1Department of Neurosurgery, Puerta de Hierro University Hospital; and 2Department of Neurosurgery, La Princesa University Hospital, Madrid, Spain Norman McOmish Dott (1897–1973) developed surgical neurology in Edinburgh, Scotland, and was a scholar of world- wide renown. One of Dott’s most notable contributions to neurosurgery was his understanding of hypothalamic physiol- ogy, mostly acquired through the comprehensive study of patients with lesions involving this region of the diencephalon, particularly craniopharyngiomas (CPs). Recognition of symptoms caused by hypothalamic disturbances allowed him to predict the accurate anatomical relationships between CPs and the hypothalamus, despite the rudimentary radiological methods available during the 1930s. His sophisticated knowledge permitted Dott to perform radical removals of CPs originating within the third ventricle floor with acceptable success. Between 1934 and 1937, he operated on 4 CP cases originating in the hypothalamus, achieving a satisfactory postoperative outcome in 3 of the 4 patients. Aware of the strong attachment of hypothalamic CPs to the infundibulo-tuberal area, Dott used a double transbasal and transventricu- lar approach to these lesions, a strategy providing an optimal view and control of the tumor boundaries. The decisive mentorship of several legendary figures of physiology and neurosurgery greatly influenced Dott’s surgical evolution. The experimental pituitary gland work he performed with Sir Edward Sharpey-Schäfer at the beginning of his career stirred Dott’s curiosity about the issue of hypothalamus-pituitary relationships. As a result, he decided to move to Peter Bent Brigham Hospital (Boston, Massachusetts) in 1923, to train in neurosurgery and neuropathology under the guidance of the leaders in these fields, Harvey Williams Cushing (1869–1939) and Percival Sylvester Bailey (1892–1973). They inspired the young Dott and shared with him their clinical and pathological expertise, in addition to their surgical strate- gies for best approaching and removing these challenging tumors. In time, Dott would come to surpass his mentors. This paper aims to credit Norman M. Dott for his decisive, modern contributions to hypothalamic CP surgery. https://thejns.org/doi/abs/10.3171/2016.9.JNS16702 KEY WORDS craniopharyngioma; Harvey W. Cushing; history; pituitary surgery; hypothalamus; Norman M. Dott; Percival Bailey; third ventricle The most fertile source of our information regarding the tions to neurosurgery, Dott is credited as the main advo- Hypothalamus is the observation of patients with tumors of cate for the transsphenoidal approach to pituitary tumors this and related parts. in the first half of the 20th century, a technique he learned — Norman M. Dott, 193834 from Cushing.42,43,45,61 Less well known are the original, in- novative procedures Norman Dott performed in the 1930s Norman McOmish Dott (1897–1973) developed his for radical excision of hypothalamic tumors, in particular specialization in surgical neurology—the term he defi- craniopharyngiomas (CPs). These particularly challenging nitely favored—in Edinburgh (Fig. 1), a vocation undoubt- operations were described in detail in the 1938 master- edly influenced by the immense respect he held for Harvey piece, The Hypothalamus: Morphological, Functional, Williams Cushing (1869–1939), the father of modern sci- Clinical and Surgical Aspects.34 Dott devised a 2-stage entific neurosurgery.31,61 Among his well-known contribu- approach, involving first a subfrontal exposure of the ret- ABBREVIATIONS CP = craniopharyngioma; DI = diabetes insipidus; TVF = third ventricle floor. SUBMITTED March 18, 2016. ACCEPTED September 7, 2016. INCLUDE WHEN CITING Published online January 6, 2017; DOI: 10.3171/2016.9.JNS16702. ©AANS, 2017 J Neurosurg Volume 127 • October 2017 927 Unauthenticated | Downloaded 10/06/21 02:54 PM UTC R. Prieto and J. M. Pascual learned from Cushing and Bailey was that the patients’ severe morbidity or death almost inevitably followed any surgical injury to the hypothalamus.15,26,27,30,34,40,53 This study reviews Dott’s innovative surgical tech- niques for the treatment of hypothalamic CPs. In partic- ular, our work analyzes the knowledge Dott acquired at Peter Bent Brigham Hospital that significantly contributed to his success with this specific topographical CP variant, judged as the most “baffling” type of brain tumor by Har- vey Cushing.14 We have systematically examined the in- formation related to the treatment of CPs at Brigham Hos- pital stored in the Manuscripts and Archives Department at Sterling Memorial Library, Yale University, New Hav- en, Connecticut, for the two periods Norman Dott spent as a visiting neurosurgical fellow at Cushing’s department: first, from November 1923 to June 1924, and later, in the summer of 1929.20 In addition, an extensive review was performed of the Cushing-Dott correspondence kept at Yale, as well as the published literature on the subjects of CPs and the hypothalamus by Harvey Cushing, Percival Bailey, and Norman M. Dott.21–23 Our major objective was to draw attention to the pathological concepts and surgi- cal lessons about CPs that Dott learned from Cushing and Bailey, which allowed him to achieve a radical removal of hypothalamic tumors. These essential lessons remain valid for neurosurgeons even today. Intellectual Background: From Engineer Apprentice to Committed Pituitary Gland Researcher Norman M. Dott was born in Colinton, on the south- ern outskirts of Edinburgh, Scotland, on August 26, 1897. Raised in a family promoting the enjoyment of culture and rational thinking, Dott aspired to become an engineer, but FIG. 1. Portrait of Professor Norman McOmish Dott (1897–1973) by on August 29, 1913, he suffered a motorcycle accident, a Sir William Oliphant Hutchinson in 1960. The original oil painting was 61 donated by Dr. Jean Hider, Dott’s daughter, in 1983 to the Royal College stroke of fate that altered the tenor of his life. He suffered of Surgeons of Edinburgh. It hangs at the Main Hall of the College. Re- a compound fracture of his left femur and tibia, requir- printed with permission of the Royal College of Surgeons of Edinburgh, ing complex surgery and from which he endured a painful owners of the portrait. Figure is available in color online only. limp for the rest of his life. His own disability along with the impression that other sick and injured patients made on him, prompted a desire to study medicine at the Uni- rochiasmatic area, followed by a second transcortical- versity of Edinburgh, from which he graduated in Decem- transventricular procedure to remove the upper portion of 61 34 ber 1919. From 1920 to 1921, Dott was trained in general the lesion within the third ventricle. Such a combination surgery under Dr. John Wheeler Dowden at the Royal In- of basal and upper approaches to complex intra-extraven- firmary (Fig. 2A). In 1923, he obtained the Fellowship of tricular CPs remains the standard method for removal of the Royal College of Surgeons of Edinburgh (FRCSE). 63,65 these lesions today. Considering Dott lacked accurate In 1908, Sir Edward Albert Sharpey-Schäfer (1850– neuroradiological methods of diagnosis, surgical micro- 1935), chair of physiology at the University of Edinburgh scopes, hormonal replacement therapies, and antibiotics, and discoverer of the active principle of the posterior pitu- his record of hypothalamic CP removal should be regard- itary gland, was invited to deliver a lecture on the physiol- ed as a remarkable accomplishment. ogy of the pituitary gland at Johns Hopkins University in During his fellowship in Boston (1923–1924), Harvey Baltimore, Maryland.38 Stunned by the lecture, a young Cushing kindled Dott’s enthusiasm for pituitary tumors Harvey Cushing immediately embarked upon his impor- and the study of pituitary and hypothalamic disturbanc- tant series of experimental hypophysectomies in dogs, and es.38,61 Dott also had the good fortune to meet Percival Syl- shortly afterward he began to treat clinical cases of pitu- vester Bailey (1892–1973), who taught him the essential itary disease.11,16,38 Nearly a decade later, in 1917, Sharpey- concepts of hypothalamic dysfunction necessary to un- Schäfer offered Dott the opportunity to join his labora- derstand the sort of symptoms observed in patients with tory of physiology as a researcher (Fig. 2B).61,62 During his CPs.2,3 Dott witnessed firsthand the disheartening results training in general surgery, Dott became actively engaged that followed Cushing’s early attempts to remove CPs in- in experiments on gastric secretions and on thyroid and pi- volving the hypothalamus. The fundamental lesson Dott tuitary physiology. Therefore, Professor Sharpey-Schäfer 928 J Neurosurg Volume 127 • October 2017 Unauthenticated | Downloaded 10/06/21 02:54 PM UTC Norman M. Dott, hypothalamic craniopharyngioma surgeon FIG. 2. Dott’s research at Sharpey-Schäfer’s laboratory in the early 1920s. A: Norman Dott as part of a group of residents from the Royal Infirmary of Edinburgh in 1920–1921. Courtesy of Lothian Health Services Archive, Edinburgh University Li- brary. B: Photograph of Sir Edward Albert Sharpey-Schäfer (1850–1935), English physiologist, who is regarded as a founder of endocrinology. CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/).