Harvey Cushing's Paradigmatic Contribution to Neurosurgery and the Evolution of His Thoughts about Specialization

Bulletin of the History of Medicine

Volumn 77, Issue 4, 2003, Pages

  Greenblatt, Samuel H ^a,b  

^a Department of Clinical Neuroscience ^*  (United States)

^b BROWN UNIVERSITY   (United States)

Author keywords

Brain tumors; Harvey Cushing; History; Intracranial pressure; Neurosurgery; Paradigm; Specialization; Translational research

Indexed keywords

EID: 0348225018     PISSN: 00075140     EISSN: None     Source Type: Journal    
DOI: 10.1353/bhm.2003.0168     Document Type: Review

References (179)

1. See Samuel H. Greenblatt, "The Historiography of Neurosurgery: Organizing Themes and Methodological Issues," in A History of Neurosurgery in Its Scientific and Professional Contexts, ed. Samuel H. Greenblatt, T. Forcht Dagi, and Mel H. Epstein (Park Ridge, III.: American Association of Neurological Surgeons, 1997), pp. 3-9, on pp. 3-4+ADs- Robert H. Wilkins, ed., Neurosurgical Classics (New York: Johnson Reprint Corp., 1965+ADs- reprinted Park Ridge, III.: American Association of Neurological Surgeons, 1992), p. 15.
2. See Samuel H. Greenblatt, "The Historiography of Neurosurgery: Organizing Themes and Methodological Issues," in A History of Neurosurgery in Its Scientific and Professional Contexts, ed. Samuel H. Greenblatt, T. Forcht Dagi, and Mel H. Epstein (Park Ridge, III.: American Association of Neurological Surgeons, 1997), pp. 3-9, on pp. 3-4+ADs- Robert H. Wilkins, ed., Neurosurgical Classics (New York: Johnson Reprint Corp., 1965+ADs- reprinted Park Ridge, III.: American Association of Neurological Surgeons, 1992), p. 15.
3. See Samuel H. Greenblatt and Dale C. Smith, "The Emergence of Cushing's Leadership 1901-1920," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 167-90+ADs- Wilder Penfield, "The Passing of Harvey Cushing," Yale J. Biol. & Med., 1940, 12:323-26, on p. 325+ADs- Ernest Sachs, "The Most Important Steps in the Development of Neurological Surgery," ibid., 1955-56, 25:444-50, on p. 445.
4. See Samuel H. Greenblatt and Dale C. Smith, "The Emergence of Cushing's Leadership 1901-1920," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 167-90+ADs- Wilder Penfield, "The Passing of Harvey Cushing," Yale J. Biol. & Med., 1940, 12:323-26, on p. 325+ADs- Ernest Sachs, "The Most Important Steps in the Development of Neurological Surgery," ibid., 1955-56, 25:444-50, on p. 445.
5. See Samuel H. Greenblatt and Dale C. Smith, "The Emergence of Cushing's Leadership 1901-1920," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 167-90+ADs- Wilder Penfield, "The Passing of Harvey Cushing," Yale J. Biol. & Med., 1940, 12:323-26, on p. 325+ADs- Ernest Sachs, "The Most Important Steps in the Development of Neurological Surgery," ibid., 1955-56, 25:444-50, on p. 445.
6. See Greenblatt, "Historiography of Neurosurgery" (n. 1), pp. 3-5.
7. William Macewen, "Tumour of the Dura Mater - Convulsions - Removal of the Tumour by Trephining - Recovery," Glasgow Med. J., 1879, 12:210-13; for later citations of this and other cases by Macewen, see Samuel H. Greenblatt, "Cerebral Localization: From Theory to Practice. Paul Broca and Hughlings Jackson to David Ferrier and William Macewen," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 137-52, on p. 152. Some authors have dated the modern era of neurosurgery to the operation of Bennett and Godlee in 1884 (see n. 5 below), because that was the first time that a brain tumor operation was widely recognized by the medical and general public. Nonetheless, most historians of neurosurgery in the past half-century have recognized Macewen's contributions: see, e.g., John E. Scarff, "Fifty Years of Neurosurgery, 1905-1955," Surg. Gyn. Obstet., 1955, 101: 417-513, on pp. 418-19 (reprinted in Loyal Davis, ed., Fifty Years of Surgical Progress 1905-1955 [Chicago: Martin Memorial Foundation, 1955], pp. 303-99 on pp. 304-5) ; A. Earl Walker, The Genesis of Neuroscience (Park Ridge, III.: American Association of Neurological Surgeons, 1998, p. 257; Wilkins, Neurosurgical Classics (n. 1), p. 391. Arthur E. Lyons, "The Crucible Years 1880 to 1900: Macewen to Cushing," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 153-66, on pp. 153-57, offers a different perspective by dating the public appearance of neurological surgery to 1881, when David Ferrier "won" the famous debate with Friedrich Goltz about cerebral localization at the International Medical Congress in London.
8. William Macewen, "Tumour of the Dura Mater - Convulsions - Removal of the Tumour by Trephining - Recovery," Glasgow Med. J., 1879, 12:210-13; for later citations of this and other cases by Macewen, see Samuel H. Greenblatt, "Cerebral Localization: From Theory to Practice. Paul Broca and Hughlings Jackson to David Ferrier and William Macewen," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 137-52, on p. 152. Some authors have dated the modern era of neurosurgery to the operation of Bennett and Godlee in 1884 (see n. 5 below), because that was the first time that a brain tumor operation was widely recognized by the medical and general public. Nonetheless, most historians of neurosurgery in the past half-century have recognized Macewen's contributions: see, e.g., John E. Scarff, "Fifty Years of Neurosurgery, 1905-1955," Surg. Gyn. Obstet., 1955, 101: 417-513, on pp. 418-19 (reprinted in Loyal Davis, ed., Fifty Years of Surgical Progress 1905-1955 [Chicago: Martin Memorial Foundation, 1955], pp. 303-99 on pp. 304-5) ; A. Earl Walker, The Genesis of Neuroscience (Park Ridge, III.: American Association of Neurological Surgeons, 1998, p. 257; Wilkins, Neurosurgical Classics (n. 1), p. 391. Arthur E. Lyons, "The Crucible Years 1880 to 1900: Macewen to Cushing," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 153-66, on pp. 153-57, offers a different perspective by dating the public appearance of neurological surgery to 1881, when David Ferrier "won" the famous debate with Friedrich Goltz about cerebral localization at the International Medical Congress in London.
9. William Macewen, "Tumour of the Dura Mater - Convulsions - Removal of the Tumour by Trephining - Recovery," Glasgow Med. J., 1879, 12:210-13; for later citations of this and other cases by Macewen, see Samuel H. Greenblatt, "Cerebral Localization: From Theory to Practice. Paul Broca and Hughlings Jackson to David Ferrier and William Macewen," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 137-52, on p. 152. Some authors have dated the modern era of neurosurgery to the operation of Bennett and Godlee in 1884 (see n. 5 below), because that was the first time that a brain tumor operation was widely recognized by the medical and general public. Nonetheless, most historians of neurosurgery in the past half-century have recognized Macewen's contributions: see, e.g., John E. Scarff, "Fifty Years of Neurosurgery, 1905-1955," Surg. Gyn. Obstet., 1955, 101: 417-513, on pp. 418-19 (reprinted in Loyal Davis, ed., Fifty Years of Surgical Progress 1905-1955 [Chicago: Martin Memorial Foundation, 1955], pp. 303-99 on pp. 304-5) ; A. Earl Walker, The Genesis of Neuroscience (Park Ridge, III.: American Association of Neurological Surgeons, 1998, p. 257; Wilkins, Neurosurgical Classics (n. 1), p. 391. Arthur E. Lyons, "The Crucible Years 1880 to 1900: Macewen to Cushing," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 153-66, on pp. 153-57, offers a different perspective by dating the public appearance of neurological surgery to 1881, when David Ferrier "won" the famous debate with Friedrich Goltz about cerebral localization at the International Medical Congress in London.
10. William Macewen, "Tumour of the Dura Mater - Convulsions - Removal of the Tumour by Trephining - Recovery," Glasgow Med. J., 1879, 12:210-13; for later citations of this and other cases by Macewen, see Samuel H. Greenblatt, "Cerebral Localization: From Theory to Practice. Paul Broca and Hughlings Jackson to David Ferrier and William Macewen," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 137-52, on p. 152. Some authors have dated the modern era of neurosurgery to the operation of Bennett and Godlee in 1884 (see n. 5 below), because that was the first time that a brain tumor operation was widely recognized by the medical and general public. Nonetheless, most historians of neurosurgery in the past half-century have recognized Macewen's contributions: see, e.g., John E. Scarff, "Fifty Years of Neurosurgery, 1905-1955," Surg. Gyn. Obstet., 1955, 101: 417-513, on pp. 418-19 (reprinted in Loyal Davis, ed., Fifty Years of Surgical Progress 1905-1955 [Chicago: Martin Memorial Foundation, 1955], pp. 303-99 on pp. 304-5) ; A. Earl Walker, The Genesis of Neuroscience (Park Ridge, III.: American Association of Neurological Surgeons, 1998, p. 257; Wilkins, Neurosurgical Classics (n. 1), p. 391. Arthur E. Lyons, "The Crucible Years 1880 to 1900: Macewen to Cushing," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 153-66, on pp. 153-57, offers a different perspective by dating the public appearance of neurological surgery to 1881, when David Ferrier "won" the famous debate with Friedrich Goltz about cerebral localization at the International Medical Congress in London.
11. William Macewen, "Tumour of the Dura Mater - Convulsions - Removal of the Tumour by Trephining - Recovery," Glasgow Med. J., 1879, 12:210-13; for later citations of this and other cases by Macewen, see Samuel H. Greenblatt, "Cerebral Localization: From Theory to Practice. Paul Broca and Hughlings Jackson to David Ferrier and William Macewen," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 137-52, on p. 152. Some authors have dated the modern era of neurosurgery to the operation of Bennett and Godlee in 1884 (see n. 5 below), because that was the first time that a brain tumor operation was widely recognized by the medical and general public. Nonetheless, most historians of neurosurgery in the past half-century have recognized Macewen's contributions: see, e.g., John E. Scarff, "Fifty Years of Neurosurgery, 1905-1955," Surg. Gyn. Obstet., 1955, 101: 417-513, on pp. 418-19 (reprinted in Loyal Davis, ed., Fifty Years of Surgical Progress 1905-1955 [Chicago: Martin Memorial Foundation, 1955], pp. 303-99 on pp. 304-5) ; A. Earl Walker, The Genesis of Neuroscience (Park Ridge, III.: American Association of Neurological Surgeons, 1998, p. 257; Wilkins, Neurosurgical Classics (n. 1), p. 391. Arthur E. Lyons, "The Crucible Years 1880 to 1900: Macewen to Cushing," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 153-66, on pp. 153-57, offers a different perspective by dating the public appearance of neurological surgery to 1881, when David Ferrier "won" the famous debate with Friedrich Goltz about cerebral localization at the International Medical Congress in London.
12. William Macewen, "Tumour of the Dura Mater - Convulsions - Removal of the Tumour by Trephining - Recovery," Glasgow Med. J., 1879, 12:210-13; for later citations of this and other cases by Macewen, see Samuel H. Greenblatt, "Cerebral Localization: From Theory to Practice. Paul Broca and Hughlings Jackson to David Ferrier and William Macewen," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 137-52, on p. 152. Some authors have dated the modern era of neurosurgery to the operation of Bennett and Godlee in 1884 (see n. 5 below), because that was the first time that a brain tumor operation was widely recognized by the medical and general public. Nonetheless, most historians of neurosurgery in the past half-century have recognized Macewen's contributions: see, e.g., John E. Scarff, "Fifty Years of Neurosurgery, 1905-1955," Surg. Gyn. Obstet., 1955, 101: 417-513, on pp. 418-19 (reprinted in Loyal Davis, ed., Fifty Years of Surgical Progress 1905-1955 [Chicago: Martin Memorial Foundation, 1955], pp. 303-99 on pp. 304-5) ; A. Earl Walker, The Genesis of Neuroscience (Park Ridge, III.: American Association of Neurological Surgeons, 1998, p. 257; Wilkins, Neurosurgical Classics (n. 1), p. 391. Arthur E. Lyons, "The Crucible Years 1880 to 1900: Macewen to Cushing," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 153-66, on pp. 153-57, offers a different perspective by dating the public appearance of neurological surgery to 1881, when David Ferrier "won" the famous debate with Friedrich Goltz about cerebral localization at the International Medical Congress in London.
13. William Macewen, "Tumour of the Dura Mater - Convulsions - Removal of the Tumour by Trephining - Recovery," Glasgow Med. J., 1879, 12:210-13; for later citations of this and other cases by Macewen, see Samuel H. Greenblatt, "Cerebral Localization: From Theory to Practice. Paul Broca and Hughlings Jackson to David Ferrier and William Macewen," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 137-52, on p. 152. Some authors have dated the modern era of neurosurgery to the operation of Bennett and Godlee in 1884 (see n. 5 below), because that was the first time that a brain tumor operation was widely recognized by the medical and general public. Nonetheless, most historians of neurosurgery in the past half-century have recognized Macewen's contributions: see, e.g., John E. Scarff, "Fifty Years of Neurosurgery, 1905-1955," Surg. Gyn. Obstet., 1955, 101: 417-513, on pp. 418-19 (reprinted in Loyal Davis, ed., Fifty Years of Surgical Progress 1905-1955 [Chicago: Martin Memorial Foundation, 1955], pp. 303-99 on pp. 304-5) ; A. Earl Walker, The Genesis of Neuroscience (Park Ridge, III.: American Association of Neurological Surgeons, 1998, p. 257; Wilkins, Neurosurgical Classics (n. 1), p. 391. Arthur E. Lyons, "The Crucible Years 1880 to 1900: Macewen to Cushing," in Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), pp. 153-66, on pp. 153-57, offers a different perspective by dating the public appearance of neurological surgery to 1881, when David Ferrier "won" the famous debate with Friedrich Goltz about cerebral localization at the International Medical Congress in London.
14. The full report with discussion is in A. Hughes Bennett and Rickman J. Godlee, "Case of Cerebral Tumour," Medico-Chirurg. Trans., 1885, 68:243-75. The surgery took place on 23 November 1884, and the Lancet gave a one-paragraph report ("Excision of Tumour From the Brain") on 29 November (p. 971). There were also subsequent short progress reports in the Lancet on 26 December 1884 (p. 1017) and 3 January 1885 (p. 13, and editorial on pp. 23-24), as well as a case report under the names of Hughes Bennett and Rickman J. Godlee, "Excision of a Tumour from the Brain," Lancet, 20 December 1884, pp. 1090-91. The British Medical Journal began to discuss the case on 3 January 1885 (pp. 19, 48), and the Boston Medical and Surgical Journal (now the New England Journal of Medicine) chimed in with an editorial on 8 January 1885 (112: 41-42), titled "Vivisection or Antivivisection; Which Is the More Humane?" Vivisection was also the reason for the attention that the case received in letters to the editor of the Times of London on several dates, including 16 December 1884 (p. 5), 29 December 1884 (p. 8), 3 January 1885 (p. 10), 5 January 1885 (p. 7), and 6 January 1885 (p. 10).
15. The full report with discussion is in A. Hughes Bennett and Rickman J. Godlee, "Case of Cerebral Tumour," Medico-Chirurg. Trans., 1885, 68:243-75. The surgery took place on 23 November 1884, and the Lancet gave a one-paragraph report ("Excision of Tumour From the Brain") on 29 November (p. 971). There were also subsequent short progress reports in the Lancet on 26 December 1884 (p. 1017) and 3 January 1885 (p. 13, and editorial on pp. 23-24), as well as a case report under the names of Hughes Bennett and Rickman J. Godlee, "Excision of a Tumour from the Brain," Lancet, 20 December 1884, pp. 1090-91. The British Medical Journal began to discuss the case on 3 January 1885 (pp. 19, 48), and the Boston Medical and Surgical Journal (now the New England Journal of Medicine) chimed in with an editorial on 8 January 1885 (112: 41-42), titled "Vivisection or Antivivisection; Which Is the More Humane?" Vivisection was also the reason for the attention that the case received in letters to the editor of the Times of London on several dates, including 16 December 1884 (p. 5), 29 December 1884 (p. 8), 3 January 1885 (p. 10), 5 January 1885 (p. 7), and 6 January 1885 (p. 10).
16. The full report with discussion is in A. Hughes Bennett and Rickman J. Godlee, "Case of Cerebral Tumour," Medico-Chirurg. Trans., 1885, 68:243-75. The surgery took place on 23 November 1884, and the Lancet gave a one-paragraph report ("Excision of Tumour From the Brain") on 29 November (p. 971). There were also subsequent short progress reports in the Lancet on 26 December 1884 (p. 1017) and 3 January 1885 (p. 13, and editorial on pp. 23-24), as well as a case report under the names of Hughes Bennett and Rickman J. Godlee, "Excision of a Tumour from the Brain," Lancet, 20 December 1884, pp. 1090-91. The British Medical Journal began to discuss the case on 3 January 1885 (pp. 19, 48), and the Boston Medical and Surgical Journal (now the New England Journal of Medicine) chimed in with an editorial on 8 January 1885 (112: 41-42), titled "Vivisection or Antivivisection; Which Is the More Humane?" Vivisection was also the reason for the attention that the case received in letters to the editor of the Times of London on several dates, including 16 December 1884 (p. 5), 29 December 1884 (p. 8), 3 January 1885 (p. 10), 5 January 1885 (p. 7), and 6 January 1885 (p. 10).
17. The full report with discussion is in A. Hughes Bennett and Rickman J. Godlee, "Case of Cerebral Tumour," Medico-Chirurg. Trans., 1885, 68:243-75. The surgery took place on 23 November 1884, and the Lancet gave a one-paragraph report ("Excision of Tumour From the Brain") on 29 November (p. 971). There were also subsequent short progress reports in the Lancet on 26 December 1884 (p. 1017) and 3 January 1885 (p. 13, and editorial on pp. 23-24), as well as a case report under the names of Hughes Bennett and Rickman J. Godlee, "Excision of a Tumour from the Brain," Lancet, 20 December 1884, pp. 1090-91. The British Medical Journal began to discuss the case on 3 January 1885 (pp. 19, 48), and the Boston Medical and Surgical Journal (now the New England Journal of Medicine) chimed in with an editorial on 8 January 1885 (112: 41-42), titled "Vivisection or Antivivisection; Which Is the More Humane?" Vivisection was also the reason for the attention that the case received in letters to the editor of the Times of London on several dates, including 16 December 1884 (p. 5), 29 December 1884 (p. 8), 3 January 1885 (p. 10), 5 January 1885 (p. 7), and 6 January 1885 (p. 10).
18. The full report with discussion is in A. Hughes Bennett and Rickman J. Godlee, "Case of Cerebral Tumour," Medico-Chirurg. Trans., 1885, 68:243-75. The surgery took place on 23 November 1884, and the Lancet gave a one-paragraph report ("Excision of Tumour From the Brain") on 29 November (p. 971). There were also subsequent short progress reports in the Lancet on 26 December 1884 (p. 1017) and 3 January 1885 (p. 13, and editorial on pp. 23-24), as well as a case report under the names of Hughes Bennett and Rickman J. Godlee, "Excision of a Tumour from the Brain," Lancet, 20 December 1884, pp. 1090-91. The British Medical Journal began to discuss the case on 3 January 1885 (pp. 19, 48), and the Boston Medical and Surgical Journal (now the New England Journal of Medicine) chimed in with an editorial on 8 January 1885 (112: 41-42), titled "Vivisection or Antivivisection; Which Is the More Humane?" Vivisection was also the reason for the attention that the case received in letters to the editor of the Times of London on several dates, including 16 December 1884 (p. 5), 29 December 1884 (p. 8), 3 January 1885 (p. 10), 5 January 1885 (p. 7), and 6 January 1885 (p. 10).
19. Victor Horsley, "Brain Surgery," Brit. Med. J., 1886, 2: 670-75.
20. Scarff, "Fifty Years," in Davis, Fifty Years of Surgical Progress (n. 4), pp. 306-7.
21. See n. 14 below.
22. See Louis Bakay, Neurosurgeons of the Past (Springfield, III.: Thomas, 1987), pp. 73-83; William C. Hanigan, William Ragen, and Mary Ludgera, "Neurological Surgery in the Nineteenth Century: The Principles and Techniques of Ernst von Bergmann," Neurosurgery, 1992, 50: 750-57.
23. See Louis Bakay, Neurosurgeons of the Past (Springfield, III.: Thomas, 1987), pp. 73-83; William C. Hanigan, William Ragen, and Mary Ludgera, "Neurological Surgery in the Nineteenth Century: The Principles and Techniques of Ernst von Bergmann," Neurosurgery, 1992, 50: 750-57.
24. Ernst von Bergmann, Die Lehre von den Kopfverletzungen (Stuttgart: Ferdinand Enke, 1880).
25. Ernst von Bergmann, "Die chirurgische Behandlung von Hirngeschwulsten," in Chirurgie des Kopfes, ed. Ernst von Bergmann et al., vol. 1 of Handbuch der Praktischen Chirurgie, ed. Ernst von Bergmann, P. von Bruns, and J. von Mikulicz (Stuttgart: Ferdinand Enke, 1900), pp. 346-52. The Handbuch was translated by W. T. Bull and W. Martin as A System of Practical Surgery, vol. 1, Surgery of the Head (New York: Lea Brothers, 1904); in this translation, the section on "Surgical Treatment of Brain Tumors," pp. 317-24, omits a paragraph in the original German edition (p. 346) that gives valuable outcome data. Also, in the section on "Compression of the Brain and the Operations for Compression" (p. 189), the translation omits a long historical/introductory passage from the original (pp. 189-90).
26. Ernst von Bergmann, "Die chirurgische Behandlung von Hirngeschwulsten," in Chirurgie des Kopfes, ed. Ernst von Bergmann et al., vol. 1 of Handbuch der Praktischen Chirurgie, ed. Ernst von Bergmann, P. von Bruns, and J. von Mikulicz (Stuttgart: Ferdinand Enke, 1900), pp. 346-52. The Handbuch was translated by W. T. Bull and W. Martin as A System of Practical Surgery, vol. 1, Surgery of the Head (New York: Lea Brothers, 1904); in this translation, the section on "Surgical Treatment of Brain Tumors," pp. 317-24, omits a paragraph in the original German edition (p. 346) that gives valuable outcome data. Also, in the section on "Compression of the Brain and the Operations for Compression" (p. 189), the translation omits a long historical/introductory passage from the original (pp. 189-90).
27. Ernst von Bergmann, "Die chirurgische Behandlung von Hirngeschwulsten," in Chirurgie des Kopfes, ed. Ernst von Bergmann et al., vol. 1 of Handbuch der Praktischen Chirurgie, ed. Ernst von Bergmann, P. von Bruns, and J. von Mikulicz (Stuttgart: Ferdinand Enke, 1900), pp. 346-52. The Handbuch was translated by W. T. Bull and W. Martin as A System of Practical Surgery, vol. 1, Surgery of the Head (New York: Lea Brothers, 1904); in this translation, the section on "Surgical Treatment of Brain Tumors," pp. 317-24, omits a paragraph in the original German edition (p. 346) that gives valuable outcome data. Also, in the section on "Compression of the Brain and the Operations for Compression" (p. 189), the translation omits a long historical/introductory passage from the original (pp. 189-90).
28. Philip C. Knapp, "The Treatment of Cerebral Tumors," Boston Med. & Surg. J., 1899, 141: 333-37, 359-63, 384-87. Knapp stated that he was uncertain about the exact number of cases in his analysis, because some were probably reported more than once, and he was not always able to sort them out (p. 334). In any case, this paper is a striking example of premodern metanalysis, which we tend to think of as a phenomenon of the later twentieth century. Knapp's method of combining many cases from the literature is no different from our current practice. The major difference is in the statistical tools that are applied to the compilation; Knapp did not even use percentages very much, although Bergmann certainly did in analyzing his own cases (see n. 11).
29. These percentages are taken from Scarff's analysis of Knapp's data: Scarff, "Fifty Years" (n. 4), p. 420.
30. Harvey Cushing, "The Special Field of Neurological Surgery," Bull. Johns Hopkins Hasp., 1905, 16: 77-87, quotation on p. 78 (also printed with the same title in the Cleveland Med. J., 1905, 4: 1-25). It is important to point out some nontechnical, professional aspects of this quotation. Notice that Cushing spoke about an "operator," not a surgeon. This was a deliberate insult. Cushing would not dignify the fictional "operator" in this tragedy with the title of surgeon for two reasons, which are given later on the same page: First, he felt very strongly that the surgeon who operates on the brain should be his own neurologist, because even the most informed neurologist could not possibly understand the surgeon's intraoperative problems and the surgeon must therefore solve those problems for himself. Second, the surgeon is likely to find those solutions only if he devotes a large portion of his time and energy to intracranial surgery, which is exactly what Cushing was doing at the time.
31. Harvey Cushing, "The Special Field of Neurological Surgery," Bull. Johns Hopkins Hasp., 1905, 16: 77-87, quotation on p. 78 (also printed with the same title in the Cleveland Med. J., 1905, 4: 1-25). It is important to point out some nontechnical, professional aspects of this quotation. Notice that Cushing spoke about an "operator," not a surgeon. This was a deliberate insult. Cushing would not dignify the fictional "operator" in this tragedy with the title of surgeon for two reasons, which are given later on the same page: First, he felt very strongly that the surgeon who operates on the brain should be his own neurologist, because even the most informed neurologist could not possibly understand the surgeon's intraoperative problems and the surgeon must therefore solve those problems for himself. Second, the surgeon is likely to find those solutions only if he devotes a large portion of his time and energy to intracranial surgery, which is exactly what Cushing was doing at the time.
32. John F. Fulton, Harvey Cushing: A Biography (Springfield, III.: Thomas, 1946), p. 262.
33. Ibid., p. 162.
34. Fulton (ibid.) does not mention anything about this possibility. My own review of Cushing's letters to his father in the Cushing archives at Yale University has not revealed anything on this subject around the time when Cushing would have been planning his trip, or during its early stages.
35. Fulton, Harvey Cushing (n. 15), pp. 176-84, 190-93, describes Cushing's time in Bern in some detail. For the most extensive available discussion of the relationship between Cushing and Kocher (and also between Halsted and Kocher), see Ira M. Rutkow, "Theodor Kocher and His Relationship with the American Surgeons Harvey Cushing and William Halsted," in Theodor Kocher 1841-1917: Beiträge zur Würdigung von Leben und Werk, ed. Urs Boschung (Bern: Hans Huber, 1991), pp. 41-51.
36. Fulton, Harvey Cushing (n. 15), pp. 176-84, 190-93, describes Cushing's time in Bern in some detail. For the most extensive available discussion of the relationship between Cushing and Kocher (and also between Halsted and Kocher), see Ira M. Rutkow, "Theodor Kocher and His Relationship with the American Surgeons Harvey Cushing and William Halsted," in Theodor Kocher 1841-1917: Beiträge zur Würdigung von Leben und Werk, ed. Urs Boschung (Bern: Hans Huber, 1991), pp. 41-51.
37. See Theodor Kocher, "Chirurgische Beiträge zur Physiologie des Gehirns und Rückenmarks," Deutsche Zeitschrift für Chirurgie, 1893, 35: 433-94, and 36: 1-93; idem, Hirnerschütterung, Hirndruck und chirurgische Eingriffe bei Hirnkranheiten, in Specielle Pathologie und Therapie, ed. H. Nothnagel, vol. 9, part 3 (Vienna: A. Holder, 1901).
38. See Theodor Kocher, "Chirurgische Beiträge zur Physiologie des Gehirns und Rückenmarks," Deutsche Zeitschrift für Chirurgie, 1893, 35: 433-94, and 36: 1-93; idem, Hirnerschütterung, Hirndruck und chirurgische Eingriffe bei Hirnkranheiten, in Specielle Pathologie und Therapie, ed. H. Nothnagel, vol. 9, part 3 (Vienna: A. Holder, 1901).
39. See Theodor Kocher, "Chirurgische Beiträge zur Physiologie des Gehirns und Rückenmarks," Deutsche Zeitschrift für Chirurgie, 1893, 35: 433-94, and 36: 1-93; idem, Hirnerschütterung, Hirndruck und chirurgische Eingriffe bei Hirnkranheiten, in Specielle Pathologie und Therapie, ed. H. Nothnagel, vol. 9, part 3 (Vienna: A. Holder, 1901).
40. See Ernst von Bergmann, "Der Hirndruck und die Operationen wegen Hirndruck," in Bergmann et al., Chirurgie des Kopfes (n. 11), pp. 189-208 (translated in Bergmann et al., Surgery of the Head [n. 11], pp. 189-205); and Kocher, Hirnerschütterung (n. 19), pp. 189-201. For Cushing's listing of the many European investigators who were interested in ICP, see Harvey Cushing, "Some Experimental and Clinical Observations Concerning States of Increased Intracranial Tension. The Mütter Lecture for 1901," Amer. J. Med. Sci., 1902, 124: 375-400, on pp. 375-76.
41. See Ernst von Bergmann, "Der Hirndruck und die Operationen wegen Hirndruck," in Bergmann et al., Chirurgie des Kopfes (n. 11), pp. 189-208 (translated in Bergmann et al., Surgery of the Head [n. 11], pp. 189-205); and Kocher, Hirnerschütterung (n. 19), pp. 189-201. For Cushing's listing of the many European investigators who were interested in ICP, see Harvey Cushing, "Some Experimental and Clinical Observations Concerning States of Increased Intracranial Tension. The Mütter Lecture for 1901," Amer. J. Med. Sci., 1902, 124: 375-400, on pp. 375-76.
42. See Ernst von Bergmann, "Der Hirndruck und die Operationen wegen Hirndruck," in Bergmann et al., Chirurgie des Kopfes (n. 11), pp. 189-208 (translated in Bergmann et al., Surgery of the Head [n. 11], pp. 189-205); and Kocher, Hirnerschütterung (n. 19), pp. 189-201. For Cushing's listing of the many European investigators who were interested in ICP, see Harvey Cushing, "Some Experimental and Clinical Observations Concerning States of Increased Intracranial Tension. The Mütter Lecture for 1901," Amer. J. Med. Sci., 1902, 124: 375-400, on pp. 375-76.
43. See Ernst von Bergmann, "Der Hirndruck und die Operationen wegen Hirndruck," in Bergmann et al., Chirurgie des Kopfes (n. 11), pp. 189-208 (translated in Bergmann et al., Surgery of the Head [n. 11], pp. 189-205); and Kocher, Hirnerschütterung (n. 19), pp. 189-201. For Cushing's listing of the many European investigators who were interested in ICP, see Harvey Cushing, "Some Experimental and Clinical Observations Concerning States of Increased Intracranial Tension. The Mütter Lecture for 1901," Amer. J. Med. Sci., 1902, 124: 375-400, on pp. 375-76.
44. Cushing, "Mütter Lecture" (n. 20), pp. 375-400. See also Fulton, Harvey Cushing (n. 15), pp. 190, 212-16. Michael Bliss (personal communication) has pointed out that Cushing's mind was well prepared to see the potential in the Riva-Rocci apparatus. When Cushing was a resident at Johns Hopkins, he took an interest in the problem of shock, which was a major surgical conundrum of the time. In March 1900, before he left for Europe, he published a review of George W. Crile, An Experimental Research into Surgical Shock (Philadelphia: Lippincott, 1899), in the Johns Hopkins Hasp. Bull., 1900, 11: 73-74, at the end of which he said; "It is to be hoped... that mercurial manometers, constructed so as to be applied to the extremities, may be employed in surgical operating-rooms for the purpose of recording vasomotor effects and changes in blood pressure, and to indicate impending shock more definitely than at present is possible through the medium of the anaesthetizer's finger on a peripheral artery." For a thorough review of the clinical and scientific status of studies on shock ca. 1900, see Peter C. English, Shock, Physiological Surgery, and George Washington Crile: Medical Innovation in the Progressive Era (Westport, Conn.: Greenwood Press, 1980), pp. 3-120.
45. Cushing, "Mütter Lecture" (n. 20), pp. 375-400. See also Fulton, Harvey Cushing (n. 15), pp. 190, 212-16. Michael Bliss (personal communication) has pointed out that Cushing's mind was well prepared to see the potential in the Riva-Rocci apparatus. When Cushing was a resident at Johns Hopkins, he took an interest in the problem of shock, which was a major surgical conundrum of the time. In March 1900, before he left for Europe, he published a review of George W. Crile, An Experimental Research into Surgical Shock (Philadelphia: Lippincott, 1899), in the Johns Hopkins Hasp. Bull., 1900, 11: 73-74, at the end of which he said; "It is to be hoped... that mercurial manometers, constructed so as to be applied to the extremities, may be employed in surgical operating-rooms for the purpose of recording vasomotor effects and changes in blood pressure, and to indicate impending shock more definitely than at present is possible through the medium of the anaesthetizer's finger on a peripheral artery." For a thorough review of the clinical and scientific status of studies on shock ca. 1900, see Peter C. English, Shock, Physiological Surgery, and George Washington Crile: Medical Innovation in the Progressive Era (Westport, Conn.: Greenwood Press, 1980), pp. 3-120.
46. Cushing, "Mütter Lecture" (n. 20), pp. 375-400. See also Fulton, Harvey Cushing (n. 15), pp. 190, 212-16. Michael Bliss (personal communication) has pointed out that Cushing's mind was well prepared to see the potential in the Riva-Rocci apparatus. When Cushing was a resident at Johns Hopkins, he took an interest in the problem of shock, which was a major surgical conundrum of the time. In March 1900, before he left for Europe, he published a review of George W. Crile, An Experimental Research into Surgical Shock (Philadelphia: Lippincott, 1899), in the Johns Hopkins Hasp. Bull., 1900, 11: 73-74, at the end of which he said; "It is to be hoped... that mercurial manometers, constructed so as to be applied to the extremities, may be employed in surgical operating-rooms for the purpose of recording vasomotor effects and changes in blood pressure, and to indicate impending shock more definitely than at present is possible through the medium of the anaesthetizer's finger on a peripheral artery." For a thorough review of the clinical and scientific status of studies on shock ca. 1900, see Peter C. English, Shock, Physiological Surgery, and George Washington Crile: Medical Innovation in the Progressive Era (Westport, Conn.: Greenwood Press, 1980), pp. 3-120.
47. Cushing, "Mütter Lecture" (n. 20), pp. 375-400. See also Fulton, Harvey Cushing (n. 15), pp. 190, 212-16. Michael Bliss (personal communication) has pointed out that Cushing's mind was well prepared to see the potential in the Riva-Rocci apparatus. When Cushing was a resident at Johns Hopkins, he took an interest in the problem of shock, which was a major surgical conundrum of the time. In March 1900, before he left for Europe, he published a review of George W. Crile, An Experimental Research into Surgical Shock (Philadelphia: Lippincott, 1899), in the Johns Hopkins Hasp. Bull., 1900, 11: 73-74, at the end of which he said; "It is to be hoped... that mercurial manometers, constructed so as to be applied to the extremities, may be employed in surgical operating-rooms for the purpose of recording vasomotor effects and changes in blood pressure, and to indicate impending shock more definitely than at present is possible through the medium of the anaesthetizer's finger on a peripheral artery." For a thorough review of the clinical and scientific status of studies on shock ca. 1900, see Peter C. English, Shock, Physiological Surgery, and George Washington Crile: Medical Innovation in the Progressive Era (Westport, Conn.: Greenwood Press, 1980), pp. 3-120.
48. Harvey Cushing, "Concerning a Definite Regulatory Mechanism of the Vasomotor Centre Which Controls Blood Pressure During Cerebral Compression," Bull. Johns Hopkins Hasp., 1901, 12; 290-92; idem, "Physiologische und anatomische Beobachtungen über den Einfluss von Hirnkompression auf den intracraniellen Kreislauf und über einige hiermit verwandte Erscheinungen," Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie, 1902, 9:773-808; idem, "Mütter Lecture" (n. 20), pp. 375-400. With regard to brain shifts and herniation, it should be noted that Cushing did not know about transtentorial herniation of the medial temporal lobe medially across the incisural notch and into the midbrain, which was described in the 1920s (see Samuel H. Greenblatt, ''The Crucial Decade: Modern Neurosurgery's Definitive Development in Harvey Cushing's Early Research and Practice, 1900-1910," J. Neurosurg., 1997, 87:964-71, on p. 966). Transtentorial herniation is actually the more common clinical phenomenon, but Cushing's experimental animals may have generally suffered transforaminal herniation through the foramen magnum, as he said, because the artificial masses were mostly placed centrally, near the vertex of the skull.
49. Harvey Cushing, "Concerning a Definite Regulatory Mechanism of the Vasomotor Centre Which Controls Blood Pressure During Cerebral Compression," Bull. Johns Hopkins Hasp., 1901, 12; 290-92; idem, "Physiologische und anatomische Beobachtungen über den Einfluss von Hirnkompression auf den intracraniellen Kreislauf und über einige hiermit verwandte Erscheinungen," Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie, 1902, 9:773-808; idem, "Mütter Lecture" (n. 20), pp. 375-400. With regard to brain shifts and herniation, it should be noted that Cushing did not know about transtentorial herniation of the medial temporal lobe medially across the incisural notch and into the midbrain, which was described in the 1920s (see Samuel H. Greenblatt, ''The Crucial Decade: Modern Neurosurgery's Definitive Development in Harvey Cushing's Early Research and Practice, 1900-1910," J. Neurosurg., 1997, 87:964-71, on p. 966). Transtentorial herniation is actually the more common clinical phenomenon, but Cushing's experimental animals may have generally suffered transforaminal herniation through the foramen magnum, as he said, because the artificial masses were mostly placed centrally, near the vertex of the skull.
50. Harvey Cushing, "Concerning a Definite Regulatory Mechanism of the Vasomotor Centre Which Controls Blood Pressure During Cerebral Compression," Bull. Johns Hopkins Hasp., 1901, 12; 290-92; idem, "Physiologische und anatomische Beobachtungen über den Einfluss von Hirnkompression auf den intracraniellen Kreislauf und über einige hiermit verwandte Erscheinungen," Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie, 1902, 9:773-808; idem, "Mütter Lecture" (n. 20), pp. 375-400. With regard to brain shifts and herniation, it should be noted that Cushing did not know about transtentorial herniation of the medial temporal lobe medially across the incisural notch and into the midbrain, which was described in the 1920s (see Samuel H. Greenblatt, ''The Crucial Decade: Modern Neurosurgery's Definitive Development in Harvey Cushing's Early Research and Practice, 1900-1910," J. Neurosurg., 1997, 87:964-71, on p. 966). Transtentorial herniation is actually the more common clinical phenomenon, but Cushing's experimental animals may have generally suffered transforaminal herniation through the foramen magnum, as he said, because the artificial masses were mostly placed centrally, near the vertex of the skull.
51. Harvey Cushing, "Concerning a Definite Regulatory Mechanism of the Vasomotor Centre Which Controls Blood Pressure During Cerebral Compression," Bull. Johns Hopkins Hasp., 1901, 12; 290-92; idem, "Physiologische und anatomische Beobachtungen über den Einfluss von Hirnkompression auf den intracraniellen Kreislauf und über einige hiermit verwandte Erscheinungen," Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie, 1902, 9:773-808; idem, "Mütter Lecture" (n. 20), pp. 375-400. With regard to brain shifts and herniation, it should be noted that Cushing did not know about transtentorial herniation of the medial temporal lobe medially across the incisural notch and into the midbrain, which was described in the 1920s (see Samuel H. Greenblatt, ''The Crucial Decade: Modern Neurosurgery's Definitive Development in Harvey Cushing's Early Research and Practice, 1900-1910," J. Neurosurg., 1997, 87:964-71, on p. 966). Transtentorial herniation is actually the more common clinical phenomenon, but Cushing's experimental animals may have generally suffered transforaminal herniation through the foramen magnum, as he said, because the artificial masses were mostly placed centrally, near the vertex of the skull.
52. Fulton, Harvey Cushing (n. 15), p. 187. See also Cushing, "Definite Regulatory Mechanism" (n. 22), p. 291.
53. Fulton, Harvey Cushing (n. 15), p. 187. See also Cushing, "Definite Regulatory Mechanism" (n. 22), p. 291.
54. For references to Cushing's work in Turin, see the same papers as in n. 22. In the "Mütter Lecture" (n. 20), p. 386, Cushing made a prescient qualitative statement of the current formulation of cerebral perfusion pressure (CPP), which is equal to the mean arterial blood pressure minus the ICP. For safety in our current clinical practice, we prefer to keep that figure at a positive 50-60 mmHg or more. Cushing was saying, in effect, that a smaller positive number is not associated with dire consequences in his experimental animals, but at the time he had no safe way to measure ICP in humans; see text and n. 41.
55. Fulton, Harvey Cushing (n. 15), p. 188.
56. Cushing, "Definite Regulatory Mechanism" (n. 22), p. 290. Fulton, Harvey Cushing (n. 15), p. 187 n. 6, discusses Cushing's apparent reason for sending this paper urgently to his home Bulletin and his temerity about another publication that never existed. He also discusses (pp. 191-93) the clash between Cushing's American self-assurance (Selbständigkeit) and the niceties of publishing in the continental professorial system.
57. Cushing, "Definite Regulatory Mechanism" (n. 22), p. 290. Fulton, Harvey Cushing (n. 15), p. 187 n. 6, discusses Cushing's apparent reason for sending this paper urgently to his home Bulletin and his temerity about another publication that never existed. He also discusses (pp. 191-93) the clash between Cushing's American self-assurance (Selbständigkeit) and the niceties of publishing in the continental professorial system.
58. Cushing, "Definite Regulatory Mechanism" (n. 22), p. 292 (emphasis in original). For a summary and assessment of this paper, see Bakay, Neurosurgeons (n. 9), pp. 80-83. In comparison to the older contributions of Bergmann and others, Bakay credits Cushing with (1) redemonstrating the phenomenon of the Cushing reflex by elegantly clear experiments, and (2) giving the correct interpretation of the reflex. I now suspect that neurosurgeons call it the "Cushing reflex" because he was the first to demonstrate the clinical utility of the phenomenon: it can be used as an indirect way to monitor ICP.
59. Cushing, "Definite Regulatory Mechanism" (n. 22), p. 292 (emphasis in original). For a summary and assessment of this paper, see Bakay, Neurosurgeons (n. 9), pp. 80-83. In comparison to the older contributions of Bergmann and others, Bakay credits Cushing with (1) redemonstrating the phenomenon of the Cushing reflex by elegantly clear experiments, and (2) giving the correct interpretation of the reflex. I now suspect that neurosurgeons call it the "Cushing reflex" because he was the first to demonstrate the clinical utility of the phenomenon: it can be used as an indirect way to monitor ICP.
60. The fact that the vasomotor idea was still alive in Cushing's time is easily established by the fact of his reference to it in the above quotation. However, finding explications of it to cite from the literature of the time has been one of the most vexing problems in my work on this paper. The theory goes back to the discovery of the vasomotor nerves by Charcot, and especially by Brown-Séquard, in the 1850s: see Yves Laporte, "Brown-Séquard and the Discovery of the Vasoconstrictor Nerves," J. Hist. Neurosci., 1996, 5: 21-25. In the late nineteenth century, physiologists were quite interested in the control of cerebral (and systemic) blood flow: see Edwin Clarke and C. D. O'Malley, The Human Brain and Spinal Cord: A Historical Study Illustrated by Writings from Antiquity to the Twentieth Century, 2d ed. (San Francisco: Norman, 1996), pp. 793-807. Largely because of the experimental difficulties of investigating the intracranial vasomotor system, some investigators began to deny the existence of the vasomotor nerves: see Leonard Hill, The Physiology and Pathology of the Cerebral Circulation: An Experimental Research (London: Churchill, 1896), pp. 76-77. Bergmann in 1900 ("Der Hirndruck und die Operationen wegen Hirndruck" [n. 20], pp. 189-208) touched on the function of the vasomotor center, but he said nothing directly about the role of the intracranial vasomotor nerves. For an overview of the field from the relatively neutral shores of America (where no research was being done), see W. T. Porter, "The Innervation of the Blood-Vessels," in An American Text-Book of Physiology, 2d ed., ed. William H. Howell, vol. 1 (Philadelphia: Saunders, 1903), pp. 192-210, esp. pp. 198-99. The exact location and physiological properties of the vasomotor receptor cells in the lower medulla are still subjects of uncertainty and ongoing investigation; the vasomotor center is not simply coextensive with the vagal nucleus (Anthony Marmarou, personal communication).
61. The fact that the vasomotor idea was still alive in Cushing's time is easily established by the fact of his reference to it in the above quotation. However, finding explications of it to cite from the literature of the time has been one of the most vexing problems in my work on this paper. The theory goes back to the discovery of the vasomotor nerves by Charcot, and especially by Brown-Séquard, in the 1850s: see Yves Laporte, "Brown-Séquard and the Discovery of the Vasoconstrictor Nerves," J. Hist. Neurosci., 1996, 5: 21-25. In the late nineteenth century, physiologists were quite interested in the control of cerebral (and systemic) blood flow: see Edwin Clarke and C. D. O'Malley, The Human Brain and Spinal Cord: A Historical Study Illustrated by Writings from Antiquity to the Twentieth Century, 2d ed. (San Francisco: Norman, 1996), pp. 793-807. Largely because of the experimental difficulties of investigating the intracranial vasomotor system, some investigators began to deny the existence of the vasomotor nerves: see Leonard Hill, The Physiology and Pathology of the Cerebral Circulation: An Experimental Research (London: Churchill, 1896), pp. 76-77. Bergmann in 1900 ("Der Hirndruck und die Operationen wegen Hirndruck" [n. 20], pp. 189-208) touched on the function of the vasomotor center, but he said nothing directly about the role of the intracranial vasomotor nerves. For an overview of the field from the relatively neutral shores of America (where no research was being done), see W. T. Porter, "The Innervation of the Blood-Vessels," in An American Text-Book of Physiology, 2d ed., ed. William H. Howell, vol. 1 (Philadelphia: Saunders, 1903), pp. 192-210, esp. pp. 198-99. The exact location and physiological properties of the vasomotor receptor cells in the lower medulla are still subjects of uncertainty and ongoing investigation; the vasomotor center is not simply coextensive with the vagal nucleus (Anthony Marmarou, personal communication).
62. The fact that the vasomotor idea was still alive in Cushing's time is easily established by the fact of his reference to it in the above quotation. However, finding explications of it to cite from the literature of the time has been one of the most vexing problems in my work on this paper. The theory goes back to the discovery of the vasomotor nerves by Charcot, and especially by Brown-Séquard, in the 1850s: see Yves Laporte, "Brown-Séquard and the Discovery of the Vasoconstrictor Nerves," J. Hist. Neurosci., 1996, 5: 21-25. In the late nineteenth century, physiologists were quite interested in the control of cerebral (and systemic) blood flow: see Edwin Clarke and C. D. O'Malley, The Human Brain and Spinal Cord: A Historical Study Illustrated by Writings from Antiquity to the Twentieth Century, 2d ed. (San Francisco: Norman, 1996), pp. 793-807. Largely because of the experimental difficulties of investigating the intracranial vasomotor system, some investigators began to deny the existence of the vasomotor nerves: see Leonard Hill, The Physiology and Pathology of the Cerebral Circulation: An Experimental Research (London: Churchill, 1896), pp. 76-77. Bergmann in 1900 ("Der Hirndruck und die Operationen wegen Hirndruck" [n. 20], pp. 189-208) touched on the function of the vasomotor center, but he said nothing directly about the role of the intracranial vasomotor nerves. For an overview of the field from the relatively neutral shores of America (where no research was being done), see W. T. Porter, "The Innervation of the Blood-Vessels," in An American Text-Book of Physiology, 2d ed., ed. William H. Howell, vol. 1 (Philadelphia: Saunders, 1903), pp. 192-210, esp. pp. 198-99. The exact location and physiological properties of the vasomotor receptor cells in the lower medulla are still subjects of uncertainty and ongoing investigation; the vasomotor center is not simply coextensive with the vagal nucleus (Anthony Marmarou, personal communication).
63. The fact that the vasomotor idea was still alive in Cushing's time is easily established by the fact of his reference to it in the above quotation. However, finding explications of it to cite from the literature of the time has been one of the most vexing problems in my work on this paper. The theory goes back to the discovery of the vasomotor nerves by Charcot, and especially by Brown-Séquard, in the 1850s: see Yves Laporte, "Brown-Séquard and the Discovery of the Vasoconstrictor Nerves," J. Hist. Neurosci., 1996, 5: 21-25. In the late nineteenth century, physiologists were quite interested in the control of cerebral (and systemic) blood flow: see Edwin Clarke and C. D. O'Malley, The Human Brain and Spinal Cord: A Historical Study Illustrated by Writings from Antiquity to the Twentieth Century, 2d ed. (San Francisco: Norman, 1996), pp. 793-807. Largely because of the experimental difficulties of investigating the intracranial vasomotor system, some investigators began to deny the existence of the vasomotor nerves: see Leonard Hill, The Physiology and Pathology of the Cerebral Circulation: An Experimental Research (London: Churchill, 1896), pp. 76-77. Bergmann in 1900 ("Der Hirndruck und die Operationen wegen Hirndruck" [n. 20], pp. 189-208) touched on the function of the vasomotor center, but he said nothing directly about the role of the intracranial vasomotor nerves. For an overview of the field from the relatively neutral shores of America (where no research was being done), see W. T. Porter, "The Innervation of the Blood-Vessels," in An American Text-Book of Physiology, 2d ed., ed. William H. Howell, vol. 1 (Philadelphia: Saunders, 1903), pp. 192-210, esp. pp. 198-99. The exact location and physiological properties of the vasomotor receptor cells in the lower medulla are still subjects of uncertainty and ongoing investigation; the vasomotor center is not simply coextensive with the vagal nucleus (Anthony Marmarou, personal communication).
64. The fact that the vasomotor idea was still alive in Cushing's time is easily established by the fact of his reference to it in the above quotation. However, finding explications of it to cite from the literature of the time has been one of the most vexing problems in my work on this paper. The theory goes back to the discovery of the vasomotor nerves by Charcot, and especially by Brown-Séquard, in the 1850s: see Yves Laporte, "Brown-Séquard and the Discovery of the Vasoconstrictor Nerves," J. Hist. Neurosci., 1996, 5: 21-25. In the late nineteenth century, physiologists were quite interested in the control of cerebral (and systemic) blood flow: see Edwin Clarke and C. D. O'Malley, The Human Brain and Spinal Cord: A Historical Study Illustrated by Writings from Antiquity to the Twentieth Century, 2d ed. (San Francisco: Norman, 1996), pp. 793-807. Largely because of the experimental difficulties of investigating the intracranial vasomotor system, some investigators began to deny the existence of the vasomotor nerves: see Leonard Hill, The Physiology and Pathology of the Cerebral Circulation: An Experimental Research (London: Churchill, 1896), pp. 76-77. Bergmann in 1900 ("Der Hirndruck und die Operationen wegen Hirndruck" [n. 20], pp. 189-208) touched on the function of the vasomotor center, but he said nothing directly about the role of the intracranial vasomotor nerves. For an overview of the field from the relatively neutral shores of America (where no research was being done), see W. T. Porter, "The Innervation of the Blood-Vessels," in An American Text-Book of Physiology, 2d ed., ed. William H. Howell, vol. 1 (Philadelphia: Saunders, 1903), pp. 192-210, esp. pp. 198-99. The exact location and physiological properties of the vasomotor receptor cells in the lower medulla are still subjects of uncertainty and ongoing investigation; the vasomotor center is not simply coextensive with the vagal nucleus (Anthony Marmarou, personal communication).
65. The idea of physiological exhaustion probably came from nineteenth-century concepts of the conservation of energy. In the case of vasomotor collapse, the older concept was very close to our current ideas about loss of cerebrovascular auioregulation, especially in aneurysmal and traumatic subarachnoid hemorrhage. Cushing was on the cusp of the newer idea when in 1902 he wrote about "the collapse of the vasomotor regulatory mechanism" ("Mütter Lecture" [n. 20], p. 394).
66. See Greenblatt, "Crucial Decade" (n. 22), p. 965; G. C. Roman, "Cerebral Congestion: A Vanished Disease," Arch. Neural., 1987, 44:444-48.
67. See Greenblatt, "Crucial Decade" (n. 22), p. 965; G. C. Roman, "Cerebral Congestion: A Vanished Disease," Arch. Neural., 1987, 44:444-48.
68. See Cushing, "Mütter Lecture" (n. 20), p. 381 n. 1. The first sentence of this footnoted summary of Bergmann's ideas begins: "According to the most recent view of v. Bergmann, if we interpret it correctly (italics added).
69. Walter E. Dandy and Kenneth D. Blackfan, "An Experimental and Clinical Study of Internal Hydrocephalus,"JAMA 1913, 61: 2216-17. See also Clarke and O'Malley, Human Brain (n. 28), pp. 744-49; Wilkins, Neurosurgical Classics (n. 1), pp. 69-118.
70. Walter E. Dandy and Kenneth D. Blackfan, "An Experimental and Clinical Study of Internal Hydrocephalus,"JAMA 1913, 61: 2216-17. See also Clarke and O'Malley, Human Brain (n. 28), pp. 744-49; Wilkins, Neurosurgical Classics (n. 1), pp. 69-118.
71. Walter E. Dandy and Kenneth D. Blackfan, "An Experimental and Clinical Study of Internal Hydrocephalus,"JAMA 1913, 61: 2216-17. See also Clarke and O'Malley, Human Brain (n. 28), pp. 744-49; Wilkins, Neurosurgical Classics (n. 1), pp. 69-118.
72. See quotation above at n. 26.
73. Nils Lundberg, "Continuous Recording and Control of Ventricular Fluid Pressure in Neurosurgical Practice," Acta Psychiatrica et Neurologica Scandinavica, 1960, 36: Suppl. 149.
74. Obviously, removal of the mass is better if it is feasible without major damage to the brain.
75. Fulton, Harvey Cushing (n. 15), pp. 190-91.
76. Cushing, "Physiologische und anatomische Beobachtungen" (n. 22). See also n. 26 above.
77. Kocher, Hirnerschütterung (n. 19).
78. Cushing, "Mütter Lecture" (n. 20), p. 375.
79. The most complete report of his experimental results was given in Cushing, "Physiologische und anatomische Beobachtungen" (n. 22).
80. Cushing, "Mütter Lecture" (n. 20), p. 396. Harvey Cushing Society, A Bibliography of the Writings of Harvey Cushing, 3d ed. (Park Ridge, III.: American Association of Neurological Surgeons, 1993), p. 24, states that the Mütter Lecture contained Cushing's "first reference to blood-pressure determinations," which he pioneered in America, His complete description of the instrument and its use was given in a presentation at the Boston Medical Library on 19 January 1903 and published as Harvey Cushing, "On Routine Determinations of Arterial Tension in Operating Room and Clinic," Boston Med. & Surg. J., 1903, 148: 250-56. Further details about the subsequent career of Cushing's imported innovation are given in Bibliography (n. 41 ), pp. 24-25, and especially in Fulton, Harvey Cushing (n. 15), pp. 212-16.
81. Cushing, "Mütter Lecture" (n. 20), p. 396. Harvey Cushing Society, A Bibliography of the Writings of Harvey Cushing, 3d ed. (Park Ridge, III.: American Association of Neurological Surgeons, 1993), p. 24, states that the Mütter Lecture contained Cushing's "first reference to blood-pressure determinations," which he pioneered in America, His complete description of the instrument and its use was given in a presentation at the Boston Medical Library on 19 January 1903 and published as Harvey Cushing, "On Routine Determinations of Arterial Tension in Operating Room and Clinic," Boston Med. & Surg. J., 1903, 148: 250-56. Further details about the subsequent career of Cushing's imported innovation are given in Bibliography (n. 41 ), pp. 24-25, and especially in Fulton, Harvey Cushing (n. 15), pp. 212-16.
82. Cushing, "Mütter Lecture" (n. 20), p. 396. Harvey Cushing Society, A Bibliography of the Writings of Harvey Cushing, 3d ed. (Park Ridge, III.: American Association of Neurological Surgeons, 1993), p. 24, states that the Mütter Lecture contained Cushing's "first reference to blood-pressure determinations," which he pioneered in America, His complete description of the instrument and its use was given in a presentation at the Boston Medical Library on 19 January 1903 and published as Harvey Cushing, "On Routine Determinations of Arterial Tension in Operating Room and Clinic," Boston Med. & Surg. J., 1903, 148: 250-56. Further details about the subsequent career of Cushing's imported innovation are given in Bibliography (n. 41 ), pp. 24-25, and especially in Fulton, Harvey Cushing (n. 15), pp. 212-16.
83. Cushing, "Mütter Lecture" (n. 20), p. 396. Harvey Cushing Society, A Bibliography of the Writings of Harvey Cushing, 3d ed. (Park Ridge, III.: American Association of Neurological Surgeons, 1993), p. 24, states that the Mütter Lecture contained Cushing's "first reference to blood-pressure determinations," which he pioneered in America, His complete description of the instrument and its use was given in a presentation at the Boston Medical Library on 19 January 1903 and published as Harvey Cushing, "On Routine Determinations of Arterial Tension in Operating Room and Clinic," Boston Med. & Surg. J., 1903, 148: 250-56. Further details about the subsequent career of Cushing's imported innovation are given in Bibliography (n. 41 ), pp. 24-25, and especially in Fulton, Harvey Cushing (n. 15), pp. 212-16.
84. Cushing, "Mütter Lecture" (n. 20), p. 396. Harvey Cushing Society, A Bibliography of the Writings of Harvey Cushing, 3d ed. (Park Ridge, III.: American Association of Neurological Surgeons, 1993), p. 24, states that the Mütter Lecture contained Cushing's "first reference to blood-pressure determinations," which he pioneered in America, His complete description of the instrument and its use was given in a presentation at the Boston Medical Library on 19 January 1903 and published as Harvey Cushing, "On Routine Determinations of Arterial Tension in Operating Room and Clinic," Boston Med. & Surg. J., 1903, 148: 250-56. Further details about the subsequent career of Cushing's imported innovation are given in Bibliography (n. 41 ), pp. 24-25, and especially in Fulton, Harvey Cushing (n. 15), pp. 212-16.
85. Fulton, Harvey Cushing (n. 15), pp. 93-97.
86. Harvey Cushing, "The Blood Pressure Reaction of Acute Cerebral Compression, Illustrated by Cases of Intracranial Hemorrhage: A Sequel to the Mütter Lecture for 1901," Amer. J. Med. Sci., 1903, 125: 1017-44.
87. Ibid., p. 1018.
88. Our current standard method of monitoring ICP measures intraventricular pressure via a catheter in the frontal horn of either lateral ventricle, usually on the right. This is anatomically supratentorial (rostral to the incisural notch that surrounds the midbrain), so it is largely an early warning system for transtentorial herniation, which Cushing did not know about (see n. 22). In truth, we still do not have a safe and reliable way of recording ICP from the posterior fossa in humans, where the medulla is located. Nonetheless, the combination of monitoring supratentorial ICP and the ready availability of computerized imaging generally allows us to begin corrective action long before rising ICP drives the blood pressure to the precariously high levels that Cushing was encountering.
89. Kocher, Hirnerschütterung (n. 19), pp. 186-89, 197-201. Bergmann, in "Der Hirndruck" (n. 20), pp. 194-96, also proposed a less detailed staging scheme, based partly on his own work and partly on that of others.
90. Kocher, Hirnerschütterung (n. 19), pp. 186-89, 197-201. Bergmann, in "Der Hirndruck" (n. 20), pp. 194-96, also proposed a less detailed staging scheme, based partly on his own work and partly on that of others.
91. Cushing, "Mütter Sequel" (n. 43), pp. 1019-22. The fact that Kocher (Hirnerschütterung [n. 19]) postulated four pathophysiological stages (pp. 186-89) and three clinical stages (pp. 197-201) can be confusing. In this "Mütter Sequel," Cushing is clearly referring to the pathophysiological stages, because he gives the German names for them.
92. Cushing, "Mütter Sequel" (n. 43), pp. 1019-22. The fact that Kocher (Hirnerschütterung [n. 19]) postulated four pathophysiological stages (pp. 186-89) and three clinical stages (pp. 197-201) can be confusing. In this "Mütter Sequel," Cushing is clearly referring to the pathophysiological stages, because he gives the German names for them.
93. Cushing, "Mütter Sequel" (n. 43), p. 1022.
94. In his publications of this period, Cushing generally used the term "fracture of the base" to refer to both epidural and subdural hematomas, presumably because he associated both types of intracranial/extra-axial hemorrhages with basal skull fractures: see Cushing, "Mütter Lecture" (n. 20), p. 392, and "Mütter Sequel" (n. 43), pp. 1024, 1027. We still observe the frequent correlation between temporal bone fractures (more often squamous than basal) and epidural hematomas, but many acute subdural hematomas are not necessarily associated with skull fractures.
95. In his publications of this period, Cushing generally used the term "fracture of the base" to refer to both epidural and subdural hematomas, presumably because he associated both types of intracranial/extra-axial hemorrhages with basal skull fractures: see Cushing, "Mütter Lecture" (n. 20), p. 392, and "Mütter Sequel" (n. 43), pp. 1024, 1027. We still observe the frequent correlation between temporal bone fractures (more often squamous than basal) and epidural hematomas, but many acute subdural hematomas are not necessarily associated with skull fractures.
96. Cushing, "Mütter Sequel" (n. 43), p. 1037. With computerized imaging, we can now locate spontaneous ("hypertensive") intracerebral hemorrhages easily and quickly, but the indications for their surgical removal are still unsettled and controversial. The essence of the problem is the fact that patients who suffer major damage to the basal ganglia have high rates of morbidity and mortality, even if the clot is removed expeditiously.
97. Ibid., p. 1044.
98. Cushing pointed this out in a footnote at the beginning of his "Mütter Lecture" (n. 20), p. 1017: "In a slowly forming intracranial process, as tumor growth, hydrocephalus, etc., the [blood pressure] reactions are inconspicuous, the cerebrum accommodating itself to the gradual increase of tension."
99. See, e.g., Cushing, "Special Field" 1905 (n. 14), p. 79.
100. This brief statement glosses over one of the most important aspects of Cushing's early development as a neurological surgeon: his application of gentle Halstedian technique to the nervous system. Respect for neural tissue was a hallmark of Cushing's technique throughout his career and a fundamental lesson that he taught to other surgeons. See Harvey Cushing, "William Stewart Halsted, 1852-1922," Science, 1922, 56: 461-64; Elliott C. Cutler, "Harvey (Williams) Cushing. April 8, 1869-October 7, 1939," Science, 1939, 90: 475-82; Penfield, "Passing of Harvey Cushing" (n. 2), p. 324. For the theme of the present paper, this point is critical, because damaged brain tissue swells and thereby contributes to the mass effect that raises ICP; hence, it is especially important to minimize tissue damage in situations where the ICP is already raised.
101. This brief statement glosses over one of the most important aspects of Cushing's early development as a neurological surgeon: his application of gentle Halstedian technique to the nervous system. Respect for neural tissue was a hallmark of Cushing's technique throughout his career and a fundamental lesson that he taught to other surgeons. See Harvey Cushing, "William Stewart Halsted, 1852-1922," Science, 1922, 56: 461-64; Elliott C. Cutler, "Harvey (Williams) Cushing. April 8, 1869-October 7, 1939," Science, 1939, 90: 475-82; Penfield, "Passing of Harvey Cushing" (n. 2), p. 324. For the theme of the present paper, this point is critical, because damaged brain tissue swells and thereby contributes to the mass effect that raises ICP; hence, it is especially important to minimize tissue damage in situations where the ICP is already raised.
102. This brief statement glosses over one of the most important aspects of Cushing's early development as a neurological surgeon: his application of gentle Halstedian technique to the nervous system. Respect for neural tissue was a hallmark of Cushing's technique throughout his career and a fundamental lesson that he taught to other surgeons. See Harvey Cushing, "William Stewart Halsted, 1852-1922," Science, 1922, 56: 461-64; Elliott C. Cutler, "Harvey (Williams) Cushing. April 8, 1869-October 7, 1939," Science, 1939, 90: 475-82; Penfield, "Passing of Harvey Cushing" (n. 2), p. 324. For the theme of the present paper, this point is critical, because damaged brain tissue swells and thereby contributes to the mass effect that raises ICP; hence, it is especially important to minimize tissue damage in situations where the ICP is already raised.
103. See Greenblatt, "Crucial Decade" (n. 22).
104. Harvey Cushing, "The Establishment of Cerebral Hernia as a Decompressive Measure for Inaccessible Brain Tumors; With the Description of Intermuscular Methods of Making the Bone Defect in Temporal and Occipital Regions," Surg. Gyn. & Obstet., 1905, 1: 297-314. In his "Special Field" lecture of November 1904 (n. 14, pp. 79-80), Cushing talked extensively about palliative decompressions for tumors and other intracranial masses, with some references to the underlying logic of relieving ICP.
105. Harvey Cushing, "The Establishment of Cerebral Hernia as a Decompressive Measure for Inaccessible Brain Tumors; With the Description of Intermuscular Methods of Making the Bone Defect in Temporal and Occipital Regions," Surg. Gyn. & Obstet., 1905, 1: 297-314. In his "Special Field" lecture of November 1904 (n. 14, pp. 79-80), Cushing talked extensively about palliative decompressions for tumors and other intracranial masses, with some references to the underlying logic of relieving ICP.
106. Early in his career on the Johns Hopkins faculty, Cushing teamed with the ophthalmologist James Bordley Jr. to study the optic fundus in relation to ICP. In "Establishment of Cerebral Hernia" (n. 56), p. 298 (n. 1 in col. 1), Cushing relates: "I once, while Dr. Bordley watched the fundus of one eye, slowly inflated a Riva-Rocci blood pressure apparatus, the armlet of which had been placed around the neck. When a pressure of about 36 mm. of mercury had been reached, the veins had become perceptibly dilated, and they increased in size and tortuosity corresponding with an increase of the pressure until the latter became so disagreeable as to lead to symptoms of faintness and nausea." This can only be interpreted to mean that Cushing was strangling his own neck!
107. The gross appearance of the tumor in Cushing's fig. 8, on p. 305 of "Establishment of Cerebral Hernia" (n. 56), looks like a tentorial-falx meningioma. Cushing (p. 302) called it a "neuroglioma, " but that was before our current classification of tumors had been established by Cushing and his many co-workers in the 1920s and 1930s. Dr. Frank P. Smith, emeritus professor of neurological surgery at the University of Rochester (personal communication), has reviewed the pathologist's autopsy and microscopic report of the case; he concluded that the tumor was probably a ganglioglioma.
108. Ibid., p. 302.
109. This procedure, now called a "subtemporal craniectomy," is used only infrequently in current practice. The contemporary equivalent would be a partial anterior temporal lobectomy (removal of the tip of the temporal lobe), which is performed through a subtemporal craniectomy. In the same paper, Cushing also advocated suboccipital decompression for masses in the posterior fossa (brain stem, and especially cerebellum). Again, this procedure is not generally done any longer, because we have the diagnostic means to see the mass and deal with it accordingly. However, even more than subtemporal craniectomy, suboccipital craniectomy (decompression) remained a valid and not uncommon strategy well into the second half of the twentieth century.
110. Greenblatt, "Crucial Decade" (n. 22), pp. 966-67.
111. Cushing, "Establishment of Cerebral Hernia" (n. 56), p. 300.
112. Harvey Cushing, "The Special Field of Neurological Surgery After Another Interval," Arch. Neural. & Psychiatry, 1920, 4: 603-44, quotation on p. 613. The potential discrepancy between the fifteen decompressive operations (reported in 1905) and the twenty-nine total tumor cases in the same early period (to 1905) is explained here (on p. 613) in 1920 by Cushing's statement that there had been "no instance of a really successful tumor extirpation" in the twenty-nine cases that he had done up to 1905. Presumably, the term "really successful tumor extirpation" meant to Cushing what we now mean by the current expression "gross total tumor removal," which implies that the surgeon cannot see any tumor in or on the brain when he finishes.
113. Cushing, "Special Field" 1905 (n. 14), p. 80. One of these two cases of dehiscence was apparently "Karl L." after his second procedure.
114. Harvey Cushing, "The Special Field of Neurological Surgery: Five Years Later," Bull. Johns Hopkins Hasp., 1910, 21:325-39, on p. 331. See also Greenblatt, "Crucial Decade" (n. 22), pp. 967-68.
115. Harvey Cushing, "The Special Field of Neurological Surgery: Five Years Later," Bull. Johns Hopkins Hasp., 1910, 21:325-39, on p. 331. See also Greenblatt, "Crucial Decade" (n. 22), pp. 967-68.
116. Cushing, "Establishment of Cerebral Hernia" (n. 56).
117. Cushing, "Special Field" 1910 (n. 65), p. 329 (emphasis added).
118. A possible exception to this rather gross (but valid) generalization is the team of the neurologist William G. Spiller and the surgeon Charles H. Frazier in Philadelphia. In June 1906 they made a long presentation to the Section on Nervous and Mental Diseases of the American Medical Association on "Cerebral Decompression: Palliative Operations in the Treatment of Tumors of the Brain, Based on the Observation of Fourteen Cases," published in JAMA, 1906, 47: 679-83, 744-51, 849-53, 923-26. In Spiller's part of the publication (on p. 682), he gave a two-line mention and a reference to Cushing's decompression paper of 1905 ("Establishment of Cerebral Hernia" [n. 561). Frazier (on p. 746) gives priority to Alfred Sänger of Hamburg for the idea of doing decompressions over "silent" areas of the brain. Cushing had quoted Sänger's paper on palliative operations in "Special Field" 1905 (n. 14), p. 79, and he mentioned Sänger in the first paragraph of "Establishment of Cerebral Hernia" (n. 56). Frazier had part of his training with Bergmann in Berlin (see Samuel H. Greenblatt, "Neurosurgery's Ideals in Historical Perspective," in Philosophy of Neurological Surgery, ed. Issam A. Awad [Park Ridge, III.: American Association of Neurological Surgeons, 1995], p. 20), so he might have had the background to understand Cushing's technical discussions of ICP. There is no clear evidence in Frazier's published remarks that he really grasped Cushing's new conceptualization of ICP, but he obviously understood the management of ICP by decompression, because there was only one death and one failure-to-improve in his fourteen cases. The timing and tone of Spiller and Frazier's paper gives me the impression that they were attempting to compete with Cushing's decompression paper of 1905 by trying to show that it was nothing new. Fulton, in Harvey Cushing (n. 15), does not say that Cushing attended the AMA meeting in 1906, and Fulton generally made note of such travels.
119. A possible exception to this rather gross (but valid) generalization is the team of the neurologist William G. Spiller and the surgeon Charles H. Frazier in Philadelphia. In June 1906 they made a long presentation to the Section on Nervous and Mental Diseases of the American Medical Association on "Cerebral Decompression: Palliative Operations in the Treatment of Tumors of the Brain, Based on the Observation of Fourteen Cases," published in JAMA, 1906, 47: 679-83, 744-51, 849-53, 923-26. In Spiller's part of the publication (on p. 682), he gave a two-line mention and a reference to Cushing's decompression paper of 1905 ("Establishment of Cerebral Hernia" [n. 561). Frazier (on p. 746) gives priority to Alfred Sänger of Hamburg for the idea of doing decompressions over "silent" areas of the brain. Cushing had quoted Sänger's paper on palliative operations in "Special Field" 1905 (n. 14), p. 79, and he mentioned Sänger in the first paragraph of "Establishment of Cerebral Hernia" (n. 56). Frazier had part of his training with Bergmann in Berlin (see Samuel H. Greenblatt, "Neurosurgery's Ideals in Historical Perspective," in Philosophy of Neurological Surgery, ed. Issam A. Awad [Park Ridge, III.: American Association of Neurological Surgeons, 1995], p. 20), so he might have had the background to understand Cushing's technical discussions of ICP. There is no clear evidence in Frazier's published remarks that he really grasped Cushing's new conceptualization of ICP, but he obviously understood the management of ICP by decompression, because there was only one death and one failure-to-improve in his fourteen cases. The timing and tone of Spiller and Frazier's paper gives me the impression that they were attempting to compete with Cushing's decompression paper of 1905 by trying to show that it was nothing new. Fulton, in Harvey Cushing (n. 15), does not say that Cushing attended the AMA meeting in 1906, and Fulton generally made note of such travels.
120. A possible exception to this rather gross (but valid) generalization is the team of the neurologist William G. Spiller and the surgeon Charles H. Frazier in Philadelphia. In June 1906 they made a long presentation to the Section on Nervous and Mental Diseases of the American Medical Association on "Cerebral Decompression: Palliative Operations in the Treatment of Tumors of the Brain, Based on the Observation of Fourteen Cases," published in JAMA, 1906, 47: 679-83, 744-51, 849-53, 923-26. In Spiller's part of the publication (on p. 682), he gave a two-line mention and a reference to Cushing's decompression paper of 1905 ("Establishment of Cerebral Hernia" [n. 561). Frazier (on p. 746) gives priority to Alfred Sänger of Hamburg for the idea of doing decompressions over "silent" areas of the brain. Cushing had quoted Sänger's paper on palliative operations in "Special Field" 1905 (n. 14), p. 79, and he mentioned Sänger in the first paragraph of "Establishment of Cerebral Hernia" (n. 56). Frazier had part of his training with Bergmann in Berlin (see Samuel H. Greenblatt, "Neurosurgery's Ideals in Historical Perspective," in Philosophy of Neurological Surgery, ed. Issam A. Awad [Park Ridge, III.: American Association of Neurological Surgeons, 1995], p. 20), so he might have had the background to understand Cushing's technical discussions of ICP. There is no clear evidence in Frazier's published remarks that he really grasped Cushing's new conceptualization of ICP, but he obviously understood the management of ICP by decompression, because there was only one death and one failure-to-improve in his fourteen cases. The timing and tone of Spiller and Frazier's paper gives me the impression that they were attempting to compete with Cushing's decompression paper of 1905 by trying to show that it was nothing new. Fulton, in Harvey Cushing (n. 15), does not say that Cushing attended the AMA meeting in 1906, and Fulton generally made note of such travels.
121. A possible exception to this rather gross (but valid) generalization is the team of the neurologist William G. Spiller and the surgeon Charles H. Frazier in Philadelphia. In June 1906 they made a long presentation to the Section on Nervous and Mental Diseases of the American Medical Association on "Cerebral Decompression: Palliative Operations in the Treatment of Tumors of the Brain, Based on the Observation of Fourteen Cases," published in JAMA, 1906, 47: 679-83, 744-51, 849-53, 923-26. In Spiller's part of the publication (on p. 682), he gave a two-line mention and a reference to Cushing's decompression paper of 1905 ("Establishment of Cerebral Hernia" [n. 561). Frazier (on p. 746) gives priority to Alfred Sänger of Hamburg for the idea of doing decompressions over "silent" areas of the brain. Cushing had quoted Sänger's paper on palliative operations in "Special Field" 1905 (n. 14), p. 79, and he mentioned Sänger in the first paragraph of "Establishment of Cerebral Hernia" (n. 56). Frazier had part of his training with Bergmann in Berlin (see Samuel H. Greenblatt, "Neurosurgery's Ideals in Historical Perspective," in Philosophy of Neurological Surgery, ed. Issam A. Awad [Park Ridge, III.: American Association of Neurological Surgeons, 1995], p. 20), so he might have had the background to understand Cushing's technical discussions of ICP. There is no clear evidence in Frazier's published remarks that he really grasped Cushing's new conceptualization of ICP, but he obviously understood the management of ICP by decompression, because there was only one death and one failure-to-improve in his fourteen cases. The timing and tone of Spiller and Frazier's paper gives me the impression that they were attempting to compete with Cushing's decompression paper of 1905 by trying to show that it was nothing new. Fulton, in Harvey Cushing (n. 15), does not say that Cushing attended the AMA meeting in 1906, and Fulton generally made note of such travels.
122. A possible exception to this rather gross (but valid) generalization is the team of the neurologist William G. Spiller and the surgeon Charles H. Frazier in Philadelphia. In June 1906 they made a long presentation to the Section on Nervous and Mental Diseases of the American Medical Association on "Cerebral Decompression: Palliative Operations in the Treatment of Tumors of the Brain, Based on the Observation of Fourteen Cases," published in JAMA, 1906, 47: 679-83, 744-51, 849-53, 923-26. In Spiller's part of the publication (on p. 682), he gave a two-line mention and a reference to Cushing's decompression paper of 1905 ("Establishment of Cerebral Hernia" [n. 561). Frazier (on p. 746) gives priority to Alfred Sänger of Hamburg for the idea of doing decompressions over "silent" areas of the brain. Cushing had quoted Sänger's paper on palliative operations in "Special Field" 1905 (n. 14), p. 79, and he mentioned Sänger in the first paragraph of "Establishment of Cerebral Hernia" (n. 56). Frazier had part of his training with Bergmann in Berlin (see Samuel H. Greenblatt, "Neurosurgery's Ideals in Historical Perspective," in Philosophy of Neurological Surgery, ed. Issam A. Awad [Park Ridge, III.: American Association of Neurological Surgeons, 1995], p. 20), so he might have had the background to understand Cushing's technical discussions of ICP. There is no clear evidence in Frazier's published remarks that he really grasped Cushing's new conceptualization of ICP, but he obviously understood the management of ICP by decompression, because there was only one death and one failure-to-improve in his fourteen cases. The timing and tone of Spiller and Frazier's paper gives me the impression that they were attempting to compete with Cushing's decompression paper of 1905 by trying to show that it was nothing new. Fulton, in Harvey Cushing (n. 15), does not say that Cushing attended the AMA meeting in 1906, and Fulton generally made note of such travels.
123. A possible exception to this rather gross (but valid) generalization is the team of the neurologist William G. Spiller and the surgeon Charles H. Frazier in Philadelphia. In June 1906 they made a long presentation to the Section on Nervous and Mental Diseases of the American Medical Association on "Cerebral Decompression: Palliative Operations in the Treatment of Tumors of the Brain, Based on the Observation of Fourteen Cases," published in JAMA, 1906, 47: 679-83, 744-51, 849-53, 923-26. In Spiller's part of the publication (on p. 682), he gave a two-line mention and a reference to Cushing's decompression paper of 1905 ("Establishment of Cerebral Hernia" [n. 561). Frazier (on p. 746) gives priority to Alfred Sänger of Hamburg for the idea of doing decompressions over "silent" areas of the brain. Cushing had quoted Sänger's paper on palliative operations in "Special Field" 1905 (n. 14), p. 79, and he mentioned Sänger in the first paragraph of "Establishment of Cerebral Hernia" (n. 56). Frazier had part of his training with Bergmann in Berlin (see Samuel H. Greenblatt, "Neurosurgery's Ideals in Historical Perspective," in Philosophy of Neurological Surgery, ed. Issam A. Awad [Park Ridge, III.: American Association of Neurological Surgeons, 1995], p. 20), so he might have had the background to understand Cushing's technical discussions of ICP. There is no clear evidence in Frazier's published remarks that he really grasped Cushing's new conceptualization of ICP, but he obviously understood the management of ICP by decompression, because there was only one death and one failure-to-improve in his fourteen cases. The timing and tone of Spiller and Frazier's paper gives me the impression that they were attempting to compete with Cushing's decompression paper of 1905 by trying to show that it was nothing new. Fulton, in Harvey Cushing (n. 15), does not say that Cushing attended the AMA meeting in 1906, and Fulton generally made note of such travels.
124. Cushing, "Special Field" 1905 (n. 14). The publication in the Cleveland Med. J. (4:1-25) is dated January 1905, and the publication in the Bull. Johns Hopkins Hasp. (16: 77-87) is dated March 1905.
125. Cushing, "Special Field" 1905 (n. 14). The publication in the Cleveland Med. J. (4:1-25) is dated January 1905, and the publication in the Bull. Johns Hopkins Hasp. (16: 77-87) is dated March 1905.
126. Cushing, "Special Field" 1905 (n. 14). The publication in the Cleveland Med. J. (4:1-25) is dated January 1905, and the publication in the Bull. Johns Hopkins Hasp. (16: 77-87) is dated March 1905.
127. Cushing, "Special Field" 1910 (n. 65), and "Special Field" 1920 (n. 63).
128. Cushing, "Special Field" 1910 (n. 65), and "Special Field" 1920 (n. 63).
129. Cushing, "Special Field" 1905 (n. 14), p. 78.
130. Despite some continuing controversy about specialization in 1904-5, progress toward our present practice patterns was fairly well along in American medicine: see Rosemary Stevens, American Medicine and the Public Interest, rev. ed. (Berkeley: University of California Press, 1998), pp. 43-52.
131. Cushing, "Special Field" 1905 (n. 14), p. 87.
132. Fulton, Harvey Cushing (n. 15), pp. 231-32. For Cushing's recollection of how the society was originally conceived, see ibid., p. 169. William J. Mayo was one of Cushing's original cofounders, and Cushing's account agrees with the description of the same events in Helen Clapesattle, The Doctors Mayo (Garden City, N.Y.: Garden City Publishing, 1941), pp. 295-96. According to Clapesattle, it was actually James Mumford of Boston and George Crile of Cleveland who called the organizational meeting of the society in New York in 1903. Crile's autobiography (George Crile: An Autobiography, ed. Grace Crile, vol. 1 [Philadelphia: Lippincott, 1947], pp. 140-42), contains his version of these events, but it adds some confusion, because he calls the same organization the "American Society of Clinical Surgery."
133. Fulton, Harvey Cushing (n. 15), pp. 231-32. For Cushing's recollection of how the society was originally conceived, see ibid., p. 169. William J. Mayo was one of Cushing's original cofounders, and Cushing's account agrees with the description of the same events in Helen Clapesattle, The Doctors Mayo (Garden City, N.Y.: Garden City Publishing, 1941), pp. 295-96. According to Clapesattle, it was actually James Mumford of Boston and George Crile of Cleveland who called the organizational meeting of the society in New York in 1903. Crile's autobiography (George Crile: An Autobiography, ed. Grace Crile, vol. 1 [Philadelphia: Lippincott, 1947], pp. 140-42), contains his version of these events, but it adds some confusion, because he calls the same organization the "American Society of Clinical Surgery."
134. Fulton, Harvey Cushing (n. 15), pp. 231-32. For Cushing's recollection of how the society was originally conceived, see ibid., p. 169. William J. Mayo was one of Cushing's original cofounders, and Cushing's account agrees with the description of the same events in Helen Clapesattle, The Doctors Mayo (Garden City, N.Y.: Garden City Publishing, 1941), pp. 295-96. According to Clapesattle, it was actually James Mumford of Boston and George Crile of Cleveland who called the organizational meeting of the society in New York in 1903. Crile's autobiography (George Crile: An Autobiography, ed. Grace Crile, vol. 1 [Philadelphia: Lippincott, 1947], pp. 140-42), contains his version of these events, but it adds some confusion, because he calls the same organization the "American Society of Clinical Surgery."
135. Cushing, "Special Field" 1910 (n. 65), p. 325.
136. I b i d.
137. See Greenblatt, "Crucial Decade" (n. 22).
138. The operating room logbooks for 1 October 1907 to 30 April 1908, and for 21 July 1908 to 11 April 1910, are in the Alan Mason Chesney Archives of the Johns Hopkins Medical Institutions, Baltimore, Md. Unfortunately, there are no extant logbooks for the earlier period of Cushing's tenure on the faculty at Johns Hopkins (1901 to 30 September 1907); there are Nursing Records of Surgical Procedures and Dressings for 1901 to 1907, but these do not include the surgeons' names. The Chesney Archives also has the operating room logbook for 29 January 1912 to 9 December 1913, which is of interest because Cushing left for Harvard in late September 1912. His last recorded surgical procedure at Johns Hopkins was a "Craniotomy" on 29 August 1912. In the period from 29 January 1912 to 29 August 1912, many neurosurgical procedures are recorded by Walter E. Dandy (18 procedures), and smaller numbers by Samuel J. Crowe (1), Emil Goetsch (2), George J. Heuer (1), and Howard C. Naffziger (1); at this time, these five men were all residents. Most of the procedures listed for Dandy and the others were "Craniotomy" or "Decompression." After Cushing left, from 9 September 1912 to 31 December 1912, Heuer did eleven procedures, mostly decompressions, and Crowe did one "Hypophysis."
139. Cushing, "Special Field" 1910 (n. 65), p. 332 (emphasis added).
140. Ibid., p. 331.
141. See Fulton, Harvey Cushing (n. 15), p. 339.
142. Cushing, "Special Field" 1910 (n. 65), p. 327.
143. Abraham Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (New York: Carnegie Foundation, 1910).
144. For a sketch of how Kelly was perceived in the Johns Hopkins community, see Michael Bliss, William Osier: A Life in Medicine (Toronto: University of Toronto Press, 1999), pp. 215-16.
145. Cushing, "Special Field" 1910 (n. 65), p. 328. Three years later, in a major "Address in Surgery" at the Seventeenth International Congress of Medicine in London, Cushing expressed a similar sentiment in a more positive way: "it would be rejuvenating to many of the surgical specialties if they could be periodically absorbed by general surgery, to be born again under the leadership of individuals who through fresh contributions could give a new impulse to a senescent subject" ("Realinements [sic] in Greater Medicine: Their Effect upon Surgery and the Influence of Surgery upon Them," Lancet, 9 August 1913, 2:369-75, quotation on p. 373).
146. Cushing, "Special Field" 1910 (n. 65), p. 328. Three years later, in a major "Address in Surgery" at the Seventeenth International Congress of Medicine in London, Cushing expressed a similar sentiment in a more positive way: "it would be rejuvenating to many of the surgical specialties if they could be periodically absorbed by general surgery, to be born again under the leadership of individuals who through fresh contributions could give a new impulse to a senescent subject" ("Realinements [sic] in Greater Medicine: Their Effect upon Surgery and the Influence of Surgery upon Them," Lancet, 9 August 1913, 2:369-75, quotation on p. 373).
147. Harvey Cushing, "Neurological Surgery and the War," Boston Med. & Surg. J., 1919, 181: 549-52.
148. Ibid., pp. 551-52; Harvey Cushing, From A Surgeon's Journal (Boston: Little, Brown, 1936), pp. 357, 382. Because he sent his wife a harsh criticism of a British surgeon, Cushing was nearly court-martialed in May 1918: see Fulton, Harvey Cushing (n. 15), pp. 426-28.
149. Ibid., pp. 551-52; Harvey Cushing, From A Surgeon's Journal (Boston: Little, Brown, 1936), pp. 357, 382. Because he sent his wife a harsh criticism of a British surgeon, Cushing was nearly court-martialed in May 1918: see Fulton, Harvey Cushing (n. 15), pp. 426-28.
150. Ibid., pp. 551-52; Harvey Cushing, From A Surgeon's Journal (Boston: Little, Brown, 1936), pp. 357, 382. Because he sent his wife a harsh criticism of a British surgeon, Cushing was nearly court-martialed in May 1918: see Fulton, Harvey Cushing (n. 15), pp. 426-28.
151. Harvey Cushing, "Brain Tumor Statistics," Med. Rec., New York, 6 March 1920, 97: 417-18; Cushing's Bibliography (n. 41), p. 40, states that this was "A stenographer's note of remarks at the Clinical Congress of the American College of Surgeons held in New York, October 21, 1919. Paper never published." In the Cushing Archives at Yale University, New Haven, Conn., Series III, folder 133 (reel 143, box 179), there is a large collection of material that is labeled "Brain tumor statistics (179) 1920," but it is not a coherent manuscript; rather, it is pieces of a manuscript interspersed with notes about individual cases and handwritten compilations of statistics. The short report in the Medical Record is more useful as a record of what Cushing actually said.
152. Harvey Cushing, "Brain Tumor Statistics," Med. Rec., New York, 6 March 1920, 97: 417-18; Cushing's Bibliography (n. 41), p. 40, states that this was "A stenographer's note of remarks at the Clinical Congress of the American College of Surgeons held in New York, October 21, 1919. Paper never published." In the Cushing Archives at Yale University, New Haven, Conn., Series III, folder 133 (reel 143, box 179), there is a large collection of material that is labeled "Brain tumor statistics (179) 1920," but it is not a coherent manuscript; rather, it is pieces of a manuscript interspersed with notes about individual cases and handwritten compilations of statistics. The short report in the Medical Record is more useful as a record of what Cushing actually said.
153. Harvey Cushing, "Concerning the Results of Operations for Brain Tumor," JAMA, 1915, 64:189-95, on p. 193. The operative mortality rate for 149 procedures on these 130 patients was 7.4%.
154. Cushing, "Special Field" 1920 (n. 63), p. 615.
155. Ernest Sachs, Fifty Years of Neurosurgery: A Personal Story (New York: Vantage Press, 1958), p. 68.
156. Cushing, "Special Field" 1920 (n. 63), p. 604.
157. I b i d.
158. Cushing, "Special Field" 1910 (n. 65), p. 327.
159. Cushing, "Special Field" 1920 (n. 63), p. 605.
160. Ibid, pp. 605-6.
161. Ibid., p. 634. Since most of the transcranial injuries in World War I were due to low-velocity missiles (bullets, shrapnel), their emergent neurosurgical care would have consisted of debridement without decompression. Acute rises in ICP would have occurred later, due to cerebral edema in the tract of the missile or the appearance of cerebral abscess or meningitis.
162. Ibid., p. 609.
163. I b i d.
164. Cushing, "Special Field" 1910 (n. 65), p. 329.
165. Cushing, "Special Field" 1920 (n. 63), p. 637.
166. In my introductory chapter to Greenblatt, Dagi, and Epstein, History of Neurosurgery (n. 1), p. 3, I proposed a set of criteria for defining a profession. When that was written, I had no conscious intention to derive the criteria from any Kuhnian standard, but the similarity between those criteria and my present understanding of Kuhn's paradigm (as expressed in the next paragraph of this paper) now seems quite striking.
167. This is my interpretation of Kuhn's use of the term "paradigm" throughout Thomas Kuhn, The Structure of Scientific Revolutions, 2d ed. (Chicago: University of Chicago Press, 1970), and in idem, "Second Thoughts on Paradigms" (1974), reprinted in idem, The Essential Tension: Selected Studies in Scientific Tradition and Change (Chicago: University of Chicago Press, 1977), pp. 105-26. Despite the controversy and misunderstandings that the word "paradigm" has evoked, Kuhn did not really elaborate on it in his later writings; see Thomas Kuhn, The Road Since Structure: Philosophical Essays, 1970-1993, with an Autobiographical Interview, ed. James Conant and John Haugeland (Chicago: University of Chicago Press, 2000), where it is seldom mentioned.
168. This is my interpretation of Kuhn's use of the term "paradigm" throughout Thomas Kuhn, The Structure of Scientific Revolutions, 2d ed. (Chicago: University of Chicago Press, 1970), and in idem, "Second Thoughts on Paradigms" (1974), reprinted in idem, The Essential Tension: Selected Studies in Scientific Tradition and Change (Chicago: University of Chicago Press, 1977), pp. 105-26. Despite the controversy and misunderstandings that the word "paradigm" has evoked, Kuhn did not really elaborate on it in his later writings; see Thomas Kuhn, The Road Since Structure: Philosophical Essays, 1970-1993, with an Autobiographical Interview, ed. James Conant and John Haugeland (Chicago: University of Chicago Press, 2000), where it is seldom mentioned.
169. This is my interpretation of Kuhn's use of the term "paradigm" throughout Thomas Kuhn, The Structure of Scientific Revolutions, 2d ed. (Chicago: University of Chicago Press, 1970), and in idem, "Second Thoughts on Paradigms" (1974), reprinted in idem, The Essential Tension: Selected Studies in Scientific Tradition and Change (Chicago: University of Chicago Press, 1977), pp. 105-26. Despite the controversy and misunderstandings that the word "paradigm" has evoked, Kuhn did not really elaborate on it in his later writings; see Thomas Kuhn, The Road Since Structure: Philosophical Essays, 1970-1993, with an Autobiographical Interview, ed. James Conant and John Haugeland (Chicago: University of Chicago Press, 2000), where it is seldom mentioned.
170. This is my interpretation of Kuhn's use of the term "paradigm" throughout Thomas Kuhn, The Structure of Scientific Revolutions, 2d ed. (Chicago: University of Chicago Press, 1970), and in idem, "Second Thoughts on Paradigms" (1974), reprinted in idem, The Essential Tension: Selected Studies in Scientific Tradition and Change (Chicago: University of Chicago Press, 1977), pp. 105-26. Despite the controversy and misunderstandings that the word "paradigm" has evoked, Kuhn did not really elaborate on it in his later writings; see Thomas Kuhn, The Road Since Structure: Philosophical Essays, 1970-1993, with an Autobiographical Interview, ed. James Conant and John Haugeland (Chicago: University of Chicago Press, 2000), where it is seldom mentioned.
171. I think it is this communal aspect of the paradigm idea that appeals so much to physicians and others who are themselves participants in such subcommunities; e.g., see John R. Absher and D. Frank Benson, "Disconnection Syndromes: An Overview of Geschwind's Contributions," Neurology, 1993, 43: 862-67.
172. See Greenblatt and Smith, "Emergence of Cushing's Leadership" (n. 2), pp. 179-80.
173. See text above at n. 91.
174. George Rosen, The Specialization of Medicine with Particular Reference to Ophthalmology (New York: Froben Press, 1944). Rosen was explicitly undertaking "a sociological study of specialization in medicine" (p. 3), albeit with a strong historical perspective, since his doctoral thesis was written in Columbia University's Department of Sociology (p. 93).
175. Stevens, American Medicine (n. 72), p. ix (emphasis in original). This quotation is actually Stevens's summary in 1998 of her book that was originally published in 1971 and "updated" in 1998.
176. The "various factors" usually boil down to three: (1) the existence of a body of knowledge beyond the competency of the general practitioner; (2) the growth of hospitals as centers of specialized practice; and (3) the explosion of medical knowledge due to continuing research. These basic themes have recurred in the analyses of multiple scholars, presumably because they are valid observations. See, e.g., W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994), p. 193; William G. Rothstein, American Physicians in the Nineteenth Century: From Sects to Science (Baltimore: Johns Hopkins University Press, 1972), p. 14; Stevens, American Medicine (n. 72), pp. ix-x.
177. The "various factors" usually boil down to three: (1) the existence of a body of knowledge beyond the competency of the general practitioner; (2) the growth of hospitals as centers of specialized practice; and (3) the explosion of medical knowledge due to continuing research. These basic themes have recurred in the analyses of multiple scholars, presumably because they are valid observations. See, e.g., W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994), p. 193; William G. Rothstein, American Physicians in the Nineteenth Century: From Sects to Science (Baltimore: Johns Hopkins University Press, 1972), p. 14; Stevens, American Medicine (n. 72), pp. ix-x.
178. The "various factors" usually boil down to three: (1) the existence of a body of knowledge beyond the competency of the general practitioner; (2) the growth of hospitals as centers of specialized practice; and (3) the explosion of medical knowledge due to continuing research. These basic themes have recurred in the analyses of multiple scholars, presumably because they are valid observations. See, e.g., W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994), p. 193; William G. Rothstein, American Physicians in the Nineteenth Century: From Sects to Science (Baltimore: Johns Hopkins University Press, 1972), p. 14; Stevens, American Medicine (n. 72), pp. ix-x.
179. Rothstein, American Physicians (n. 109), p. 207.