The Brain Cutter
Posted by Richard Conniff on February 22, 2011
Here’s my profile of Harvey Cushing, published recently in the Yale Alumni Magazine:
Deep beneath the stacks of the Yale medical school library, a kind of grotto venerates the human brain. It’s a memorial to an era when surgery on “the closed box” of the human skull was far more mysterious, even macabre, than it seems today. It’s also a celebration of one man who made it less so, essentially inventing modern brain surgery by his odd blend of audacity and painstaking care with scalpel, drill, saw, and clamp.
You get a hint of what lies beneath on the stairway down, where a large photograph from 1930 shows a 24-year-old surgical candidate in hospital pajama bottoms, facing the camera and displaying symptoms of the form of gigantism called acromegaly. Surgeon Harvey Cushing, Class of 1891, stands at his side. He is an older and much smaller man, facing the patient, one knee canted forward, one hand in the jacket pocket of a carefully tailored glen-check suit. With his other hand, he holds the giant delicately by two fingers, as if to lead him to his fate. (The patient, a farm laborer, had been told by another doctor that he would “die if anyone operated on his pituitary.” In fact, he was able to write Cushing, three years after surgery, wishing him “high spirits and the best of health.”)
Descend one more flight of stairs, and you encounter the twisted skeleton of an acromegaly victim from 1896, before surgical intervention could alter the insidious progress of the disease. It sprawls on its back, chest hugely enlarged, feet deformed, head turned to one side as if to greet the visitor with a howl of dismay. And one level further down, you pass through the key-carded door of the Cushing Center itself, newly opened this summer after a construction and conservation project costing just over $1 million. And then—lights, camera, action—you descend a little farther, along a ramp, past a stage-lit chorus line of brains and tumors suspended in jars of glowing amber-tinted fluid. In places, the brains and photographs of their former owners pose side by side, in mute homage to the work of the difficult, demanding, and often heroic Dr. Cushing.
A photograph survives of Harvey Williams Cushing as a Yale undergraduate in 1889, doing a perilous back flip off the stoop of a university building. It was one of the rare frivolous moments in an otherwise intensely purposeful life. Cushing, the product of three generations of physicians in a wealthy Cleveland family, performed surgery as a senior at Yale, extracting the brain of a dog found wandering on campus. (Notions of ethical experimentation, on animals and humans alike, were nebulous then, though as a doctor Cushing would at least anesthetize animals before operating on them, an indulgence some European counterparts deemed frivolous.) He went on to Harvard Medical School, and spent most of his career at Johns Hopkins Hospital in Baltimore, and later at Harvard’s Peter Bent Brigham Hospital in Boston, before eventually returning to Yale.
In the late 1890s, when Cushing was starting out as a surgical resident, the skull was mostly “attacked in desperation and with dismal outcomes,” Michael Bliss writes in his 2005 biography Harvey Cushing: A Life in Surgery. Surgeons lacked imaging technologies to determine where in the brain a problem might lie, and they were ignorant about what neurological functions might be compromised by a careless move en route. Most attempts to operate ended ignominiously in bleeding, uncontrollable bulging of brain tissue, infection, and death. Young Cushing failed, too, with a pregnant woman shot in the head, and with a 16-year-old girl whose pituitary tumor eluded him in three attempts. These losses left him soul-shaken. But “having looked at the brain,” Bliss writes, Cushing went on in the first decade of the new century to learn “how to gain access to it, relieve it, and let it heal.” He thus became “the father of effective neurosurgery.” (“Ineffective neurosurgery,” Bliss adds, “had many fathers.”)
Cushing himself attributed his success to meticulous care, rather than brilliant innovation. He prided himself on “perfection of anesthesia, scrupulous technique, ample expenditure of time, painstaking closure of wounds without drainage, and a multitude of other elements, which so many operators impatiently regard as trivialities.” The delicate nature of the work made slow going essential. “An operator who persists in taking dangerous curves at high speed will be the cause of a serious or fatal accident some day,” he declared, “whether he is driving an automobile or opening a skull.” Cushing worked “almost ritualistically,” according to Bliss, shaving and draping the patient’s head himself, and doing the routine closing of the wound afterwards. “He was especially pleased if there were no blood stains on the drapes when the operation ended.” Such care enabled him to go where other surgeons did not dare, and get far better results. Without adequate lighting or magnification, he reduced his mortality rate to less than 10 percent, in an era when renowned brain surgeons elsewhere admitted to losing a third to half their brain patients.
But Cushing was also quick to invent surgical techniques and exploit new technologies. He introduced the blood pressure cuff to American medicine, after spotting the device in Italy during a year abroad, and he soon made it an essential tool for monitoring the status of surgical patients. He also adapted the idea of the inflatable cuff into a pneumatic tourniquet, wrapped around the skull before surgery to prevent heavy bleeding from the scalp. To control bleeding within the brain itself, he pioneered the use of silver surgical clamps in neurosurgery and also experimented with blood clots and living tissue to induce coagulation. Much later in his career, he introduced electrocauterization to brain surgery, using a pistol-shaped device that could cut and coagulate in the same motion. He described it as “powerful enough to electrocute a mastodon and pretty nearly as big.” It gave off the smell of burning tissue, produced shocks in early versions, and on one occasion lit up the operating room with a blue flare of ether vapor. But Cushing was thrilled at his newfound ability to remove large, heavily vascularized tumors: “I am succeeding in doing things inside the head that I never thought it would be possible to do.”
The other key to his success, along with the caution and audacity, was meticulous record keeping. It started when he was assisting with surgery as a student, using a sponge to administer ether, and the patient died in front of the entire class. Appalled and mortified, Cushing and a classmate soon developed “ether charts,” to keep track of a patient’s heart and respiration rates—his “first major contribution to medicine,” according to a recent profile in the Journal of Neurosurgery: “Such charting revolutionized surgery by greatly curbing complications and deaths” from anesthesia. A few years later the young surgeon became infuriated over a second mishap, a pathology department’s loss of a golf ball–size piece of brain tissue before he had had a chance to examine it. He demanded the right to retain all his own specimens, leading to the creation of the Cushing Brain Tumor Registry, a carefully maintained collection of tissues, detailed medical records, sketches, and patient photographs. His insistence, over the rest of his career, on almost compulsively recording what he saw enabled him to sort through irrelevant or inconsistent details and zero in relentlessly on essential facts. It also inadvertently documented the birth of neurosurgery.
In the course of inventing neurosurgery, Cushing also created the cult of the brain surgeon as high priest, difficult, demanding, devoted to his work above all else. “Not many men down here liked him,” a Baltimore colleague wrote. “He rode roughshod over them and was ruthless. Yet he had his moments and could be as charming and delightful as anyone else. Only there weren’t many such moments. … Tough hombre. Yeah, but one of America’s immortals.” If Cushing could be brutal to hospital staff, he was also extraordinarily self-sacrificing on behalf of patients. “A nurse never forgot the time a child who had been tracheotomized for diphtheria had his tube accidentally withdrawn and rushed into the hallway choking,” Bliss writes. “Cushing took hold of the boy, put his mouth to the wound, sucked out the mucus, blood, and disease-membrane, then reinserted the tube.”
Staffers who could live up to “the chief’s” high standard earned his loyalty. Louise Eisenhardt, who started as a secretary in 1915, went on to become a physician herself, a rare accomplishment for a woman then, and possible only with Cushing’s support. Trusted staffers tended to be intensely loyal in turn. When someone once proposed bypassing one of Cushing’s fussy rules, a lab worker replied, “Orders is orders, and if Dr. Cushing says that the building should be burned down,” it would soon lie in ashes.
Cushing’s wife Kate and their five children paid the price for his devotion. Once, after he had made a visit home between bouts of travel and work, she wrote, “I couldn’t talk to you Harvey—you weren’t interested.” And when he contemplated moving to Boston while she remained in Baltimore, she replied that they “would simply drift further and further apart—you absorbed in your work. I—in my work and possibly somebody else who happened to be interested in me a little.” His reply surely did not soothe her: “An awful day—hot and muggy—a bad ganglion case—several foreign visitors on my chest—patients throwing fits at unfortunate moments … and not the least your depressing letter.”
As “the chief” approached retirement age, Harvard treated him with an attitude his protégé and later biographer John Fulton characterized as “patronizing stupidity.” Among Europeans, Fulton wrote, Cushing “is regarded as the outstanding figure in American medicine of this or any previous epoch. In Harvard he is merely a troublesome member of the medical faculty.” Cushing left Harvard unceremoniously in 1932 and moved to Yale, bringing with him his priceless collection of more than 7,000 antiquarian medical books, and later the entire Tumor Registry. The books became the basis of the medical school’s historical library. A new generation of neurosurgery students also continued to use the Tumor Registry as an educational tool for years after Cushing’s death in 1939 (a heart attack at age 70, after lifting a weighty volume of a sixteenth-century illustrated human anatomy). But Cushing’s methods inevitably began to seem antiquated, and the Tumor Registry, with all its strange neurological incunabula, got put away and forgotten.
Then one night in 1991, a group of medical students went drinking at Mory’s, and someone passed along a story about a roomful of brains in the basement of their dormitory. Later that night, says Christopher Wahl ’96MD, now an orthopedic surgeon, they went to investigate, spiritually fortified and still in their jackets and ties. Getting there meant clambering over ductwork, past barrels of food supplies for a former Cold War bomb shelter, and picking a lock with a paper clip. Then, in a room illuminated by bare lightbulbs, they found themselves amid shelf after metal shelf of brains and tumors in carefully labeled jars. Against a wall were rickety stacks of glass photographic images that struck Wahl, then a first-year med student, as “super-creepy”—patients with their hands splayed out across their chests in an almost cult-like pose, children stripped bare to reveal horrific deformities, people with heads blown out by the sort of tumors rarely seen in the modern medical era.
A few months later, Wahl took a course in medical history and another lightbulb came on, in his head. “I went to Dennis Spencer, then section chief of neurosurgery, and said, ‘You know, Harvey Cushing’s brains are in the sub-basement of the dormitory,’ and he almost choked.” Spencer says choking was a natural response to the notion of inebriated, lock-picking students visiting the storage room late at night. But he offered Wahl a yearlong fellowship to sort through the collection, and Wahl soon found himself moving from riveting photographs to records of the patients in the photographs to the specimens taken from their bodies. “It seemed so poignant,” he says now. “Sometimes you need to have the patina of something being left and forgotten for a long time for it to be meaningful. You realize how much things have changed and how incredibly brave these patients were, and how much of an innovator Harvey Cushing was. He must have had a phenomenal ego to continue operating in the face of what was, when he began, almost always fatal surgery.”
Soon after, Yale began a campaign to draw attention to the medical school’s neurosurgical accomplishments. But an outside publicist fixated instead on brains in the basement, and the story ended up as a student caper on the front page of the Wall Street Journal (“Many Special Minds Are Found at Yale”). The university development office predictably flipped out, according to Wahl, demanding that he play up the academic research and hold the caper. They worried, he says, that the publicity would offend the Cushing and Whitney families (joined by the marriage of one of Harvey and Kate Cushing’s daughters) and imperil the endowment supporting the medical school library, which had only recently become known as the Harvey Cushing/John Hay Whitney Medical Library.
For Spencer and Wahl, the larger worry was that someone would declare the Tumor Registry and its precariously stored jars of human tissue in formaldehyde a health hazard, to be destroyed. Late-night visits to the brain room meanwhile became a student ritual, with visitors now leaving their signatures on a “Brain Society” whiteboard: “José ‘Hole in the Head’ Prince,” “Vivian ‘full frontal lobe’ Nereim,” “Josh Klein-oid Process,” and the unforgettable “Hana ‘I don’t even fucking go here’ Capruso.” The last may have been a reminder that the medical school couldn’t count indefinitely on the good will of its students to keep the collection intact.
Spencer, now the Harvey and Kate Cushing Professor of Neurosurgery and chair of the Department of Neurosurgery, is a genial, white-bearded figure with a passion for Harley-Davidson motorcycles. He does not fit the “high priest” mold. When he’s not in biker leathers, he wears silk suspenders, and a silver seahorse brooch on the pocket of his shirt. (The brooch, he says, belonged to his late wife and colleague, Yale neurologist Susan Spencer; its tail resembles the structure of the hippocampus, the focus of his work treating severe epileptic and other seizures.) During 2003–04, still fretting about the Tumor Registry, Spencer served as interim dean of the medical school.
“Institutions have things buried all over the place,” he says, and one of the forgotten treasures he unearthed during his term was an endowment left by the grateful family of a Cushing patient, to protect his legacy. It had grown over 70 years, enough to put the medical school’s staff photographer, Terry Dagradi, to work scanning and cataloguing and thinking about the glass photographic slides. In the days before CAT scans and MRIs, Cushing had used photographs as diagnostic tools, because certain disorders of the brain reveal their location by symptoms that show up in the face or in the cartilage of the hands and feet. But Dagradi was taken with the small human gestures that had slipped into what were meant purely as clinical photographs—the way one man holds a hand to the side of his face, bends his head to the opposite side, and winces, as if from an unbearable toothache; or the way an older woman holds her hand up in front of her, showing her palm, as if to say, “Don’t touch me.” “A lot of it was accidental,” says Dagradi, now curator of the Cushing Center. Whoever took the pictures “wasn’t trying to create an artistic image. But it’s such a lovely time capsule.”
The rediscovered endowment was also almost large enough, with additional help from the Cushing and Whitney families, to make a proper home for Cushing’s legacy. The medical school eventually settled on an odd pie-slice of basement beneath the library and chose an idiosyncratic architect, Turner Brooks ’65, ’70MArch, an adjunct professor at the Yale School of Architecture, to bring it to life. “We all felt that going underground worked quite well,” says Dagradi. “It doesn’t really need light, and there’s a mystery that Turner kept alive in this place that you felt when you were in the other place,” beneath the dormitory.
The effect is a bit like a grotto, with the ramp sweeping you down and releasing you into what Brooks calls “the pools and back eddies” of the main floor, where undulating cabinet fronts hold drawers full of specimens—an old Chinese surgical kit, a box containing the skulls of human fetuses. Glass cases on top display some of Cushing’s books—a first edition of Copernicus open to his model of the heliocentric universe, and another of Darwin’s Expression of the Emotions in Man and Animals.
“It’s not like putting on headphones and getting a guided tour,” says Brooks, “but you get pulled along by the current and make discoveries along the way. Gaston Bachelard in The Poetics of Space had this image about opening an armoire, and it keeps opening. You find drawers within drawers, and you hear a symphony playing somewhere inside.” And all around the room, in a curving line, the brains look down.
Each jar had to be emptied, cleaned, refilled with new preservative, and sealed, says Dagradi, “and when we first started cleaning, it was like, ‘Oh no, it’s too clear. It’s not going to have that beautiful honey color.’” But the specimens soon leached out into the new preservative and the jars took on their own individual glow. In places, they are like stained glass, particularly a glass wall of specimens that screens off a seminar room at the far end of the space. There, says Brooks, telemedicine will give future students a window on brain surgery around the world. But they’ll also look back, from time to time, through the wall of specimens, and thus through the history of brain surgery as pioneered by Harvey Cushing.
This past June, members of the Society of Neurological Surgeons, which Cushing founded, came to New Haven from around the world for their annual meeting, and held a reception in the new Cushing Center. Brooks came, too, and brought his five-year-old daughter, who looked up in wonder at the long line of brains lit up around the room. “She said, ‘Are they still thinking?’ and the comment reverberated around the room,” Brooks recalls. “And in my imagination, all the brains began to fizzle.”