27 December 2011

Neurosurgery at Washington University: Notes to Robert L Grubb's Excellent History

Robert L. Grubb, Neurosurgery at Washington University: A Century of Excellence (The Washington University, 2011).

Robert L. Grubb's study of the development of  neurosurgery at Washington University is a truly excellent work. As I was reading it, I took fairly extensive notes from the work. These may well interest regular readers. Where appropriate, I provide a bit of context. Those of you who are familiar with my interest in the historical work of Paul Forman and the advent of modern neuroscience, will note that I have emphasized certain themes. My comments below are in bold italics.

Grubb begins with a brief history of Washington University and medicine in St. Louis.

St. Louis Medical College and the Missouri Medical College were the “oldest [medical schools] west of the Mississippi River” and were “proprietary schools, owned by their faculty and operated for profit – a common approach in the late 19th century.” (p. 7)

Grubb involves himself in an important project: namely examining the history of medicine from a point-of-view that isn't largely predicated upon views from the Northeastern USA. For example:-

William Welch once said: “One of the most significant events in the recent history of medical education in America, significant for the South and West of this country, has been the reorganization of the Washington University Medical School  in accordance with the most advanced standards of modern teaching and medical research.” (p. 17)

At moments, Grubb explains the views of early neurosurgeons on controversial changes in the way professors of medicine were remunerated. These passages are particularly choice:-

“At the end of the first decade of the 20th century, Harvey Cushing (1869-1939), the father of modern neurosurgery in the United States, was widely considered to be one of the world’s most brilliant surgeons. Early in 1910, an intense competition began to lure him from Johns Hopkins. In January 1910, he was invited to a meeting at the Carnegie Foundation in New York City where Abraham Flexner, Henry Pritchett, Robert Brookings, and David Edsall presented Cushing with the vision of a reorganized medical school at Washington University. At this meeting, he was also offered the job of chair of surgery.” (p. 21)

“In the spring of 1913, the Harvard Medical School applied for a grant for funds to implement a full-time plan [for clinical professors who normally worked part-time in clinical practice]. Among the surgeons in opposition [to full-time work] was Harvey Cushing, who had left Johns Hopkins in September 1912, just before the furor over their [full-time] plan had erupted. In his negotiations with Harvard, Cushing agreed to limit his private practice to the Peter Bent Brigham Hospital, believe that “geographic full time” was an ideal compromise position. Privately, he said that this dispute stemmed from the fact that Abraham Flexner was a socialist, who wanted everyone to have a $5000-per-year salary. In principle, Cushing said he agreed with the full-time system, since no one should neglect teaching and research to “whoring” after money: on the other hand, he did not see why he should place control of his professional future and income in the hands of hospital and university board members. (p. 23)

Grubb's brief history of neurosurgery is pithy, compact, and useful. These are the points that people might emphasize in teaching about the history of the development of sub-specialties:-

“On November 23, 1884, Sir Rickman Godlee (1849-1925) performed the first removal of a brain tumor, diagnosed and localized only by neurological symptoms and signs. Although the patient died of meningitis a month later, the surgery proved that such a procedure could be done.”  (p. 27)

A very difficult textbook to find!

“In 1889, [Ernst Von Bergmann (1836-1907)] published a widely read monograph, the first modern neurosurgical textbook, in which he concluded that brain surgery remained extremely dangerous, as operative mortality rates exceeded 50 percent. Critical analyses such as his began to temper the enthusiasm for brain surgery, which had gained momentum in the 1880s.” (p. 29)

Attitudes like these explain why neurologists in Britain became therapeutic nihilists and viewed Cushing and his disciple in Britain, Hugh Cairns, with some hostility:- 

“In the 1890s and early 1900s, surgeons undertook brain tumor operations more frequently, but the results remained discouraging. [Victor] Horsley stated in 1906: “The advance in technique of the surgical disease of the brain and spinal cord has been relatively less than the improvement in our knowledge of the seat and nature of the diseases for which surgical intervention is useful and necessary.” In 1903 [Moses] Allen Starr (1854-1932), a New York City neurologist and proponent of brain tumor surgery, analyzed 365 cases; he concluded that the absence of localized signs meant that a brain tumor was inaccessible, though tumors lying one or two inches below the brain surface might be accessible. In his opinion, cerebellopontine angle tumors were inaccessible and surgery was futile. In 1906, he wrote that only epilepsy cases with a focal aura might be helped with an operation, 60 percent of surgically treated brain abscesses recovered, and only five percent of brain tumor procedures were successful.” (p. 29)

Harvey Cushing's war diary should be required reading for every neurosurgeon - especially because of its elegance. 

“World War I produced a great many neurosurgical cases for surgery and investigation, including peripheral nerve, spinal, and head injuries; brain abscesses; and posttraumatic epilepsy. Early in the war, the mortality form serious penetrating wounds of the brain exceeded 50 percent. In fall 1917, Cushing and his assistant, Gilbert Horrax (1887-1957), were deployed with Harvard’s Base Hospital No. 5 and assigned to a forward station during the battle of Passchendaele. In the first three months of the battle, they reduced the mortality from penetrating wounds of the dura and brain from 54.5 percent to 28.8 percent. They used Cushing’s techniques for wound debridement, which consisted of encircling the wound, sucking out foreign debris and pulped brain, cleaning the fragment tracts in the brain, and meticulously closing the wound. Another significant advance during the war was the development of local anesthesia for cranial surgery by French neurosurgeon Thierry de Martel (1876-1940).” (p. 34)

Otfrid Foerster was undoubtedly one of the most innovative neurosurgeons of his day. Of course, some called him a neurologist...

“In early 20th century, pain-relieving spinal procedures began to appear. Otfrid Foerster (1878-1941), working in Germany, divided the seventh through the tenth thoracic sensory roots in a patient suffering from gastric crisis of tabes.  Foerster later devised posterior rhizotomy for the treatment of spasticity. A much better operation for relief of pain in the trunk and lower extremities was proposed by William G. Spiller and initially performed by his surgical colleague Edward Martin in 1911 at the University of Pennsylvania. This procedure, known as cordotomy, divided the spinothalamic tracts in the spinal cord. The procedure was popularized by Charles Frazier and further refined by Foerster.” (p. 36)

Notice that visualizing the brain became important at about the same time as the advent of the lobotomy:- 

“Antonio Caetano de Egas Moniz (1874-1955) of Lisbon, Portugal, who was awarded the Nobel Prize in 1949 for his description of prefrontal leucotomy for psychiatric disorders, introduced cerebral angiography in 1927. In 1933, Moniz reported the first angiographic demonstration of cerebral aneurysm.” (p. 37)

I didn't know this story - fascinating!

“In 1886, [John Hughlings] Jackson convinced [Victor} Horsley to perform a craniotomy to try to cure epilepsy in a 22-year-old male, who had suffered a depressed comminuted skull fracture 15 years earlier and developed  prolonged focal motor seizures. Horsley excited a cortical scar, along with a border of surrounding cortex, and arrested the seizures – thus supporting the theory of cerebral localization and the Jacksonian concept of the etiology of focal epilepsy.”

Grubb's brief biography of Ernest Sachs is a real contribution to the history of neurology and neurosurgery. And stories like these are worth repeating over and over again:-

“Often Bernard Sachs (Ernest’s uncle) expressed his concern about the poor results obtained by surgeons in neurosurgical cases during the early 1900s. In his autobiography, Ernest Sachs noted that he did not see a single brain tumor successfully removed during his training at Mount Sinai (1904-07). Bernard Sachs advised his nephew to devote his life to the development of nervous system surgery and arranged for him to work with Sir Victor Horsley, the first surgeon appointed to the staff of the National Hospital for Paralysis and Epilepsy, Queen Square, London. At this time, Horsley had the only well-established neurosurgical practice in the world, and Bernard Sachs felt that by sending his nephew to London, he would create a specialist surgeon. Ernest Sachs set about his training to become a neurosurgeon in an orderly manner, becoming the first person trained for this new specialty with the explicit intention of making it his life’s work.” (p. 44)

And this one should be repeated very loudly in the presence of academics who steal the work of their junior colleagues:-

“In the publication of [Sach’s paper ‘On the Structure and Functional Relations of the Optic Thalamus’], Horsley demonstrated one of his many admirable qualities: his generosity towards his younger colleagues. In a 1957 article, Sachs noted: ‘When I had completed the research (on the optic thalamus) I had been carrying on in his laboratory, I presented him with the manuscript and, naturally had put his name and mine on the title page. He crossed out his name with the remark: ‘as long as it is customary, when two men published a paper, to give credit to one who is better known, I shall not allow my name to appear.’” (p. 46)

I talk about this in my forthcoming volume: The Neurological Patient in History:-

“Sachs felt that Horsley’s diagnostic ability was remarkable. A trained neurologist and a student of neurophysiology, who approached all neurological problems from an anatomic-physiologic angle, he did not consult with neurologists to plan operative approaches, feeling that a neurosurgeon should make his own diagnoses and localizations.” (p. 48).

Check this out: this passage is certain one of the best demonstrations of the structural changes World War I introduced into medicine:-

“With the entrance of the United States into World War I, a new duty was added to [Sachs’ workload]. In May 1917, the Surgeon General of the Army, Colonel William C. Gorgas, convened a meeting in Washington D.C., to discuss the neurosurgical needs of the Army. While Cushing had left for France, Sachs, Charles Frazier (1870-1936), Dean Lewis, Allen Kanavel, William Spiller (1863-1940), and others attended the meeting. Gorgas informed the group that the Army was planning to set up 100 hospitals and wanted a neurosurgeon at each one. When he heard there were not that many neurosurgeons in the world, Gorgas told the group that it was up to them to furnish the men.” (p. 57)

A terrific anecdote:-

“In 1919, Cushing gave a major address to the American College of Surgeons meeting in New York City, describing his results from a large series of patients with brain tumors. At the conclusion of his presentation, William J Mayo, chairman of the session, announced: “Gentleman, we have this day witnessed the birth of a new specialty – neurological surgery.” (p. 64)

The interdisciplinary view begins: shades of proto-neuroscience?

“During the late 1930s, Joseph Erlanger, the chairman of the physiology department [at Washington University], promoted and chaired a research focused group called “Executive Committee of the Neurological Institute.” This idea for a neurological institute began with the neurophysiologists at Washington University, but it was always seen as an interdisciplinary activity that would facilitate the exchange of ideas, pool resources for equipment, and obtain funds…” (p. 70)

Sachs saw the advantage of neuroimaging technologies. In some sense that makes sense. Neurosurgery was almost certainly the driver for technological change in neurological medicine. The word translational comes to mind.

“Another fact in the increase [in neurosurgery’s success] was Sachs’ acceptance of ventriculography and penumoencephalography as routine ways to image patients with neurological problems.” (p. 81)

The story of how American scientists and physicians aided Jewish emigres, which has been told in a limited fashion, really requires a full exploration.

“In the late 1930s, Sachs participated in a committee, headed by his uncle Bernard Sachs, that aided physicians displaced by the rise of Fascist-inspired anti-Semitism in Europe.” (p. 83)

Words of wisdom, which I hope to remember.

“In early September, Sachs flew to Paris for a meeting and met his son, Ernest there. He noted, ‘it took me several years to adjust to a sedentary life after the physically active life I had lived for almost forty years, and I missed the thrill and excitement of the operating room, but I felt it was a wise decision. It is far better to step out while the going is good than to realize one is gradually being replaced.” (p. 101)

My backyard...but I've never visited.

“On December 2, 1958, just a few weeks before his 80th birthday, Ernest Sachs quietly died of pneumonia in New Haven, Connecticut. He is buried beside his wife and daughter in Keene Valley, New York, at the foot of Mt. Marcy, the highest peak in the Adirondack Mountains, surrounded by scenes of his happy youth and even happier later years.” (p. 104)

Grubb's discussion of neurosurgery's major formative period in the 20th century:

“Modern psychosurgery is often described as beginning in 1935 when Antonio Caetano de Egas Moniz (1874-1955) of Lisbon, Portugal, performed his first prefrontal leucotomy. He was inspired by the 1935 presentations of John Fulton (1899-1960) and Carlyle Jacobsen (1902-74) at the Second International Neurology Congress in London, describing the behavioral changes seen in monkeys after a frontal lobotomy. Moniz shared the Nobel Prize in Physiology and Medicine in 1949 with Walter Hess for his work on prefrontal lobotomy, described as ‘one of the most important discoveries ever made in psychiatric therapy.’” (p. 127)

Grubb's return to scanning and visualization technologies.

The advent of CT scanning in the early 1970s and MR scanning in the early 1980s enhanced stereotaxis. The Leksell stereotactic system was modified for use with a CT scanner and further modified for use with a MR imagining device. The Brown-Roberts-Wells stereotactic system, introduced in 1980, was an interlocking arc system designed for use initially with a CT scanner to localize a target and calculate stereotactic coordinates. When MR imaging became available, the system was modified for us with MR scanning to localize targets and calculate stereotactic coordinates.” (p. 130)

Grubb's brief biography of Henry Schwartz is extremely useful. These passages on World War II are extremely illuminating, because other than John Silver's study of nerve injuries, there is little work done on them in Second War.

“At the beginning of [World War II], army policy was to debride and primarily close penetrating brain injuries only if they were less than 12 hours old; otherwise, they were to be debrided and packed open, with the instillation of sulfon-amide powder into the open wound. However, the rapidly shifting battle lines in the North African campaign and difficulties with transportation made rapid evacuation of many casualties difficult. Schwartz soon began to debride and primarily close penetrating brain wounds that were several days old. He used suction and direct visualization of the missile track to radically debride necrotic brain and remove all the bone fragments in the brain, except those located in deeper, inaccessible areas where their removal might cause unacceptable neurological deficits. Missile fragments were only removed in they were easily accessible. The dura was not closed, unless it could be primarily approximated; the scalp was debrided and primarily closed. Almost immediately, Schwartz noted improved results and a reduced incidence of infection and cerebral fungus formation. The instillation of sulfonamides into a contaminated wound had little effect in preventing infections.” (p. 152)

Patrons always matter:-

“During his tenure as chairman [of Washington University’s Department of Surgery], Schwartz had cared for several members of the Busch family and become friends with August A. Busch, Jr., the Anheuser-Busch chairman. In 1970, the Anheuser-Busch Charitable Trust gave $500,000 to endow a professorship in neurological surgery in tribute to Schwartz. Although Washington University had appointed the world’s first professor of neurosurgery in 1919, it had never before had an endowment to support a permanent professorship in neurological surgery.” (p. 169)

Education matters!

“Throughout his life, Henry Schwartz had an overriding interest in education. In 1975, Paul Bucy, editor of the journal Surgical Neurology wrote: ‘…He has organized and conducted one of the most outstanding neurosurgical training programs in the world. He has demonstrated how neurology and neurosurgery can effectively work together and still be independent. He has successfully incorporated training and scientific research into a superb training program in clinical neurosurgery.’” (p. 183)

And being a good educator can really matter!

“When Schwartz retired as chairman of the Division of Neurosurgery in June  1974, he commented, “I feel that if I had to list my accomplishments, I would want to be remembered for the training of outstanding doctors in neurological surgery.” Of the 37 residents who completed their training under Henry Schwartz, 16 became chairman of neurosurgery training programs in United States medical schools and six others became full professors in neurosurgical academic programs. No other neurosurgical training program in the United States matched this record in the latter part of the 20th century.” (p. 184)

See, it really does matter!

“Schwartz set the same high standards for himself that he did for others. He paid meticulous attention to detail and was a dedicated physician, a perfectionist in patient care. He had an uncanny ability to impart his remarkable sense of responsibility and ethics to his trainees. His influence on them remained throughout their lives; they never quite lost the feeling that he was looking over their shoulders, checking to be certain they were doing the right thing. Nothing pleased him more than to see his residents succeed in their careers, both in academic neurosurgery and in private practice. Schwartz always put immense emphasis on loyalty to the institutions he served and to the people whom he worked with, and this sense of loyalty also applied to his former residents. In return, he expected them to remain loyal to their fellow residents and their program. This feeling led to the legendary, but entirely fictitious, “St. Louis Neurosurgical Mafia”. (p. 186)

A Brief Biography about Sidney Goldring and Neuroscience, 1974-89

“In his 1985 American Association of Neurological Surgeons (AANS) presidential address, [Sidney Goldring] summarized his perspective: ‘History tells us that if we are to sustain neurological surgery as a vibrant surgical specialty, we must continue to give top priority to the preparation of top minds through education and research.” (p. 199)

Developing trends in computing played an enormously important role in the making of Washington University’s neurological sciences program.

“James O’Leary and Sidney Goldring submitted an application to the NIH – the only one submitted by clinicians – and were awarded a LINC computer. One condition of the award was that an investigator had to go to MIT and not only learn how to use the computer, but also participate in the final assembly of the computer they would use. Goldring and Lloyd Simpson, who provided technical and engineering support to neurology and neurosurgery investigators working in McMillan, spent nearly a month during the summer of 1963 in Cambridge learning how to program and use the LINC computer, and also how to partially assemble and repair it. Goldring and O’Leary had decided to use the computer to do the computations involved in averaging evoked potential responses – a process that separated the responses from the background noise created by spontaneous electrical waves in the brain – and Goldring wrote a program for averaging these responses. O’Leary and Goldring thought that the LINC computer would be extremely helpful in studies of the sensory input into the human brain, which could be done during operations for epilepsy. Through the efforts of electrical engineering faculty member Jerome Cox, Clark and Molnar moved to Washington University in 1966 and established the Computer Systems Laboratory. For the next 25 years, Goldring used the LiNC computer in his laboratory, while acquiring other more up-to-date equipment.” (p. 204-5)

The Founding of the McDonnell Centre for Studies of Higher Brain Function

“James S. McDonnell, Jr., founded the McDonnell Aircraft Corporation in St. Louis in 1939. His company purchased the Douglas Aircraft Company in 1967, and two years later the MCDonnell-Douglas Corporation became the first aerospace manufacturer to record more than $100 million of profit in a single year. As his business grew, he became interested in community service and philanthropy. He joined the Washington University board in 1960, became its chairman in 1963, and soon knew everything about every issue involving the university.”  (p. 217)

“The concept of establishing a center for studies of higher brain function gradually evolved from discussion with McDonnell in the 1970s. Outside his business concerns, McDonnell was interested in three areas: space science, genetics, and higher brain function, especially the relationship of the mind and brain. He had become interested in extrasensory perception (ESP) during his college years at Princeton University. During a trip across the country, he found himself in a small Midwestern town where, with nothing to do, he went to the local library. A book on parapsychology caught his eye, and after he had read part of the book, he decided that this was the most exciting field that he had encountered. Upon his return to Princeton, he told his faculty advisor that he wanted to change his major from engineering to psychology, with the idea of studying ESP and other paranormal phenomena. His advisor rejected the idea.” ((p. 218)

“And it was a really big check.”

“McDonnell was prepared to give a large sum of money to Washington University, and perhaps other institutions, if they would agree to set up a department for the study of ESP and psychic research. Since William Danforth and other members of the University community had great respect for McDonnell, and were indebted to him in many ways, they wanted to give his ideas a ‘fair shake’.” (p. 218)

ESP proved very difficult to study – so too did other paranormal activity.

“McDonnell was disappointed, but he again said he believe that extrasensory phenomenon existed. [William Maxwell] Cowan later recalled saying: “Would you agree, Mr. Mac [McDonnell’s nickname], that such phenomena as ESP and ‘remote viewing’ must ultimately be mediated by the human brain” McDonnell replied: “I agree with that.” Cowan then said: “Perhaps the problem lies in the fact that we do not know enough about how our brains work. We may be trying to understand the paranormal when we still know very little about the normal function of the brain. It is like trying to put a man into space or on the moon before Kitty Hawk has left the ground.” McDonnell replied: “Now you are talking my language. You might be right. I need to think about this.”’ (p. 220)

How these activities turned into a program of research

“During the 1970s, Cowan had become increasingly involved with the Salk Institute in La Jolla, California, and in 1979 he decided to leave Washington University and take a position there. Meanwhile, McDonnell had become friendly with Wilder Penfield – a 1913 Princeton University graduate, neurosurgeon, and director of the Montreal Neurological Institute – who had won widespread acclaim for his surgical treatment of certain types of epilepsy and his studies of cortical brain functions using electrical stimulation awake patients undergoing craniotomies. Penfield believe that he had thoroughly mapped functions of the brain by his observations of epileptic patients and his functional localization studies in human patients in the operating room. However had had never found a location in the brain where mental activities reside. He had observed that stimulation of the brain never changed a person’s opinion. Admitting that this did not prove that mental activities were not controlled by the brain, Penfield still felt that his research, and the inferences it stimulated suggested that the mind might be more ethereal. These concepts were discussed in his book The Mystery of the Mind. McDonnell frequently recommended Penfield’s book when discussing his ideas about the function of the mind.

Eventually McDonnell asked Guze and Danforth if there was anyone at the University who shared Penfield’s interest in epilepsy surgery. He also inquired about the new technology of positron emission tomography (PET), which was being developed at the School of Medicine. In a meeting on February 6, 19080, Guze arranged for McDonnell to hear three presentations: Goldring described his experience in the surgery of epilepsy; Michael Ter-Pogossia discussed developments in PET; and Thomas Thach, and neurobiologist who was interested in the sequence of events that occur in the brain to initiate involuntary movement, presented his work. The meeting was extremely successful. Goldring and McDonnell debated whether or not the brain and human mind are separate entities, discussing evidence on both sides. Goldring asked McDonnell: “Let us say that I can no more prove that the mind and brain are one than you can that they are separate, but let us agree that whatever the answers to those questions are, that we need to know as much as we can about the brain.”  McDonnell replied: “Agreed…. I want you write me a proposal. It can be large or it can be small. But I want you to write me a proposal.” The following day, McDonnell wrote to Danforth, Guze, Goldring, Ter-Pogossian and Thatch: “Having pondered and slept on it, I want to again thank you for yesterday morning’s briefing. What a wonderful briefing!” (p. 221-222)

“When Goldring had finalized his proposal, it contained an appendix listing a one-page summary of 47 investigators, both basic scientists and clinicians, in the field of neuroscience at Washington University. The operating cost of the center over a five-year period was project to be $1.8 million, and it was proposed that a total contribution of $5.5 million be given to the center over the first five years.” (p. 222) 

The upshot! Amazing....

“On April 16, Goldring walked into his office and noticed that his secretary had a “funny look” on her face. Danforth had called and left a message. “Board of McDonnell Foundation has acted favorably.” Many years later Danforth recalled: “Sid had been chosen to lead a multi-departmental, multi-disciplinary effort that we had named the Center for the Study of Higher Brain Function. “ (p. 223)

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