“No performance in surgery more interesting and satisfactory”: Harvey Cushing and his experience with spinal cord tumors at the Johns Hopkins Hospital

Historical vignette

Restricted access

Although Harvey Cushing was a neurosurgical pioneer, his work on the spine remains largely unknown. In fact, other than his own publications, Cushing's patients with pathological lesions of the spine who were treated while he was at the Johns Hopkins Hospital, including those with spinal cord tumors, have never been previously described. The authors report on 7 patients with spinal cord tumors that Cushing treated surgically between 1898 and 1911: 2 extradural, 3 intradural extramedullary, and 2 intramedullary tumors. The authors also describe 10 patients in whom Cushing performed an “exploratory laminectomy” expecting to find a tumor, but in whom no oncological pathological entity was found. Cushing's spine surgeries were limited by challenges in making the correct diagnosis, lack of surgical precedent, and difficulty in achieving adequate intraoperative hemostasis. Other than briefly mentioning 2 of the 4 adult patients in his landmark monograph on meningiomas, these cases—both those involving tumors and those in which he performed exploratory laminectomies—have never been published before. Moreover, these cases illustrate the evolution that Harvey Cushing underwent as a spine surgeon.

Abbreviation used in this paper: LE = lower extremity.

Article Information

Address correspondence to: Ali Bydon, M.D., Department of Neurosurgery, Johns Hopkins University, 600 North Wolfe Street, Meyer 5-109, Baltimore, Maryland 21287. email: abydon1@jhmi.edu.

Please include this information when citing this paper: published online January 21, 2011; DOI: 10.3171/2010.10.SPINE10147.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 5. This 17-year-old boy presented with difficulty walking, urinary retention, and a 25-lb weight loss. His sensory examination is shown in these drawings by Cushing, with shaded areas representing decreased sensation from a lateral (A), posterior (B), anterior (C), and medial (D) view; his deficits are most consistent with a lesion in the spinal cord at L-5. Cushing noted landmarks in these drawings, including the fibula (A), the interior malleolus (C), and that the view was posterior (B).

  • View in gallery

    Case 2. This 40-year-old physician from Richmond, Virginia, presented with right arm radiculopathy and bilateral LE weakness. Cushing made a sketch of the patient's sensory examination, which was most consistent with a lesion extending from C-7 through the upper thoracic levels, and has written “Total (?) anesthesia to Pain … on back same—but incl[ude]s most of forearm. Only a very narrow radial strip Escapes.”

  • View in gallery

    Left: Case 11. This 68-year-old man presented with low-back pain, right LE radicular pain, and urinary incontinence; his examination was remarkable for right LE weakness and hyporeflexia, loss of rectal tone, and saddle anesthesia, depicted in this sketch by Cushing. Right: Case 14. This 40-year-old woman with a history of episodic LE motor and sensory deficits presented with numbness in the region drawn by Cushing. He noted her sensory deficits began “10 cm above the navel” and extended to her midthigh.

  • View in gallery

    Case 1. This 31-year-old woman presented with progressive paraplegia. Cushing performed an exploratory laminectomy and durotomy, where he found a “large lobulated tumor of the spinal meninges … [it] is impossible to enucleate the growth.” Cushing thought that the growth was a sarcoma, and sketched his intraoperative view, labeling the spinous process of “1st thoracic, completely free” as well as the spinous processes of T-6 and T-7.

  • View in gallery

    Case 10. This 20-year-old man presented with episodic LE motor and sensory deficits, as well as bowel and bladder dysfunction. Intraoperatively, the only pathological entity that Cushing found was arachnoid adhesions, and he sketched the intraoperative view of the spinal cord.

  • View in gallery

    Case 7. This 2.5-year-old girl presented with a congenital sacrococcygeal mass which measured 9 × 9 × 4.5 cm. Cushing's meticulous drawings depict this unusual mass from the posterior (A) and lateral (B) views; he also had the child and her mass photographed, with posterior (C) and supine (D) views.

References

1

Bailey P: Report of two cases of tumor of the spinal cord, unaccompanied with severe pain. J Nerv Ment Dis 21:1711781896

2

Barksdale EM JrObokhare I: Teratomas in infants and children. Curr Opin Pediatr 21:3443492009

3

Black PM: Harvey Cushing at the Peter Bent Brigham Hospital. Neurosurgery 45:99010011999

4

Burchiel K: Cushing and Bovie: lessons learned. J Neurosurg 102:5996002005

5

Caponotto: Removal of an intradural spinal tumor. Ann Surg 18:691893

6

Cohen-Gadol AALiu JKLaws ER Jr: Cushing's first case of transsphenoidal surgery: the launch of the pituitary surgery era. J Neurosurg 103:5705742005

7

Cohen-Gadol AASpencer DD: Harvey W. Cushing and cerebrovascular surgery: Part I, aneurysms. J Neurosurg 101:5475522004

8

Cohen-Gadol AASpencer DD: Harvey W. Cushing and cerebrovascular surgery: Part II, vascular malformations. J Neurosurg 101:5535592004

9

Cohen-Gadol AASpencer DD: Inauguration of pediatric neurosurgery by Harvey W. Cushing: his contributions to the surgery of posterior fossa tumors in children. Historical vignette. J Neurosurg 100:2 Suppl Pediatrics2252312004

10

Cohen-Gadol AASpencer DD: The Legacy of Harvey Cushing: Profiles of Patient Care New YorkThieme2007

11

Cohen-Gadol AASpencer DDKrauss WE: The development of techniques for resection of spinal cord tumors by Harvey W. Cushing. J Neurosurg Spine 2:92972005

12

Cushing H: Haematomyelia from gunshot wounds of the spine: a report of two cases, with recovery following symptoms of hemilesion of the cord. Am J Med Sci 115:6546821898

13

Cushing H: Haematomyelia from gunshot wounds of the spine: preliminary report presented before the Johns Hopkins Hospital Medical Society, May 3, 1897. Bull Johns Hopkins Hosp 8:1931961897

14

Cushing H: I. The control of bleeding in operations for brain tumors: with the description of silver “clips” for the occlusion of vessels inaccessible to the ligature. Ann Surg 54:1191911

15

Cushing H: The intracranial tumors of preadolescence. Report of a clinic for the combined meeting of the Pediatric Section of the New York Academy of Medicine, the Philadelphia Pediatric Society, and the New England Pediatric Society, held at the Peter Bent Brigham Hospital, Boston, October 16, 1926. Am J Dis Child 33:5515841927

16

Cushing H: IV. Intradural tumor of the cervical meninges With early restoration of function in the cord after removal of the tumor. Ann Surg 39:9349551904

17

Cushing H: The meningiomas (dural endotheliomas): their source, and favoured seat of origin. Brain 45:2823161922

18

Cushing H: The special field of neurological surgery. Bull Johns Hopkins Hosp 16:77871905

19

Cushing H: The special field of neurological surgery. Cleveland Med J 4:1251905

20

Cushing H: The special field of neurological surgery: five years later. Bull Johns Hopkins Hosp 21:3253391910

21

Cushing HEisenhardt L: Meningiomas: Their Classification Regional Behaviour Life History and Surgical End Results Springfield, ILCharles C Thomas1938. 1:

22

Danzer ESydorak RMHarrison MRAlbanese CT: Minimal access fetal surgery. Eur J Obstet Gynecol Reprod Biol 108:3132003

23

Elsworth RC: XI. Tumor of the cauda equina removed by operation: recovery. Ann Surg 46:6036071907

24

Fadler KMAskin DF: Sacrococcygeal teratoma in the newborn: a case study of prenatal management and clinical intervention. Neonatal Netw 27:1851912008

25

Gandhi CDChristiano LDEloy JAPrestigiacomo CJPost KD: The historical evolution of transsphenoidal surgery: facilitation by technological advances. Neurosurg Focus 27:3E82009

26

Gowers WRHorsley VA: A case of tumour of the spinal cord. Removal; Recovery. Med Chir Trans 71:3774301888

27

Harte RH: IV. The surgical treatment of intraspinal tumors. Ann Surg 42:5245421905

28

Hecht D: The surgery of spinal cord tumors from a neurologic viewpoint. Surg Gynecol Obstet 16:4754791913

29

Horrax G: Some of Harvey's Cushing's contributions to neurological surgery. J Neurosurg 54:4364471981

30

Horsley V: Antiseptic wax. BMJ 1:11651892

31

Hunt JRWoolsey G: I. A contribution to the symptomatology and surgical treatment of spinal cord tumors. Ann Surg 52:2893571910

32

Keen WWCoplin WM: Sacrococcygeal tumor (teratoma). Surg Gynecol Obstet 3:6616711906

33

Kunschner LJ: Harvey Cushing and medulloblastoma. Arch Neurol 59:6426452002

34

Lanzino GMaartens NFLaws ER Jr: Cushing's case XLV: Minnie G. J Neurosurg 97:2312342002

35

Laws ER: Harvey Cushing and the unity of surgery. Bull Am Coll Surg 89:8122004

36

Leopold SPhillips LB: Report of a case of sacroteratoma. N Y Med J 84:4794811906

37

Light RU: The contributions of Harvey Cushing to the techniques of neurosurgery. Surg Neurol 35:69731991

38

Liu JKCohen-Gadol AALaws ER JrCole CDKan PCouldwell WT: Harvey Cushing and Oskar Hirsch: early forefathers of modern transsphenoidal surgery. J Neurosurg 103:109611042005

39

Long DM: Harvey Cushing at Johns Hopkins. Neurosurgery 45:9839891999

40

Molnár CNemes CSzabó SFülesdi B: Harvey Cushing, a pioneer of neuroanesthesia. J Anesth 22:4834862008

41

Moore MRRossitch E JrBlack PM: The development of neurosurgical techniques: the postoperative notes and sketches of Dr. Harvey Cushing. Acta Neurochir (Wien) 101:93991989

42

Murray TJ: The history of multiple sclerosis: the changing frame of the disease over the centuries. J Neurol Sci 277:Suppl 1S3S82009

43

Osler W: Principles and Practice of Medicine ed 6New YorkD. Appleton and Company1905

44

Perrelli LD'Urzo CManzoni CPintus CDe Santis MMasini L: Sacrococcygeal teratoma. Outcome and management. An analysis of 17 cases. J Perinat Med 30:1791842002

45

Pinkus RL: Mistakes as a social construct: an historical approach. Kennedy Inst Ethics J 11:1171332001

46

Putnam JJWarren JC: The surgical treatment of tumors within the spinal canal. Am J Med Sci 118:3773931899

47

Rossitch E JrMoore MRBlack PM: Harvey Cushing operates on a child with tuberculosis of the spine. Am J Dis Child 144:17191990

48

Schulder MBlack PMAlexander E IIILoeffler JS: The influence of Harvey Cushing on neuroradiologic therapy. Radiology 201:6716741996

49

Schulder MLoeffler JSHowes AEAlexander E IIIBlack PM: Historical vignette. The radium bomb: Harvey Cushing and the interstitial irradiation of gliomas. J Neurosurg 84:5305321996

50

Sears BWGramstad GGGhanayem AJ: Cauda equina syndrome in an eleven-month-old infant following sacrococcygeal teratoma tumor resection and coccyx excision: case report. Spine 35:E22E242010

51

Sebire NJFowler DRamsay AD: Sacrococcygeal tumors in infancy and childhood; a retrospective histopathological review of 85 cases. Fetal Pediatr Pathol 23:2953032004

52

Shrivastava RKSegal SCamins MBSen CPost KD: Harvey Cushing's Meningiomas text and the historical origin of resectability criteria for the anterior one third of the superior sagittal sinus. J Neurosurg 99:7877912003

53

Starr MA: A contribution to the subject of tumors of the spinal cord. J Nerv Ment Dis 21:4234241896

54

Toledo-Pereyra LH: Harvey Cushing: father of American neurosurgery. J Invest Surg 15:1151162002

55

Udelsman R: Presidential address: Harvey Cushing: the artist. Surgery 140:8418462006

56

Voorhees JRCohen-Gadol AALaws ERSpencer DD: Battling blood loss in neurosurgery: Harvey Cushing's embrace of electrosurgery. J Neurosurg 102:7457522005

57

Walker AE: A History of Neurological Surgery BaltimoreWilliams & Wilkins1951

58

Ward BJ: A case of tumour of the spinal cord removed by operation: a review of the chief diagnostic points, variety, and operability of tumours met with in this region. BMJ 2:108310861905

59

Zaccara AIacobelli BDAdorisio OPetrarca MDi Rosa GPierro MM: Gait analysis in patients operated on for sacrococcygeal teratoma. J Pediatr Surg 39:9479522004

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 57 57 21
Full Text Views 49 49 8
PDF Downloads 138 138 12
EPUB Downloads 0 0 0

PubMed

Google Scholar