A neurosurgeon’s photographic legacy

Early in the 20th century the country’s leading neurosurgeon was Harvey Cushing, M.D., a practitioner whose meticulous standards and innovative techniques set the stage for those who followed. Surgical tools and neurological diseases bear his name; among his achievements are improved patient survival rates, the introduction of local anesthesia to brain surgery and the use of X-rays to diagnose brain tumors.

His attention to detail also led to the creation of the Brain Tumor Registry, a collection of more than 2,200 patient case studies that includes human whole-brain specimens, tumor specimens, microscope slides, notes, journal excerpts and more than 15,000 photographic negatives. The materials, which date from as early as 1887, were organized and classified by Cushing’s assistants, Percival Bailey, M.D., and Louise Eisenhardt, M.D. In addition, from 1922 until Cushing’s retirement a decade later, Eisenhardt kept a “little black book” that included case results, diagnoses and mortality percentages for every type of tumor operated on at the Peter Bent Brigham Hospital in Boston.

Cushing arrived in Boston in 1912 from Johns Hopkins Hospital, where he had completed his surgical residency. The trustees of the new Brigham Hospital had offered him not only a post as surgeon in chief but also the opportunity to help design the building, set policies and establish a section of neurological surgery. In addition, Cushing had a position as a professor of surgery at Harvard. Within three years he had achieved a surgical mortality rate of 8.4 percent, while other leading neurosurgeons were reporting rates of 38 to 50 percent. He attributed his success to his insistence on sterile procedures that reduced infections, a leading cause of mortality in brain operations. Cushing also laid the groundwork for the basic classification of brain tumors and was responsible for the first applications of electricity to neurosurgery by using a newly developed electric scalpel.

On Cushing’s retirement from Harvard in 1932, he returned to Yale, where he had received his bachelor’s degree in 1891, as the Sterling Professor of Medicine in Neurology. His tumor registry followed him. Its first home at Yale was the Brady Museum, where anyone interested in brain tumors was invited to use the collection for study. Over time the collection fell into disuse and ended up in a room in the basement of the Harkness dormitory. Christopher J.Wahl, M.D. ’96, rediscovered the collection as a medical student and wrote his degree thesis on it.

Last fall Dennis D. Spencer, M.D., HS ’77, chair and the Harvey and Kate Cushing Professor of Neurosurgery, and Aaron A. Cohen-Gadol, M.D., published The Legacy of Harvey Cushing: Profiles of Patient Care. An excerpt from the introduction, written by Wahl, Spencer, Cohen-Gadol and Terry Dagradi, curator of the photography collection, follows.

In 1902, a golf ball-sized piece of brain tissue, or more to the point, the conspicuous absence of a golf ball-sized piece of tissue, was the catalyst that led to the conception of the Cushing Brain Tumor Registry. Cushing’s opportunities for intracranial tumor surgery at Johns Hopkins Hospital were few and far between and successes were rare. Still, he regularly examined all tissues removed during surgical cases, a habit he learned from his mentors, William S. Halsted, M.D., chief of surgery at Hopkins, and Emil Theodore Kocher, M.D., a Swiss surgeon who won the 1909 Nobel Prize in physiology or medicine for his work on the physiology, pathology and surgery of the thyroid gland. Following the removal of a “pituitary cyst” from a female patient, the Johns Hopkins Pathology Department “misplaced” Cushing’s tissue specimen. The young surgeon, prone to fits of anger—which occasionally drew admonition from chief of medicine William Osler, M.D.—failed to contain his fury. He insisted that from that day on, he would be allowed to personally retain all specimens removed during his operative cases or autopsy.

[Cushing moved to Harvard and the Brigham Hospital in 1912, where he continued his practice of keeping meticulous records on each and every patient. Upon reaching Harvard’s mandatory retirement age of 63 in 1932, he accepted a position at Yale and opened his collection to the medical community. Cushing died in New Haven in 1939.]

For two decades, Yale’s Brain Tumor Registry, with Eisenhardt at the helm, remained a site of pilgrimage for young neurosurgeons and neuropathologists to study intracranial pathologies. Elias E. Manuelidis, M.D., became Eisenhardt’s successor in the section of neuropathology and curator of the enormous archive. Throughout the 1940s and ’50s, many young scholars, particularly neurosurgeons and neuropathologists studying for their certification boards, came to New Haven to utilize the collection. Over time, however, the gross specimens and photographic negatives came to be little used for research purposes. By 1968, the year after Eisenhardt’s death, Manuelidis faced a tremendous problem; the section of neuropathology at Yale prepared to secede from pathology. With the organizational split, laboratory space would be scarce; and vast bookshelves, stacked floor to ceiling with gallon receptacles containing brain specimens and stacks of photographic negatives, would play a minor role in the changing atmosphere of scientific research.

The 40-year-old specimens had fallen into a chronological void—too old to be of scientific value but ironically, too young to be of historical interest. The unwieldy archive also reeked of formaldehyde. The Edward S. Harkness Medical School Dormitory at Yale, built in 1955, retained rooms in the sub-basement for storage adjacent to a fallout shelter. Many of the storage cages contained provisions for a nuclear emergency, including large barrel tins of meal, drinking water and sanitary supplies; others were used for cold storage of building supplies, file cabinets and discarded medical equipment. Manuelidis acquired permission to stow the entire Cushing collection—photographic negatives, gross specimens, laboratory materials and dyes, even an old gurney—in a locked room near the shelter. He employed the help of faculty and students, and moved everything save the microscopic slides (which are still in use today) into the space below the dormitory. The collection remains in this sub-basement.

Patient photographs and records

Unexpectedly, the most revealing source of information related to Cushing’s work lay in the Brain Tumor Registry’s 15,000 photographic negatives. Cushing’s negatives portray patients pre- and postoperatively, gross specimens, tumor specimens, photomicrographs, journal excerpts, letters and any other number of images relating to the early years of brain tumor surgery. The photographs often portray obsolete surgical practices as well as tumors that have grown to proportions rarely seen today outside the Third World. They also allude to the symptomatology, signs and diagnostic techniques that led Cushing, Eisenhardt and Bailey to lay the foundations of modern neurosurgery and neuropathology. Approximately 80 percent of the negatives are etched into the emulsion of 5-by-7-inch glass plates; the remaining negatives appear on celluloid film. Owing to the negatives’ large format, the prints are striking for their clarity and detail.

Because the negatives are in chronological order correlated with the hospital records, Cushing preserved for history a remarkable photographic diary. In the photographic negatives, one can follow Cushing’s observations of the clinical presentation of disease. One sees the sudden emergence of new surgical approaches, documented in the records and complemented by novel intraoperative drawings and photographs of patients with craniotomy scars indicative of a changing technique. In these images, radiographs provide evidence of the emergence of the silver hemostatic clip; portraits exhibit similarities in morphology leading to Cushing’s elucidation of pituitary basophilism; and histological photomicrographs highlight the utilization of staining techniques that Bailey brought to the Brigham.

The microfilmed hospital records that accompany the photographs indicate that Cushing cultivated in his residents the same meticulous attention to factual detail for which he is known. Past medical histories, family histories, complaints, progress notes, laboratory and perimetry results, neurological and physical examinations, operative notes, postmortem reports, telegrams, correspondence, and Cushing’s ubiquitous operative sketches make the records so comprehensive that scientific studies of the cases, including the applications of premorbidity scales, are possible. The photographic negatives and patient records tell the historian much about Cushing, indeed much about the state of clinical medicine and surgery at the Peter Bent Brigham Hospital in the early part of the 20th century.

Cushing’s photographic legacy

To further understand the possible contributing factors behind Cushing’s interest in photographing his patients, one needs to review a brief history of photography itself. In 1839 Louis-Jacques-Mandé Daguerre presented to the world his technique for developing a photographic process based on mercury vapor and silver iodide fixed by hot common salt. Although fragile, the daguerreotype was extremely popular in America between 1839 and 1860, about 3 million being produced each year at a peak in the early 1850s. Medical journals began to photograph patients before and after surgery, primarily for head and neck cancers and plastic procedures.

Following the daguerreotype, a wet plate process that used collodion, a mixture of guncotton in alcohol and ether, was introduced to make the first photographs on glass. The ambrotype perfected the collodion process in 1854 but was soon replaced by the tintype, invented by Hamilton L. Smith in Ohio in 1856. In 1880, a bank clerk named George Eastman obtained a patent in the United States for a photographic dry plate developed in England in 1878. He followed his dry plates with the invention of photographic film in roll form in 1883. By 1900, cheap cellulose film and cameras were available to the public. Cushing or the unknown photographer at the Brigham, however, chose to continue using the dry glass plate technique from the earliest photo available in 1903 to the latest one in 1930. Several later photos were taken with the newer cellulose film; they have not withstood the aging process. On the other hand, the glass plates are perfectly preserved and are of remarkably high quality.

Cushing’s early 20th-century portraits were grounded in the late 19th-century tradition of scientific facial photography. Although X-ray imaging was to emerge as the next extension of human sight, peeling off one more layer of tissue between the viewer and the living brain, Cushing used photographs as an extension of his diagnostic powers and a catalog of his historical sense.

In the Cushing Brain Tumor Registry for 75 years had lain the portraits of every patient Cushing touched, almost always photographed before and after an operation, but many times serially during the hospital stay, particularly if the patient were deteriorating. When there was nothing more Cushing could do as a surgeon, he documented the unrelenting course of the illness and the patient’s death. And, for the majority of his patients who survived, he often chronicled their clinic visits, sending the patient down for a “routine photo,” as we would repeat an MRI scan today. Unfortunately, we have no clue as to who took these pictures, whether it was the same person or a series of photographers. The quality, however, speaks for a professional who understood how these diseases were to be represented for Cushing and who knew that the quality and permanence of the glass plate method were superior to the more acceptable and common practice of using cellulose film.

Cushing never wrote about his patient portraits or their faces as an emotional response to their diseases. Instead, he described brain disease, often for the first time, through the camera’s lens. Cushing’s groundbreaking work in identifying and classifying tumors of pituitary and parapituitary origin may have stimulated the first photographs of patients with these tumors. The phenotypic expression of such pituitary tumors as acromegaly, a rare disorder that results in increased growth of bone and soft tissue, could be identified in pictures and documented for publication, and the photographs could be repeated to look for progression or remission after surgery. However, Cushing did not photograph only those patients with obvious phenotypic expression of their disorders; he photographed essentially every patient in his care. Although it is not clear how most of these images contributed to patient care, education, or research at the time, the possible unintended consequences for art and history are incredibly powerful.

These patients’ photographs are most likely the first, as well as the most complete, catalog of neurological disease at the beginning of the 20th century. What makes them even more powerful is Cushing’s compulsive cross-reference process that ties each picture to the available hospital record on microfilm. Cushing also captured in the patients’ faces what we do not image today—loneliness, fear, pain, trust, despair, and often just stoicism.

By any measure, Cushing’s written and photographic diary of neurosurgery in the early part of the 20th century steps beyond semantic issues. The technique and large format of the photographic negatives capture a raw emotional energy and oftentimes macabre subject matter that bring the viewer into empathetic participation with Cushing’s patients. This relationship becomes much more sublime when one stops to consider the age of the photographs and recognizes that while neurosurgery has changed so much over this past century, the experience of being a patient has not. In 1969, the year Cushing would have been a centenarian, the neurosurgeon and author Wilder Penfield, M.D., qualified him as “an artist, a Leonardo da Vinci devoting his talent to surgery.” The passing of time and the re-evaluation of the materials belonging to the Harvey Cushing Brain Tumor Registry confirm the accuracy of Penfield’s statement. YM