Surgery Leadership: A History
By Donald O. Quest’70
|CLOCKWISE FROM TOP LEFT: Byron Stookey,
Lester Mount, Bennett Stein, and Edward Schlesinger
In 1909 the Neurological Institute of New York was incorporated as the first hospital in America devoted solely to the care of patients with neurological illnesses. A building purchased at 149 E. 67th St. in New York housed 57 patient beds, offices, clinic facilities, and an operating room where Charles Elsberg performed the first operation — the removal of an intramedullary spinal cord tumor.
Elsberg was the first chairman of the neurosurgical department. He was a member of the pioneer generation of American neurosurgery and was a founder, along with Harvey Cushing, Charles Frazier, Bernard Sachs, and others, of the Society of Neurological Surgeons. He popularized the surgical technique of operating on spinal cord tumors in two stages, first simply incising the cord to return some weeks later for removal of the tumor that had extruded. He wrote a classic book on spine surgery. When he retired at age 65, he had served as chairman of the department for 27 years.
In 1925 the Neurological Institute and Presbyterian Hospital decided to join forces at what had become known as Columbia-Presbyterian Medical Center. The Neurological Institute of New York moved into a new building that housed offices, patient rooms, operating rooms, radiological suites, and laboratories.
The Neurological Institute continued to have its own Medical Board and Board of Trustees until becoming part of Presbyterian Hospital in 1943.
Byron Stookey followed Elsberg as chairman of the neurosurgical department in 1937. He mastered peripheral nerve surgery during his service in World War I, partnered with Elsberg in his work on spinal surgery, and developed the procedure of puncturing the lamina terminalis as a treatment for hydrocephalus. He was a renowned teacher and meticulous surgeon, demanding and imperious, and his personality traits most likely contributed to his loss of the chairmanship two years later. He was a founding member of the American Board of Neurological Surgery and in retirement wrote a widely acclaimed book, “A History of Colonial Medical Education.”
Tracy Putnam, in an expanded role, followed Stookey as chairman. He was a “Boston Brahmin,” tracing his distinguished family heritage to the Plymouth and Massachusetts Bay colonies. A graduate of Harvard Medical School, he trained in pathology at Johns Hopkins and surgery at Massachusetts General Hospital and was one of Harvey Cushing’s residents. He became director of the Neurological Institute and chair of both neurosurgery and neurology in 1939. He achieved lasting fame as the co-developer (with H. Houston Merritt) of phenytoin, the premier medication to treat epilepsy. Putnam ran afoul of the leaders of the hospital who felt he lacked administrative competence, and he was dismissed in 1946. He moved to Los Angeles and became chief of neurosurgery at Cedars of Lebanon Hospital, where he worked until retirement.
J. Lawrence Pool was appointed chairman of the neurosurgical department in 1949 after a three-year interim period led by John E. “Teddy” Scarff, a Cushing trainee, long-time member of the department, and a Stookey colleague. “Larry” Pool was a dynamic, innovative, and brilliant individual who made many contributions to the field of neurosurgery: early use of the surgical microscope, hypothermia and temporary clips in aneurysm surgery, extracranial-intracranial bypass, to name a few. He was multi-talented: a great athlete (twice winning the national squash championship while an undergraduate at Harvard), seaplane aviator, Bermuda Cup sailor, author of many books (medical and non-medical), and a superb water colorist. He was a wonderful mentor and teacher, erudite, witty, and elegant.
After Pool’s retirement in 1972, Lester Mount led the department as acting chairman for one year. Words like fastidious, deliberate, resolute, assiduous, tenacious, unrelenting, undaunting, and pertinacious fail to fully capture his unique personal characteristics and operative style. He was a busy surgeon and his patients did superbly well. In 1973, Edward Schlesinger became chairman. His interest and expertise was in spinal disorders, being one of the first neurosurgeons to elucidate the pathogenesis, symptomatology, and management of spinal stenosis.
In 1980, Bennett Stein assumed the chairmanship. With his intrepid and innovative surgical skills, abiding interest in teaching, and superb leadership qualities, he became a role model for medical students, residents, and faculty. He made significant contributions in the areas of pineal tumors, arteriovenous malformations, and intramedullary spinal cord tumors. He developed the administrative foundation of the department, setting the stage for its advent into the modern era.
Upon the retirement of Ben Stein in 1996 the author led the department for one year until Robert Solomon was selected as chairman. He greatly expanded the department’s cerebrovascular research efforts, with productive investigation of hemorrhagic and ischemic cerebrovascular disease. His research interests coincide with his surgical mastery in the management of aneurysms, arteriovenous malformations, and carotid disease. His strong and creative leadership ensures that the department stays in the vanguard of advances in the field of neurosurgery.
The past 100 years in the life of the Neurological Institute of New York have hosted many illustrious leaders in neurology, pediatric neurology, neuroradiology, neuropathology, and neuroscience.
Many eminent Neurological Institute neurosurgery alumni are in academia and private practice, and many leaders in American neurosurgery have come from this institution. Of the more than 170 neurosurgeons who have trained at the Institute, 26 have become department chairmen and 25 have been president of national neurosurgical organizations. P&S continues to supply more medical students to neurosurgical residencies throughout the country than any other medical school. The Neurological Institute of New York is proud of its past and looks forward to a promising future.
Donald Quest, M.D., FACS, graduated from P&S, then started his training at Massachusetts General Hospital. He completed his residency in neurological surgery at Neurological Institute of New York and has been a member of the P&S faculty since 1978. He is the J. Lawrence Pool Professor of Neurological Surgery.
NINY and Neuroradiology: A Remembrance
Before CT and MRI imaging changed the landscape of clinical neurology, medical students and residents at NINY relied on radiology basics while preparing to be neurologists. Donald H. Harter, M.D., a P&S graduate who completed his residency at NINY, recalls the role of the resident in the emerging specialty of neuroradiology.
By Donald H. Harter’57
|A special chair designed by neuroradiologist
Gordon Potts helped rotate patients for
No rational person would contend that clinical
neurology before the introduction of brain imaging was a golden or utopian period. The ability to visualize the human nervous system by non-invasive means was a true medical revolution that benefited both the patient and the neurological practitioner.
A significant portion of the first-year resident’s time in the late 1950s and early 1960s was spent in the performance of the most common radiological procedures: angiography, pneumoencephalography, and lumbar myelography. These procedures were time-consuming and difficult to perform.
Angiography was done by direct puncture of the common carotid or vertebral artery. The patient was positioned on the procedure table with his or her neck hyperextended. After testing for sensitivity to the radiographic dye, a local anesthetic was applied to the neck, the carotid artery was held in position, and puncture of the vessel was attempted with a needle containing a trochar. When one believed that the artery had been successfully punctured, the trochar was removed and arterial blood would spurt forth. A resident was often allowed only a limited number of attempts before the task was turned over to another resident or fellow whose efforts might prove more successful.
A syringe containing contrast material was then hooked up to the needle, dye was injected, and a scout film of the neck was taken to ensure that the contrast material was entering the artery and no extravasation of dye into soft tissues had occurred. If the needle was correctly positioned and the common carotid artery and bifurcation were properly outlined, a larger volume of dye was injected and an automatically timed series of X-ray films was exposed. The films were developed in wet solutions in a darkroom adjacent to the procedure room and placed on an apparatus consisting of two large reels that could be turned by handles. Dripping wet, the films were taken to the neuroradiology reading room for review by Dr. Juan Taveras, one of the outstanding neuroradiologists of his time, or another staff neuroradiologist. During this entire period, the patient remained in position in the procedure room in case additional views were required to define a suspicious region.
Puncture of the vertebral artery was considerably more difficult than carotid puncture because one had to use a longer needle and place it perpendicularly to the patient’s neck to impale the artery against the vertebral body without being able to palpate the artery or utilize any distinct anatomical landmarks. Nevertheless, some members of the house staff became very adept at vertebral artery puncture.
Pneumoencephalography was technically a simpler procedure, but it was many times more taxing to the patient. It involved a lumbar puncture and the exchange of air for cerebrospinal fluid using a spinal tap. Approximately 10 to 20 ml. of air was introduced, and a scout skull film was taken to ensure that the air had entered the cerebral ventricles correctly. If the air was correctly positioned, volumes of spinal fluid (usually in 15 to 20 ml. increments) were removed and replaced with air. Films were taken first with the patient in a sitting position. Then the patient was placed on a radiography table and films were taken in different head positions, allowing the intraventricular air to move about within the ventricular system.
Most patients responded adversely to the exchange of spinal fluid with air. They quickly became ashen and diaphoretic and often vomited. Movement of the patient from a sitting position to the radiography table was often problematic because the patient’s distress made cooperation difficult. Later on, the situation was alleviated somewhat by the use of a special chair designed by Dr. Gordon Potts, a staff neuroradiologist. This chair made it possible to rotate the patient into the optimal position for the film exposure with greater ease.
Lumbar myelography, while uncomfortable, was probably the most benign of the major procedures. Lumbar puncture was performed, followed by the introduction of lipiodal into the spinal canal. Problems could arise if the lumbar puncture needle was not correctly positioned and dye collected in a subdural pocket. If preliminary films indicated correct placement, additional dye was introduced. The patient was then tilted on a radiographic table while the neuroradiologist inspected the flow of the radioopaque substance in the spinal canal using fluoroscopy and X-ray photography.
Although the NINY resident of 50 years ago spent much time performing neuroradiologic procedures, the time helped the resident better understand the cause of the patient’s condition, and much was to be learned by reviewing the patient’s films with senior neuroradiologists. There is no question, though, that CT and MRI imaging, coupled with the development of training programs in neuroradiology and interventional neuroradiology, resulted in a revolutionary change in neurological practice.
The author lives in Washington, D.C., where he retired as senior scientific officer from the Howard Hughes Medical Institute. He also is professor emeritus of neurology at the George Washington University School of Medicine and Health Sciences.
Beyond 168 Street
In “The Immobile Man” (2008), Lud Gutmann’59 tells stories from his career as a neurologist, including stories from his P&S student days and stories from his career at West Virginia University, where he is the Hazel Ruby McQuain Professor of Neurology and where he chaired neurology for 28 years. In this chapter from the book, Dr. Gutmann relates an experience that lasted only a few moments during his first year at P&S but may have influenced his entire career.
By Ludwig Gutmann’59
I stood, with two other freshman medical students, at the comer of 168th Street and Fort Washington Avenue in New York City, waiting nervously for the light to change. We had spent a frustrating morning getting supplies and trying to find lecture halls in a large, confusing building. Now, after having waited with some irritation in line for lunch at a busy deli, we were hurrying back, worried we might be late. An unseasonably cold wind off the Hudson made us draw our light coats tightly around us. It was not a day to stand still.
A complex of tall gray buildings, Columbia University’s College of Physicians and Surgeons filled one side of the street with an imposing, four-story armory opposite. The drabness of this part of Manhattan was broken up by glimpses of the Hudson River and the George Washington Bridge far below. The area has always been a sort of “college town” — its own island in the city — with professors in long white coats and students in shorter white jackets moving quickly, often talking excitedly in groups, rushing from class to class and building to building. The subway stop at the Broadway corner is always filled with people running up the steps from rides or down the steps to get them. People move quickly in that part of town.
As I looked up the street, I suddenly drew a deep breath as I saw a ragged line of older people moving directly toward us. In marked contrast to everyone else, and clearly purposeful, they walked at a very slow, measured pace — not together, exactly, but looking so much alike they seemed together.
“Hey, John,” I nudged one of my new buddies, “look at those people.”
We gaped at them, all conventions of politeness gone. They walked stooped over in a labored, mechanical fashion, taking small, slow, shuffling steps — like toy soldiers winding down. They didn’t swing their arms at all, just held them rigidly bent at the elbow. Some had trembling hands. As they came closer, we began to see that their faces were completely spiritless and immobile. They had no expression or animation at all and they just kept staring fixedly straight ahead. These people didn’t seem to know one another, but it was clear they were all going somewhere very slowly, and with great determination, in spite of the cold. The effect was powerful and we were mesmerized, transfixed — three frozen statues, awed by what we were seeing, completely forgetting our haste, as the light changed several times. They just kept on coming, one after another, after another, after another, after another — more than 15 in all — shuffling slowly up out of the subway at the other end of the block, advancing directly toward us in a steady stream.
“Wow, they’re all look-alikes,” John whispered. “It’s as if they’re aliens from another planet.”
“If didn’t know better, I’d think we were in the middle of a science fiction movie,” David said. The comfortable, known world had suddenly become surreal.
An older man in a long white coat had been standing to one side, watching the scene with some amusement as we stood rooted, entranced. Finally he came over and said to us, “From your perplexed and astonished expressions and your clean, freshly starched white coats, I’d say you are new freshman medical students. As you will soon learn, what you are seeing here — so many people looking like a series of reproductions — should tell you something. These people all have the same illness. You can diagnose it just by looking at them. They’re all coming here for treatment. Today is Parkinson’s clinic day at the Neurological Institute.”
The world tipped back to normal — to something we could deal with. We understood. We made the connection. The spell was broken. We glanced at our watches and hurried on to class.
At that time I had no clue as to the mysteries of this debilitating disease. Like a boy using a magnet for the first time, this experiment of nature — called Parkinson’s disease — filled me with wonder and amazement and was the first step in directing my career into the world of neurons, axons, and synaptic connections.
Reprinted with permission from “The Immobile Man” (2008, McClain Printing) by Lud Gutmann’59
H. Houston Merritt: An NI Giant
In his book, “The Legacy of Tracy J. Putnam and H. Houston Merritt, Modern Neurology in the United States,” former P&S Neurology Chair Lewis P. “Bud” Rowland writes about the contrasting styles of the two men who led the Neurological Institute of New York during part of its first 100 years. This excerpt provides a glimpse of Houston Merritt’s legacy and personal appeal.
By Lewis P. Rowland, M.D.
[H. Houston] Merritt’s own research achievements resulted in the publication of books on the cerebrospinal fluid, epilepsy, neurosyphilis, headache, stroke, multiple sclerosis, and genetic diseases. In these books he recorded studies on human patients, not animal models. In the process, he was one of the founders of what is now called “clinical investigation.” He also recognized the importance of working with advocacy groups devoted to individual diseases. For instance, both he and Tracy Putnam testified in 1948 on the need for a national neurological institute at the NIH. And they were both active on the executive boards of the National Multiple Sclerosis Society (of which Putnam was the first chair) and the Epilepsy Foundation.
Merritt also wrote an enduring textbook of neurology. The sixth edition was published two weeks after Merritt’s death. In 2005, the 11th edition appeared, with chapters written by his former students. [The 12th edition will be published this year to coincide with the centennial of the New York Neurological Institute.]
His clinical skills brought him international fame, and celebrities called him for consultation, including Dimitri Shostakovich, Portuguese dictator Antonio Salazar, U.S. president Dwight D. Eisenhower, and actress Rita Hayworth. When he was at Montefiore Hospital, the chair of the Board of Trustees was Henry Moses, who had a severe stroke. Merritt became so involved in caring for Moses that he became part of their family. As one result, Lucy Moses became a lifelong benefactor of both Montefiore Hospital and the Department of Neurology at Columbia.
According to an obituary for Merritt:
His efficiency and capacity for work were extraordinary, perhaps best illustrated by an anecdote told by William Amols [a former resident of Merritt’s], who once visited the Merritts at their summer home. Mrs. Merritt met Amols at the door and told him that Dr. Merritt was at the waterfront. As Amols approached, he saw Dr. Merritt from the rear and as he drew nearer he saw that Houston was “relaxing.” He was sitting in a beach chair, facing the water. On his left was one radio, announcing the Giants game. On the right, a second radio was tuned to the Yankee game. In the middle, the Professor was doing the crossword puzzle — in ink, as usual.
Merritt also had a reputation as a fund raiser, a down-home codger who somehow could wangle donations from wealthy patrons. Most of these encounters were simple and direct. One involved his wily relations with Huntington Hartford, heir to the fortune of the family that created the Atlantic and Pacific (A&P) stores, one of the first national chains of supermarkets. Hartford believed in graphology, the science of handwriting, as a key to the “total personality,” which is “made up not only of the date of birth but of heredity, environment and daily moods.” Hartford published a book on the subject and asked Merritt to write the foreword, a challenge Merritt accepted, understanding the fine line between implausibility and doing a favor for a friend (and, undoubtedly, a possible contribution to the Department of Neurology). He explained how the physiological activity of brain controls the finger movements of handwriting: “The neurologist can understand how injury to the basal ganglia in Parkinson’s disease influences the size and shape of the letters and the flow of the script as the result of rigidity and tremor of the muscles.” He added that “the physician is not aware of the importance of such factors as rhythm, pressure, beginning strokes and the like, either because he is not trained to recognize them or because he considers them to be too erudite to be evaluated accurately.”
The exchange was typical of Merritt. He did not believe in graphology, but he explained his views politely and respectfully. Hartford responded grandly by donating a Rembrandt portrait to Columbia. Until the student antiestablishment revolt of 1968, the painting had been displayed in the office of the university president, Grayson Kirk. On Wednesday, April 24, 1968, undergraduates occupied the office, so the painting was taken down and packed away for safe keeping. It remained in hiding until it was finally sold in 1975 for $1.75 million, enough for two endowed chairs, one for Psychiatry and one for Neurology.
Lewis P. Rowland, M.D., professor of neurology, served as chair of the Department of Neurology at P&S and co-director of the Neurological Institute from 1973 to 1998. This excerpt is printed with permission from “The Legacy of Tracy J. Putnam and H. Houston Merritt. Modern Neurology in the United States,” Oxford University Press, 2009.
At a time when most parents face empty-nest syndrome, Robin Stern’s focus changed when her son, Scott Mannis, now a Columbia University student, began experiencing health problems that led to a diagnosis of epilepsy at the Columbia Comprehensive Epilepsy Center. Dr. Stern, a psychoanalyst and adjunct associate professor at Teachers College, wrote about their experience.
By Robin Stern, Ph.D.
|Scott Mannis, shown with his mother, Robin Stern,
uses his singing talent to benefit others with epilepsy
At the end of high school, Scott told me that a “weird” sensation he had felt in his left leg at times over the past year was worsening and causing him to lose balance. I immediately made an appointment with a neurologist, thinking the worst — multiple sclerosis. Scott was thinking brain tumor, so we were both relieved to hear, after an exam and an MRI, that he had neither.
Scott began college at Brandeis University, but started falling a few times a week during his second semester. Doctors tried a movement disorder medication; it not only did not work, it also made him lethargic and unable to think straight. I called to check on him multiple times a day. After repeat MRIs and 48-hour EEGs, doctors concluded that his condition was psychosomatic.
Things got progressively worse for Scott during his second year at school. He was falling more frequently and was unable to even go to the cafeteria. On a few occasions, he hit his head and ended up in a doctor’s office or hospital. More doctors were consulted, but tests continued to be normal.
During the winter of Scott’s second year, he was getting depressed because of his shrinking life; he could barely go out. His doctors prescribed Prozac which, we later learned, lowered his seizure threshold. After having a grand mal seizure, I was stunned to find him in a Boston hospital with many cuts and bruises on one side of his face, a result of many falls. He said he had not told me about his injuries because he was determined to “beat it,” thinking he had to gain control of what he was told was a psychological problem.
He took a medical leave from school and within a week had another grand mal seizure. After an in-hospital consultation with doctors on the epilepsy team and a referral to Lawrence J. Hirsch, M.D., a neurologist with the Columbia Comprehensive Epilepsy Center, Scott’s epilepsy was diagnosed. Having Dr. Hirsch’s confidence that he would find the right medications to control Scott’s seizures was reassuring. Scott is now on a medication regimen that mostly controls his seizures.
Scott was fortunate to be able to transfer to Columbia’s School of General Studies, where he is majoring in biophysics and would ultimately like to study medicine.
Scott has been able to get on with his life: He is in school, sees friends, and enjoys his hobby of singing. I still call at least three times a day to check in, but I am working hard on letting go!