Neurosurgery at the Massachusetts General Hospital - 1909 to 1983 - A Short History and Alumni Record.
Edited by Dr Nicholas T. Zervas, M.D. and the Neurosurgical Staff
[extract dated 1983] [Copyright 1984 Massachusetts General Hospital - First Edition]

THE DEVELOPMENT OF NEUROSURGERY AT MGH (1909-1983) - [extract dated 1983]

Neurosurgery at the Massachusetts General Hospital evolved over the past century from a casual activity of general surgeons caring for patients with head trauma to a major science utilizing almost 10% of the hospital's beds and encompassing the full range of contemporary practice.

Currently, the Neurosurgical Service has an average daily census of about 70 to 90 patients, and approximately 1500 neurosurgical operations are per- loaned yearly. Twenty- neurosurgeons, 12 of whom are residents-in- training, are on the stati. There are seven basic science laboratories directed by independent researchers, and five laboratories directed by staff neurosurgeons. The 1981 budget for clinical and basic science investigations amounted to 1.3 million dollars.

The first stirrings of this activity were felt at the beginning of this century. In 1910, neurosurgery was an occasional practice, and operations on the central nervous system were performed but rarely, and then h general surgeons. The evolution of neurosurgery at MGH during the next 70 years reflects the development of the specialty in America.
In the 19th century, neurosurgery was in its infancy. European and British surgeons were pioneering the first programs of surgery of the central nervous system, and in the late 1800s many American surgeons traveled to Europe to study these new operative techniques. One of them, John W. Elliot, a member of the staff of the Massachusetts General Hospital, journeyed to London in 1889 to study with Sir Victor Horsley. Horsley, a brilliant anatomist and surgeon, elaborated a systematic surgical approach to intracranial lesions. Al though criticized by the more conservative physicians of his day, he none the less attracted worldwide attention.

When Elliott returned from England, he worked actively on neurosurgical problems and sought to interest colleagues in this new surgical discipline. Two of these were Samuel J. Mixter, a young staff surgeon at MC and H an Cushing, a senior medical student at Harvard. An interesting version of these developments is given in a letter written by H.T. Ballantine Jr. to Frank Turnbull in Vancouver on April 1, 1970:

In 1895, Haney Cushing then a senior medical student at Harvard spent two months with Elliot and assisted in two operations for brain rumors, It was John Fulton's opinion that this experience was of prime importance in turning Cushing toward brain surgery.
Elliot was one of the visits' on the South Surgical Service which had been in augurated at about the rime Haney Cushing came to the Harvard Medical School. It was to supplement the so-called East and West Services hut had only a very short life. One of Elliot's younger colleagues on the Service was S.J. Mixter, who shared in these early experiences with brain tumor surgery and developed a continuing interest in surgery of the brain and spinal cord When William Jason Miner came to the MGH as a House Officer in 1907, he was assigned to South Surgical and it was undoubtedly this close association with his father that drew him toward neurosurgery….

It would appear that an argument can be made to the effect that the ineage of the American School of Neurosurgery can be traced directly from 1-lors and Elliot to Cushing and that another branch, later by some ten years, sprang from Elliot to Samuel J. Miner and then to William Jason Miner.

(H.T. Ballantine Jr.)

Early operations at the MGH that involved the central nervous system were performed by general surgeons with considerable help from the neurologists. At that time, the surgeons were the technicians, and the neurologists told them what to do.
Formative discussions of surgery of the nervous system, were noted by the Medical Board on May 9, 1910. The proceedings indicated that the staff felt a necessity for teamwork among the physician, neurologist, and surgeon. Dr. Shattuck remarked that two surgeons should be specially trained in neurological surgery. At a later meeting, held on November 22, 1910, recommendations from a subcommittee were reported:

1. The Neurologist on service should be promptly called in consultation by the physician and surgeon in any case r which operations on the central nervous system may be in question.
2. In cases deemed inoperable and also in cases where decision as to whether they are operable or not is pending, the patient should be under the care of the neurologist so long as he remains in the medical ward.
3. On the transfer of a patient from the Medical to the Surgical Service for operation the neurologist who has had charge of his case shall send with him a written and signed the diagnosis accompanied by a clear statement of the reasons which have led him to make it.
4. There should be full co-operation between the neurologist and surgeon before and after all operations.
5. All save emergency operations on the central nervous system should be turned over for the present to one and the same surgeon.

(Signed) F.C. Shattuck
James J. Putnam
Francis B. Harrington

This recommendation was endorsed by the Medical Board, but it was not until 1911 that the newly formed Surgical Executive Committee pondered the "Special Assignment in the Surgery of the Central Nervous System." The assignment eventually was given to Samuel J. Mixter.

Samuel Mixter gave a considerable number of these cases to his son, William Jason Miner, who, in turn, became one of the pioneers of neurological surgery in this country. Between 1911 and 1915, William Jason Mixter be came known for improving the treatment oi patients with fractured skulls, the technique of laminectomy, and the treatment of tumors of the spine and cord. James B. Ayer, a world-renowned neurologist, was not only a great friend but also a close associate to Miner. Their work concerned the management and particularly the localization ot spinal cord lesions.

Mixter left the MGH in I95, two years before the United Stares became involved in World War I, to serve as a civilian surgeon at military bases in France. In 1917, he worked a military surgeon in both France and England, and, in 1919, he returned to the MGH.

In the records of the Hospital Bulletin for January 17, 1917, the following notation was made:

The surgery of the central nervous system was assigned to William Jason Miner. There have been from 80 to 100 cases a year, with the assignment steadily in creasing in number. The most effective series of cases has been fractures or the skull, and Dr. Mixter is studying and comparing these cases treated in the past at this hospital, with a view to solving the following questions: 1. Is the mortality of fractures of the base lowered by immediate operation? 2. What class of cases should be operated upon? 3. What arc the criteria for immediate operation….

Another group of great interest is tumors of the spine and cord. There has been a series of 19 such cases up to the present time, and conclusions and results will be presented in the near future….

A more careful and complete studs of the neurological cases which have been admitted to the surgical wards has been attempted, and there has been an effort made to make the records more complete and uniform. The inter-relation between the Surgical Service and the Neurological Department has been fostered, and at present it has been arranged that Dr. Mixter shall see cases in the Nerve Room of the Out-Patient Department one day a week all the year round, while members of the Neurology Staff have been definitely assigned to the work of following cases in the wards, and consulting in the Emergency Ward on all emergency cases.

Mixter's rise to prominence in Boston was not easy. Harvey Cushing had arrived in Boston and became Surgeon-In-Chief at the Peter Bent Brigham Hospital. Cushing was a powerful figure who surrounded himself with a large staff of young surgeons who would later become influential all over the world in the new specialty of neurosurgery. The tension between Mixter at the MGH and Cushing at the Brigham was cased a bit by the fact that their neurosurgical interests differed. In 1920, Cushing invited "young Mixter" to join a select group of neurosurgeons who went onto establish the Society of Neurological Surgeons.

During the 1920s, the neurosurgical case load steadily grew under Mixter's guidance. There was close cooperation between the neurosurgeons and specialists in related fields, including neurology, ophthalmology, and orthopedics. The link with neurology was especially close. Neurosurgery was still part of the West Surgical Service at this time.

A report of the Surgical Executive Committee in 1931 reads as follows:

An increase in the indications for Neurosurgery is still evident and each year finds surgery of greater value in the treatment organic neurological diseases. Present interest concerns chiefly the surgery of the sympathetic nervous system, still in its infancy and on trial, but fascinating in its possibilities. Well recognized operations such as laminectomv for cord tumor, considered a novelty a decade ago, are now carried out as routine. Needless to say the co-operation of Dr. William J .Mixter and his associates with the Neurological Service has been very close and most satisfactory. Because of the technical difficulties involved in neurosurgery special operating rooms have been set apart elsewhere for such work. Such special facilities should find a place here as soon as possible if the best results in this difficult field are to be realized.

In 1920, John Sprague Hodgson 1890-1979 began a long association with the Neurosurgical Service. After spending a year with Harvey Cushing and another as a surgical house officer at the MGH, he joined the MGH surgical staff. In time, his interest focused increasingly on neurosurgery, and he dedicated his considerable talents to the new discipline. He had, however, little interest in research, unlike his younger colleague, James Clarke White (1895-1981).

White, the son of a distinguished physician, was educated at Harvard College. He was a member of the Harvard crew that, in 1916, set a record for the course on the Thames at New London that was not bettered for a third of a century. He served as a line officer in the United Stares Na during World War I before entering Harvard Medical School. In 1923, he was awarded his MD degree. Six years were spent in postgraduate studies at Harvard Medical School and MGH but included studies in pathology at Johns Hopkins Hospital in Baltimore and research on the autonomic nervous system and surgery for pain with Professors Hovelacque and Leriche in France. This latter experience sparked White's life-long interest in pain and surgery of the sympathetic nervous system.

Tracy Putnam briefly joined the Neurosurgical Service before transferring his allegiance to the Boston City Hospital in 1933. For the most part, however, it was Mixer, Hodgson, and White who directed the evolution of the Neurosurgical Service from 1920 to 1940.

In 1933, Mixter and Barr presented a paper, "Rupture it the Intervertebral Disc with Involvement if the Spinal Canal" to the New England Surgical Society. This paper, published later in the Nee England Journal of Medicine, opened the era of surgery for disorders of the intervertebral lumbar disc.

The same year, Jason Mixter was appointed Chief of Neurosurgery at MGH, and an operating room in the new Baker Memorial Building was reserved for neurosurgical procedures.

In 1936, John T.B. Carmody became the first resident to graduate from the neurosurgical program. He was followed closely by Jost J. Michelsen, William B. Scoville, Samuel Lowis Henry Heyl and William H. Sweet. Carrmody established neurosurgery in Worcester, becoming the first neurosurgeon in Massachusetts to practice outside the Boston area. Scoville established neurosurgery in Hartford, Connecticut and Samuel Lowis became Chief of Neurosurgery at the Beth Israel Hospital in Boston.

In 1939, the Neurosurgical Service, separate from (but a subdivision of) General Surgery, was finally created and Mixter, formerly Chief of Neurosurgery, became Chief of the Neurosurgical Service. Two years later, Mixter retired, and James C. White succeeded him as Chief.

Shortly thereafter, the orderly development of the service was again disrupted by war. In 1940, Henry Heyl, then a resident, volunteered for service in England to care for the casualties resulting from the bombing of Britain, William Sweet, then a Commonwealth Fund Fellow on leave from a staff position at the University of Chicago sought to carry on his research at Harvard Medical School while serving also as neurosurgical resident at the Massachusetts General Hospital.

In January 1941, Gordon A. Donaldson and H. Thomas Ballantine Jr., both of whom were hoping for fourth year appointments in general surgery six months in the future, were recruited as assistant residents in neurosurgery. At the end of six months Donaldson returned to general surgery and Ballantine was called to active duty with the United States Army. Soon thereafter Sweet replaced Heyl in Birmingham, England, and became Acting Chief of the Neurosurgical Service at the Queen Elizabeth Hospital, Birmingham. and Regional Consultant in Neurosurgery to the British Emergency Medical Service in the Midlands. In recognition of his wartime efforts, he later received His Majesty's Medal for Service in the Cause of Freedom.

In I941, James White again joined the Navy but this time as a medical officer. Mixter resumed leadership of the Neurosurgical Service for the next five years while serving as Chief Neurosurgical Consultant to the Surgeon General of the Army. During this period the fragile service was held together by Mixter, Hodgson, and Michelsen. R.M.P. Donaghy, who became Chief of Neurosurgery at the University of Vermont Medical School, completed his residency during this period (1942).

Shortly after the end of the war in late 1945, White, Sweet, and Ballantine returned to the MGH. With White's blessing, Ballantine, who had worked in neurosurgery with Glen Spurling at Walter Reed Army Hospital and for two and a half years had performed neurosurgery in North Africa, Sicily, and Italy, went oft to work with Max Peet at the University of Michigan.

Henry Heyl (1906-1975), on returning to civilian life, assumed the post of Chief of Neurosurgery at Dartmouth Medical School. In 1965, he became editor of the Journal of Neurosurgery, in which capacity he served with distinction until his death at the age of 69.

During the postwar years ancillary services at four other hospitals participated in the training of neurosurgical residents. William Sweet set up and directed a training program at the New England Medical Center Hospital (1949-1951); the whole MGH neurosurgical staff helped John Drew run a training program at the Boston Veterans Administration Hospital (1947- 1964); Vernon Mark, Director of Neurosurgery at Boston City Hospital. was aided in training our residents by Harold Wilkinson, Edward Baker, Nicholas Papadakis, and Frederick Simeone (1964-1977); Nicholas Zervas and Richard Bergland were successive chiefs at the Beth Israel Hospital (1968- present) -

Among these many fine teachers, special note should be made of John Drew. His continuous supervision of neurosurgical technique and the effective training methods he devised and used for over two decades were especially important in developing the operative skills of the neurosurgical residents in the MGH program. Although tragically afflicted with parkinsonism, he continued for many years to train personally a generation of residents in the exacting techniques of surgery and pre- and postoperative care.

Starting in 1955, David Crockett, Associate Director of the MGH, successfully solicited funds for the construction of research laboratories to be specifically a component of the Neurosurgical Service. Two years later, in October 1957, the Mixter Laboratories for Neurosurgical Research were formally dedicated. Although gravely ill with carcinoma of the lung, William Jason Mixter was, able to attend the dedication ceremony.

James White served as Chief of Neurosurgery at MGH and Professor of Surgery at Harvard Medical School for 20 years. His teaching career spanned 35 years, and the current neurosurgical training program is largely a product of his efforts. He retired in 1961, and was succeeded by William Sweet.

White and Sweet worked so closely together that the 37 years, 1940 to 1977, can be thought of as a continuum. Their mutual interest in the scholarly recording of clinical observations and the experimental approach to neurosurgical problems led to their investigations into the mechanisms essential to the recognition of the sensation of pain and to methods for its alleviation. This union resulted in the publication in 1955 and 1969 of their classic mono graphs on pain. Most of their trainees dedicated themselves to tile academic tradition and went onto distinguished careers in this country and abroad. In 1961, Sweet appointed Robert Ojemann to the visiting staff Ojemann de voted himself to mastering the major difficult areas of operative neurosurgery over the next two decades. His tireless and dedicated devotion to this goal brought him international acclaim for his incomparable operative skills.

Sweet also understood the necessity of basic science research and recruited several preeminent investigators to set up independent laboratories as a component of the Neurosurgical Service, for example. Adelbert Ames III, Gordon Brownell, Stanley Builivant, Humberto Fernandez-Moran, and Albert Soloway.

In 1977, Nicholas T. Zervas became Chief of Neurosurgery at the hospital where he received his postgraduate education. Zervas, who graduated from Harvard College and the University of Chicago School of Medicine, interned at New York Hospital, and after a year at the Montreal Neurological Institute, took the rest of his training in neurosurgery at MGH, In 1960-1961, he studied stereotactic cerebral surgery with Professor Jean Talairach at the Hospital Ste Anne in Paris and worked with Gerard Guiot at Hospital-Foch. Following his residency he worked at Jefferson Medical College for five years before returning to Boston in 1967 to become Chief of Neurosurgery at Beth Israel Hospital, where he remained for 10 years before returning to the MGH.

In the tradition of his predecessors he sought to attract talented surgeons and basic investigators in neurobiology to continue the preeminence of the Neurosurgical Service in neuroscience research and practice. Through his cf forts, a Professorship in Neuroscience at the Harvard Medical School was established in 1981 in the name of Charles Anthony Pappas, and a new neuroscience research floor in the Wellman Building was donated to the hospital by the Thomas Anthony Pappas Foundation.

Working closely with Ojemann, Zervas endeavored to give each member of the staff a special area of expertness. Over the past five years, the number of patients with special problems referred to the Service because of the special knowledge and experience gained through this program has increased considerably -

Zervas and Joseph B. Martin, Chief of the Neurology Service, instituted a plan for unifying many aspects of the Neurosurgical and Neurology Services. The Grand Rounds of the two services have been combined, and steps have been taken to consolidate personnel and the financing of clinical teaching services and research. In addition, Zervas and Martin have developed a pilot program for training residents in neurology and neurosurgery. The programis based on the selection of a small group of residents who have demonstrated an interest in exploring the basic causes of nervous system disorders. The residents selected have the opportunity to spend two or three years working with an established senior scientist in one of the basic science laboratories at MGH, Harvard, or the Massachusetts Institute of Technology. The training received in this program prepares the participants fir academic careers combining clinical and research activities.

Thus far, the MGI Neurosurgical Service has trained 93 residents, 50 of whom hold academic appointments and 20 of whom have become chief of an academic neurosurgical service. Many have made major contributions to surgery or science. Ninety-two fellows and basic scientists have also worked on the service. Of these, 15 have become chief of a neurosurgical service, and several others head departments in various different fields.

As demonstrated in these pages. the neurosurgical tradition at MGH has been shaped by numerous personalities and events. At this point, special mention should be made of four men who have made outstanding contributions, Jost J. Michelsen, Hannibal Hamlin, H. Thomas Ballantine Jr., and Robert C. Ojemann.

Jost J. Michelsen, who joined the Neurosurgical Service in 1938, has worked tirelessly to serve patients at the MGH and neighboring community hospitals for more than 40 years. Now, at the age 80, his numerous junior colleagues still seek his expert judgment for the management of spinal disorders. The humanism and compassion so necessary for a true physician have always inspired his students, then and now. Born in Germany in 1904 he received his MD degree from the University of Berlin in 1928 and studied neurology and medicine in Germany before coming to this country as a Rockefeller Fellow. He studied neurosurgery from 1933 to 1936 at the University Clinic in Amsterdam before returning to a residency at the MGH in 1937. His major papers as a young investigator included the description of syndromes related to lesions of the corpus callosum, but his primary interest has been a life-tong study of the diseases of the spine. His practice is now centered on these disorders.

Hannibal Hamlin, who joined the MGH Neurosurgical Service In 1937, died of cancer in 1982 at the age of 78. Although his main practice was in Providence, Rhode Island, he kept up a continual association with the MGH and worked in the clinics until he became ill. Hamlin was a graduate of Phillips Exeter Academy, Yale College (1927), and Yale Medical School (1936). From 1927 to 1930 he was a leader of the Whitney South Sea Expedition for the American Museum of Natural History. During World War II, he served in the US Navy with medical units in the South Pacific and later at naval hospitals in Chelsea, Massachusetts, and Newport, Rhode Island, His research included clinical studies of the electroactivity of the human brain, measured by implanted electrodes, with Professor JM.R. Delgado of Yale University Medical School, and he was the principal investigator in a study of human brain anatomy at the MGH and the Warren Anatomical Museum of Harvard Medical School (with Professor Paul Yakovlev), In addition, he worked many years with Dr. Oskar Hirsch on the transsphenoidal surgical approach to tumors of the pituitary gland, which is the procedure of choice today.

H. Thomas Ballantine Jr. graduated from Princeton University in 1933, and from Johns Hopkins Medical School in 1937. He entered the MGH as a surgical house officer in 1938, and became assistant resident in neurosurgery for nine months in 1941. During World War II he served with the Second Auxiliary Surgical Group in North Africa and Italy. His surgical team remained in the combat zone from the invasion of Sicily to the end of the war After the war, Ballantine pursued his neurosurgical training at the University of Michigan Hospital under the direction of Max Peet from 1945 to 1947. There he also received a Master of Science degree and was Instructor in Neurosurgery at the University of Michigan Hospital Medical School. He was appointed to the neurosurgical staff of the MGH in 1947 and worked with W. J. Mixter on the treatment of the ruptured intervertbral disc until the latter's retirement. He has written two monographs on disc surgery and designed a laminectomv retractor that bears his name. Ballantine's best-known works include the application of ultrasound technology to medicine. Along with T.F. Hueter, RH. Bolt, and GD. Ludwig, he authored the first paper on the ultrasonic detection of intracranial lesions. He also wrote extensively on the use of radical surgery to treat brain abscesses, and the use of cingulotomy as therapy for severe disabling psychiatric illness and intractable pain. In addition, Ballantine has been a leader in state and national medical organizations. He was a trustee of the American Medical Association and president of the Massachusetts Medical Society. His involvement in the medico-socio-political problems in the delivery of medical care led him to the formation of the Commonwealth Institute of Medicine, of which he was president from 1972 to 19753, and led to 16 publications on medical quackery, health care financing systems, and discussions on medical ethics. President Reagan appointed him to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in 1982, and he served on this Com mission until it finished its work in 1983.

Robert G. Ojemann is now Associate Chief of the Service. Born in Iowa City, Ojemann received his undergraduate and MD degrees from the State University of Iowa, both with highest honors, and was elected to both Phi Beta Kappa and Alpha Omega Alpha. After internship at Cincinnati General Hospital and a year of general surgery at Baylor he joined the Neurosurgical Service in 1957, and assumed a major role in the development of the clinical program. He was promoted to Professor of Surgery at Harvard in 1979. He has been an editor of Clinical Neurosurgery and an editorial consultant for the New England J of Medicine and for Stroke. He has been president of the Congress of Neurological Surgeons and the Society of University Neurosurgeons. Currently, he sits on the board of directors of the American Association of Neurological Surgeons. In addition to being author or coauthor of more than 100 papers, he has coauthored a comprehensive textbook on cerebrovascular surgery with Robert Crowell. Ojemann has served on the American Board of Neurological Surgery since 1977, and was elected President of the Board in 1982. To his colleagues he has been the archetype of the master surgeon whose influence on the training of so many residents will be long remembered.

J.J.M.
H.T.B.
N.T.Z.