Medical Mountaineering

Brain surgery still vies with rocket science in our popular imagery about difficult occupations. It does not take a brain surgeon or a rocket scientist to be a politician. Brain surgeons seem to be the triathletes and mountaineers of medicine. Retired writers can’t become brain surgeons. Retired brain surgeons often become writers.

Thomas Morley, retired head of neurosurgery at the former Toronto General Hospital (now part of the absurdly named University Health Network), has exchanged scalpel for pen to profile Canada’s first brain surgeon, Kenneth George McKenzie. A doctor’s son from southwestern Ontario, McKenzie learned the basic techniques of neurosurgery from the legendary Harvey Cushing in Boston in 1922–23. McKenzie returned to Toronto and operated on patients’ heads, with a reasonable amount of success, until his retirement in 1952.

What kind of medical superman went into brain surgery? Most Canadians believe that Wilder Penfield, founding director of the Montreal Neurological Institute, was Canada’s premier neurosurgeon, and they do think of the hugely talented Penfield as a renaissance giant. Penfield wrote not only a very literate autobiography, but also essays, memoirs and fiction, including graceful celebrations of aging and classical culture. His surgical feats at the MNI were well publicized: the image of Penfield working inside the head of an epileptic under local anesthetic, mapping human consciousness by talking to his patient as he operated, helped stamp the image of the brain surgeon for Canadians. People have asked me if Harvey Cushing was one of Penfield’s students.

As Morley points out, Penfield, an American, was a relative latecomer, who began work in Montreal in 1928, half a decade after Kenneth McKenzie established his trade in Toronto. LikeMcKenzie, Penfield had learned basic neurosurgical techniques from Cushing. In the early years of the 20th century, Cushing, a Clevelander who did his most creative work at Johns Hopkins Hospital in Baltimore, became the first surgeon who could enter the skulls of patients with brain disorders with the near certainty that he would do them no harm. By 1910, Cushing was searching in patients’ brains for tumours while talking to them about their sensations. At Boston’s Peter Bent Brigham Hospital in the 1920s, Cushing removed tumours from hundreds of patients, almost single-handedly trained the first generation of neurosurgeons and became a symbol of modern miracle medicine.

Cushing and Penfield more than lived up to the notion of the neurosurgeon as a man of amazing talent, endurance, sophistication and commitment. Most pioneering brain surgeons were unusually learned, largely because of the diagnostic problems they faced, and unusually determined to persevere in the face of frequent failure and very high mortality rates—and fairly completely self-absorbed. Morley quotes the view of Toronto surgeon W.E. Gallie that Cushing and the other American and British founders of neurosurgery were “all disagreeable, pompous, and tremendously impressed with their importance.”

McKenzie’s quiet career and Morley’s straightforward, often fairly technical book are antidotes to the image of the brain surgeon as larger-thanlife. McKenzie comes across as a dour, bluecollarish working surgeon who rocked few boats and drew little attention to himself as he struggled to perfect his art. He worked very hard, invented a few new operating procedures and a better silver surgical clip, dealt with failure by becoming mildly depressed and deliberately did not build an empire in Toronto—in fact, he refrained from training many young neurosurgeons because he doubted there would be enough work to go around.McKenzie came to be overshadowed even in Toronto as a neurosurgical mover and shaker by the more flamboyant E.Harry Botterell, his first assistant and then successor. McKenzie apparently did not throw instruments and curse his nurses in the operating room. His assistants actually liked him.

Cushing had particularly liked McKenzie, too, because he had always believed that the key to the specialty was not flamboyance, manual dexterity or even great learning, but rather the quiet doggedness that McKenzie had in abundance. The secret of success in early brain surgery was careful, meticulous technique, rigorous attention to every small step to control bleeding and prevent infection, endless patience and round-theclock concern for the patient. Cushing urged his students to be dull perfectionists rather than the flashy showmen who had flourished in the heyday of 19th-century surgery and who reappeared in the mid 20th century to race each other in transplanting organs and claiming firsts. Good marathoners and mountaineers are neither flashy nor reckless; nor are they particularly interesting to read about.

McKenzie’s greatest concession to a form of surgical impatience was his willingness to do frontal lobotomies on patients suffering certain psychiatric conditions. He did approximately 150 of these psychosurgical procedures, which were far, far more invasive than the comparatively mild drug and talk therapy that has made Montreal psychiatrist Ewan Cameron a whipping boy of mental health historians and lawyers. Morley acknowledges the difficulty of assessing the lobotomy as a clinical procedure, but argues that the only alternative was to accept the horrors of severe mental illness.

In fact, the historical verdict is not yet in on the lobotomy controversy. I do not think that Cushing, who died just before some of his students started doing lobotomies, would have been comfortable with such a radical procedure. He would have insisted that the lobotomists not take that leap without better evidence that they would land on a firm footing.

Until the adoption of Canada’s system of universal single-payer health insurance in the late 1960s, the border hardly mattered in medicine. When William Osler, born just outside Toronto, left McGill in the 1880s to move to the United States, he pioneered a north-south highway that has since been travelled by many thousands of successors. Osler was Harvey Cushing’s mentor at Johns Hopkins, and did more than anyone else to support his career. Cushing’s best-known act of reciprocation was to write Osler’s biography, which became a medical classic and won a Pulitzer Prize. (Yes, Cushing really would write serious biography for a few hours, go into the hospital and take out a brain tumour, then come home and start another chapter. And yes, he also fathered three beautiful daughters, the fabulous Cushing sisters, who became the toast of New York society in the 1940s and 1950s.)

K.G.McKenzie was able to bring brain surgery to Canada because Harvey Cushing did not need the $1,000 Mickle Prize money that the University of Toronto awarded to him in 1922 for his outstanding contributions to medicine. Cushing suggested that the money be used instead to finance someone spending a year with him, so he could take the art back to Canada. This was yet another tribute to Osler and to Cushing’s other Canadian friends (and perhaps to the Canadian soldiers and medical officers whom Cushing had admired as the best units in France during the Great War). In the meantime, grants from the Rockefeller Foundation were modernizing medical education and hospitals in both Toronto and Montreal. It was Rockefeller money and an Osler connection that brought Penfield to Canada.

Because of problems with health insurance, Canadians today have trouble understanding the American commitment to medical excellence, and especially to innovation. There is little appreciation of how much we still benefit from our access to great American research and educational centres, the best in the world. In medicine, as in continental defence and the history of democracy and human rights, Canadians have profited enormously from the examples set by our wonderfully energetic neighbours. They taught us neurosurgery and, as the biographers of Marc Garneau and Roberta Bondar will be the first to acknowledge, they have also taught us rocket science.