Harvey Cushing's Early Operative Treatment of Skull Base Fractures

Introduction: At the turn of the 20th century, treatment of urgent and emergent neurosurgical complaints was limited by access to hospitals, and by high rates of infection and operative mortality. Fractures of the skull base were a particular challenge to neurosurgeons of the time. Harvey Cushing remained at the forefront of this clinical dilemma, using skills garnered from his surgical residency with William Halsted to increase the safety and success of neurosurgical treatment of skull base fractures.

Methods: Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, the surgical records of the Johns Hopkins Hospital, from 1896 to 1912, were reviewed. Patients operated on by Dr. Harvey Cushing were further analyzed. Patients who underwent operative treatment for suspected fractures of the skull base were selected and are described here.

Results: Twenty-four patients underwent operative treatment for suspected fractures of the skull base. Patient age was available in 22 files; the mean age was 30 years (range, 2–68 years). The majority (87.5%) of patients were men. The mean length of stay was 11.5 days (range, 1–35 days). The mechanisms of injury included work-related injuries (33%), falls (25%), vehicle injuries (25%), and other trauma (8%). Two patients had no mechanism of injury specified in their files. The outcome at the time of discharge from the hospital was “well” or “improved” in 12 patients (50%), the remaining 12 patients died during their admission.

Discussion: Although the mortality rate in the cases presented here remains high (50%), it is perhaps surprisingly low when the nature of the patients' injuries, the challenges of neurotrauma cases, and the mortality rate of over 50% for neurosurgical procedures performed under the best of circumstances by Cushing's contemporaries are considered. The cases described here demonstrate Cushing's commitment to transforming the field of neurosurgery into a viable surgical subspecialty; moreover, they document Cushing's extensive work in the field of neurotrauma, an arena rife with complicated anatomy and operative technique, but without the opportunities for remuneration and academic glory presented by Cushing's beloved neuro-oncology and neuroendocrine pursuits.