Gordon Holmes, the cortical retina, and the wounds of war

Documenta Ophthalmologica

93: 9-28, 1997.

9

Q 1997

KluwerAcademic Publishers. Printed n the Netherlands.

Gordon Holmes, the cortical retina, and the wounds ofwar*

The seventh Charles B. Snyder Lecture

RONALD S. FISHMAN

Washington Hospital Center, Washington, DC 20010, USA

Key words:

military medicine, neurology, ophthalmology, visual fields, visual perception

Abstract.

By the turn of the 20th century, localization of function in the cerebral cortex ofthe brain had advanced considerably, but a relatively vague idea only existed that humanvision was represented in the vicinity of the calcarine cortex. World War I produced a largenumber of isolated missile wounds of the brain. Their study yielded a complete topographicalmapping of the visual field in the primary cortical vision center, and is a basis of our moderninterpretation of visual fields. This map has been recently modified by MRI studies to showthat the magnification of the central retinal projection onto the cerebral cortex to be evengreater than previously thought. Many names are associated with the story of how war led tothis knowledge. This essay refers to Harvey Cushing, William Osier, Tatsui Inouye, and mostparticularly to the career and contributions of the British neurologist Gordon Holmes.

Cushing and the war diary

In 1915, Harvey Cushing had been a professor of surgery at Harvard for threeyears. He had the character attributes that made for success in the early daysof neurosurgery, when the surgical mortality and morbidity daunted ordinarymen. He was confident, decisive, perfectionistic, and hard working. He wasintellectual, even scholarly, and, in the right company, charming. He wasalso a complex and intensely proud person who could be cold, autocratic,intolerant, and unforgiving. He wished at all times to be in the forefront ofthe battle. In 1915, the forefront had shifted from the neurosurgical wards inBoston to the trenches in France. [2, 7, 15, 16, 23, 32].Cushing joined a volunteer medical group organized from the Harvardfaculty and in March 1915 he sailed across the Atlantic to reconnoiter themedical arrangements of the British Royal Army Medical Corps in France.He spent the month of April in France and went over again as a United StatesArmy major as soon as the United States entered the war two years later,staying until after the Armistice in November 1918 [19) (Figure 1).* Read in part, at the annual meeting of the Cogan Ophthalmic History Society, The NationalLibrary of Medicine, Bethesda, Maryland, March 15, 1996.

10He kept a diary while he was in France. After he had retired from Harvard,two decades later, he published excerpts from the diary as

From a Surgeon'sJournal

[11]. This book did not receive the Pulitzer Prize as did his biographyof Osier in 1925 [10], but it did get much attention in the lay press. Hewas lionized in the

New York Times, Newsweek, and Iime. The

idea of theneurosurgeon as a glamorous figure probably dates from this time [19].Keeping a diary for a prolonged period takes tremendous self-discipline,in addition to the utter conviction that what one is experiencing is worthwhilerecording. I suspect that Cushing had no confidants except the diary, and that,in a way, it imposed some order on his life at a hectic time.The diary is very chatty, full of incident. He goes here, he meets so-andso, he sees this, he does that. It is impossible to read straight through, but it'sworth dipping into for its re-creation of the scene.In London, signs in public caught his attention, (Figure 2); 'Men of Lon-don, our brave soldiers at the front need your help. No Price can be toohigh when Honour and Freedom are at Stake'. This is the London wherepretty young women on street comers handed out white feathers (the sign ofcowardice) to young men in civilian clothes. Conscription came later.I found the diary to be somewhat bland, considering the horrific sightshe was witnessing. At a British hospital near Ypres, Cushing saw gassedsoldiers 'especially the color of blue serge, coughing up a thick, albuminoussecretion'.The British were suffering appalling casualties, even before the Battle ofthe Somme, where 20,000 British died on the first day in an orgy of senselesswaste. The diary includes photographs that Cushing took himself (againstcensorship rules), showing some of the medical arrangements made by theBritish for the casualties. They would be brought back initially by stretcher-bearers to the 'Casualty Clearing Station' in numbers that would often swampthe relatively primitive facility. If the wounded were able to get far enoughbehind the lines, they got a semblance of better care.Cushing was a skilled amateur artist, and the diary includes a drawing ofa case where he tried to extract a piece of shrapnel from the base of the brainwith a huge electromagnet. He tried several times in front of an audience,and failed. The audience left, and only then did the foreign body come outbeautifully. 'Much emotion on all sides'. A human side of him came outdespite himself.Cushing had little complimentary to say of other doctors he met. He waseven threatened with court martial by the British when he sent a letter homethat included material critical of another surgeon, despite the tight Britishcensorship that forbade sending such negative comments to the Home Front.Only a hint of this criticism is in the book, of course [11, 17, 20].

11

Figure I.

HarveyCushing in uniform as a U.S. Army Major [10].Cushing made a significant contribution to the treatment of head wounds,trying to get them operated on by surgeons trained in his meticulous tech-niques and not in the usual quick, haphazard way, even if that meant slowingdown the clearing out of the large number of casualties. When World War IIstarted, his old papers were studied again [20].

The death of Revere Osier

Throughout the diary, Cushing kept his emotions in tight constraint. As faras the diary is concerned, he was always in control. Occasionally, however,something breaks through.