[Text on screen: Sound/Video Impressions Client: AANS Title: Dr. William Hunt Producer: C. Philips Editor: RJB Date: 7-29-92 Audio: split Job Number: 92-0975] [STATIC] [MUSIC] [Text on screen: American Association of Neurological Surgeons Formerly The Harvey Cushing Society] [Text on screen: William E. Hunt, MD Member Since: 1955 Interviewed by: Robert B. King, MD] [Text on screen: Dr. Robert King] Speaker Robert B. King, MD: I'm Robert B. King, and I have the privilege of introducing Doctor William Hunt, whom I've known for a number of years, one of the more elegant personalities in neurosurgery at this time. Bill, where did you get your start? Where did you start up from? [Text on screen: Dr. William Hunt] Speaker William Hunt, MD: Well, I was born in Columbus, Ohio, when it was a little backwards town. Speaker King, MD: Yeah, and where did you, what do you remember first—how far back? And don't tell me when you were a one-year-old, although you might Speaker Hunt, MD: That's a good question. I can remember a wool suit that scratched. I can remember wanting to be a ditch digger so I could run a steam shovel. I came from a family of doctors, and so I really wanted to be a doctor by the time I was pretty young. Speaker King, MD: And your early years in school were in Columbus? Speaker Hunt, MD: Yeah, in public school up to the 8th grade. Speaker King, MD: And after the 8th grade, what? Speaker Hunt, MD: Well, I went away to military school. Speaker King, MD: How did that happen? Speaker Hunt, MD: Well, I wanted to, curiously enough. I was five feet tall, weighed 98 pounds, had trouble tossing a Springfield out three without hunching my shoulder, but I'd been beat up a couple of times in public high school because I was, I think pretty smart, and I know I was very small and I was very obnoxious. I mean, that was a bad combination. And, I knew a little bit about Culver, having been there to summer camp. They weren't exactly easy on you, but they were fair. And the bad things that I learned there were that—two things I learned that are wrong: one of them is that the establishment is always just and decent, and the other one is that the good guys always win, and that's not necessarily true, but it's not a bad assumption. Speaker King, MD: Not even at Culver Speaker Hunt, MD: It's a good place to start. Speaker King, MD: Yeah. Speaker Hunt, MD: Yeah. Speaker King, MD: When did you start to think about medicine as a career? Speaker Hunt, MD: Probably by the time I was 10 or 11 years old. Speaker King, MD: That early? Speaker Hunt, MD: Yeah, yeah, yeah, you know, I turned down an appointment to West Point because I wanted to go into medicine—from that place. Speaker King, MD: Do you recall how or sense how you might have come to that track? Speaker Hunt, MD: Well, I come from a long line—I think I was the fourth physician in a row. My son's the fifth in the Hunt family that mostly came out of South Carolina, and up through Southern Indiana, and around Anderson. There were three generations in Anderson, not including my father, but. Speaker King, MD: What kind of physician was your father? Speaker Hunt, MD: He was not a physician. Speaker King, MD: He was not? Speaker Hunt, MD: No. My uncle Lee was, and he was, and his father, and his grandfather. But they were general physicians who did obstetrics, gynecology, ENT, tree fighting, as far as I know. Speaker King, MD: Anesthesia and the rest of it? Speaker Hunt, MD: Yeah. Speaker King, MD: And then you went to Ohio State? Speaker Hunt, MD: Yeah, yeah. Speaker King, MD: Special selection reason or proximity? Speaker Hunt, MD: Proximity and finances. I'd had money left for my education, it was all spent on preparatory schools. My father—my grandfather had died of undiagnosed diabetes, my maternal uncle of a meningioma found at autopsy, my father of tuberculosis, and we were running on a trust fund from the uncle, everybody else was broke. Speaker King, MD: So that pulled you through Culver and then back to Ohio State. Speaker Hunt, MD: Right. Speaker King, MD: Do you pick out any particularly influential teachers during that time? Ones that inspired you or— Speaker Hunt, MD: Well, Culver had a couple of guys that stick in my head. There was an English professor who made you memorize 200 lines of something, anything, poetry, literature, and you had to write them in a blue book before you went home for vacation. He didn't care what it was, it could be Shakespeare, Robert W Service, dirty songs, but you had to memorize 200 lines. And, there was an English teacher who later was beach officer on Utah. He was a reservist who wrote the field manual, under somebody else's direction, for the amphibious engineers, who was an incredible man. Went in over the beaches and later into Okinawa on a non-union of his ankle, and then to the Pentagon, and then back to being a schoolteacher in northern Indiana. Fellow by the name of Moore. Speaker King, MD: And that sticks with you all the way through? Speaker Hunt, MD: Yeah. Speaker King, MD: What was inspiring about him? Speaker Hunt, MD: I think he had a low grade, slightly amused, unequivocal integrity, and expected the same thing out of you. He was one of the people that convinced me that authority was always the way it was supposed to be. Speaker King, MD: It was always just. Speaker Hunt, MD: Yeah, right. Speaker King, MD: That's good military standard. Speaker Hunt, MD: Yeah, his wife was a school teacher. Ohio State—I really didn't get any role models, particularly, except for Doctor LeFever, the previous chief of neurosurgery, was a very inspiring guy. Speaker King, MD: That was in medical school. Speaker Hunt, MD: Yeah, that was in medical school. We hit it during that accelerated program period, and I went through undergraduate pretty rapidly, and the standards weren't all that high. Medical school was quite a shock because all of a sudden you couldn't just drift anymore. Speaker King, MD: That's right. Speaker Hunt, MD: Yeah, you know, for the people who are watching this in 2040, that is a house fly. Speaker King, MD: That's a house fly. Speaker Hunt, MD: Musca domestica, and we can't seem to get rid of it with the present day technology. But, there was Doctor LeFever and then the other big part of my education really, was at Barnes. Speaker King, MD: How did you select Barnes? Speaker Hunt, MD: I had applications in a couple other places—Illinois Neurological, New York Neurological. And Tom Weaver was my consultant. I was in the veterans hospital at that time. And I got an offer from Barnes, and Tom says, "You won't get a better one, you better take it." So I did. And, that was like the roads in the woods, you know, that's made all the difference. Speaker King, MD: Was he right? Speaker Hunt, MD: Oh yeah, I think so. I think so. Speaker King, MD: Highlights from when you were at Barnes? Speaker Hunt, MD: Yeah, I'm sorry? Speaker King, MD: Give me some highlights from when you were at Barnes. Speaker Hunt, MD: Well, of course- Speaker King, MD: That's putting you on the spot, I realize. Speaker Hunt, MD: Yeah, I know—I know you are. Doctor Schwartz, of course, was somewhat terrifying to us young fellows, but he too had that characteristic. I never thought of him as unfair, I thought he sometimes overreacted a little bit, but it was always in the right direction. I mean, you really had done something bad. That first year was an interesting time. We had one year at the assistant resident level, a year in the laboratory under O'Leary and Bishop, then the year I was chief resident, you came back, and that was sort of Valhalla, you know. I had Bill Collins and Sidney Goldring as assistant residents and you were the instructor. And, Henry and the ghost of Ernie Sachs was in the background, so when the chief resident in neurosurgery said do it, people did it. And, generally, it was a tight service,run well, and it was a lot of fun. Speaker King, MD: Is that where your interest in research first got sparked? Speaker Hunt, MD: Yeah, actually the exposure to Jim O'Leary and George Bishop was incredible. Bishop—not everybody knows that the Erlanger/Gasser Nobel Prize was based significantly on Bishop's work. And correct me if I'm wrong, but Erlanger had to do with founding neurophysiology as a separate operation for Doctor Bishop, and they split the Nobel Prize with him. Is that true? Speaker King, MD: I think they shared it with Bishop. Speaker Hunt, MD: I think they did, without necessarily the consent of the committee. Speaker King, MD: No, they did that, I think, on their own. That's right, yeah. Speaker Hunt, MD: And of course Erlanger went to Rockefeller Institute—or I mean, Gasser did and Erlanger was still professor of physiology. Speaker King, MD: You've mentioned four teachers in medical school and at Barnes who evidently had some very special meaning to you. Speaker Hunt, MD: Mhm. Speaker King, MD: Can you tell us what it was about them that was so impressive—that impressed you in that fashion? Speaker Hunt, MD: Well, Doctor Schwartz, outside of being a little bit terrifying—more than a little bit terrifying sometimes—was an enormous extension of my father, and of my previous experience with people that I respected, that didn't make easy compromises with quality. But I hadn't run into the likes—and then I'd had the literary influence of the teachers that I had in secondary school—but I hadn't run into the ranging curiosity of O'Leary, who was a PhD anatomist before he was an MD, and Bishop who was—who just thought in the abstract. I can remember him being utterly fascinated one day, when he came around and said, "Tell me more about tic douloureux." I said, "What do you want to know?" He says, "Well, what's this trigger point?" I said, "Well, that's when a light touch or something like this would fire a paroxysmal pain." He says, "Are you serious? You mean a fiber input produces a fast pain fiber discharge, and where is it?" "Well, it's very focal, it's right close to where you touched." He was utterly fascinated by that because he was not a clinician, and that's one of the things that convinced me that clinicians ought to be exposed to PhDs, and PhDs ought to be exposed to clinicians. Speaker King, MD: When you finished up at Barnes, you went back and succeeded Doctor LaFever shortly after that? Speaker Hunt, MD: Well, not too shortly. I joined Doctor LaFever. No, actually, I stayed on for a year at Barnes, and had children's hospital, which was never my favorite side of neurosurgery. And, I probably shouldn't say this, but it seems to me I was offered an assistant professorship in $7,200 a year. I was pretty broke, and I had an invitation to go back and kind of get things going in Columbus. So I went back and joined Doctor LaFever as an associate. Pete Sayers had come back a couple of years sooner, and Pete focused on children's, and I kind of focused on the university. And over the next ten years, I went from making rounds in seven or eight places, including the penitentiary, to being, essentially, all of my time at the university. And after Harry's tragic death, they looked at me for about a year and then made me chief of division. Speaker King, MD: So you were chief of that section for how long? Speaker Hunt, MD: '63 through '90, I think—something like that. Speaker King, MD: How about that? Good long stretch. Speaker Hunt, MD: Yeah, I had a little medical catastrophe that made me quit working very hard after New Year's Eve of '87. Speaker King, MD: During that period of time, you had a substantial contribution in the management of aneurysms and understanding the problems related to vascular disease. How did you get started on that track? I haven't heard the genesis of that yet. Speaker Hunt, MD: I had a good friend, a Markle fellow, as a matter of fact, like you, by the name of Bob Whatman; did you ever know him? Speaker King, MD: No. Speaker Hunt, MD: Bob was killed in that midair collision over in New York, going back to refuse a job. And he had a saying about vascular surgery that appealed to me. He said, "The thing that's good about vascular surgery is that it's difficult and it's dangerous, but it's possible." He said, "That makes the perfect surgical problem." Speaker King, MD: Well you had some significant exposure to aneurysm surgery, of course. Speaker Hunt, MD: Oh yeah, Doctor Schwartz's precision and determination got me started, but things were not going well in those days. The chief was away at a meeting once—Collins was chief resident, I was an instructor—we had a fella come in with a non-dominant middle cerebral. And the level of sophistication was—Collins says, "We might as well operate on him. Just tell the family that he's going to wake up hemiplegic, and maybe he'll live and maybe he won't." You see, that was about the time, when I left Barnes, that the publications came out of the national hospital there, Atkinson Morley. But if you took a bunch of conscious people with what looked like operable aneurysms and divided them down the middle, half of them died if you operated on them, and half of them died if you didn't, which was a true statement. Fortunately, we didn't have bureaucrats saying, "Stop operating on aneurysms, you know, because it's hopeless." But, it just seemed like a hell of a challenge, and there wasn't anybody doing it in Central Ohio. Speaker King, MD: When does the history of aneurysm management, other than in a purely passive form, what's the origin of that? How far back did that begin? Speaker Hunt, MD: Well that's something you looked up and you told me you were going to ask. Speaker King, MD: So you were warned. Speaker Hunt, MD: Well you're going to have to answer the first one, but the one I remember was the pictures of Dandy's supraclinoids in his book on surgery of the brain. And, of course, I also remember the lore, presumably true, that Cushing said that this is not a surgically approachable aneurysm—or lesion, that nobody will be able to do that. And of course, that would have been a red flag to Walter Dandy, I'm sure. Anything Cushing said you couldn't do, Dandy would probably try to do it. Speaker King, MD: Of course, Doctor Schwartz had a very strong interest in developing— Speaker Hunt, MD: Well, of course, yeah. That's what really got him started. He developed the spatial spring clips. But above all, at that time, we were still thinking in terms of technical perfection. In other words, can I get there? Can I shut it off? Can I get out? We weren't thinking, particularly, of the problems of cerebral circulation and vasospasm and brain swelling—that was just beginning to come into our consciousness. Speaker King, MD: And one of your major contributions had to do with a notion to classify these patients at entry into a health care system and classify them on the way out, etc. How did you develop that interest? Because that certainly wasn't done at Barnes. Speaker Hunt, MD: Well first, we didn't have healthcare systems in those days. That's a modern— Speaker King, MD: I meant management team. Speaker Hunt, MD: phrase, yeah. Well, the first notion, and it really sort of started with Harry Botterell, classification out of Toronto. We modified it a little bit, but we weren't paying a whole lot of attention to when you operated, except we knew that if the patient was sick, the brain would be tight and you'd have trouble. But we did find out, and the first paper in '67, I think, with Jack Mayer and so on, we were able to show that in 73 consecutive cases with a fairly clean spinal fluid and no neurologic deficit, a grade one, if you like, that we could produce a 1.8% mortality. And we had a 20—22% mortality in people with no neurologic deficit but a bloody spinal fluid. We called that grade two and figured that that was a significant change in risk. And then grade three was somebody with any neurologic deficit at all, and grade four was somebody with a lot of neurologic deficits, and grade five was somebody that looked like they weren't going to live. This never had decimals in it, it was just a common sense way of looking at it. And we took the position, from the very beginning, that grades one and two, people without neurologic deficit, ought to be operated as soon as possible. And, that's where we got the 1.8%, 22% in the good grades, and we waited on everybody else. And, as time went on, we couldn't figure out why we were having so much trouble with grade twos. Our technique improved some, but that twelve year thing still stuck in our craw. We lost a couple of more ones. We were beginning to become aware of vasospasm, and we started doing serial angiography. In other words, we do an angiogram as soon as the patient came in, and then we would repeat it as soon as they cleared their neurologic deficit. And, when they came in would be a function of when they were referred. So we got a scatter graph in which the amount of vasospasm on what day post hemorrhage told us that the onset of vasospasm tended to be out around the third day, and it tended to fade after the third week. The scatter graph looked kind of like that. And so we said, "aha," and we stopped operating on grade two if they had spasm, we said they were worse risk. And then we got ten years with no mortality, but we had a lot of people who'd died of rebleed. Speaker King, MD: This was with or without the microscope? Speaker Hunt, MD: Well, the microscope came in during that second series. We had a 12-year series and then a 6-year series, and then beyond that, the first one was '54 to '66, the next one was '66 to '72. Speaker King, MD: So, many things were changing in the technique- Speaker Hunt, MD: Yeah, anesthesia got better. We learned how to shrink the brain. Instrumentation got better. The microscope was a very big thing. But we still had these mysterious collapses, you know. You'd do a perfect operation on the second day and the patient would break your heart by going hemiplegic on the ninth. And of course, being good surgeons, anything that happens after you operate is supposed to be your fault. [Text on screen: Dr. William Hunt] We got to wondering, maybe it's the fault of the disease. And then we saw that the spasm tended to set up, maintain itself, and not fade until the third week. And then somehow it dawned on us that we were treating people with subarachnoid hemorrhage the same way we treated head trauma in the old days: bedrest, dark room, dehydration, hypotension. And we would take somebody in good shape, put them to sleep, let a little blood run out, get their blood pressure down while we operate on their aneurysm, do a perfect operation, and they'd wake up hemiplegic. And they'd have a central venous pressure of negative, and they'd have a low mean arterial, and we'd pump the pressure up and they'd come right around. So it occurred to me that maybe it wasn't the vasospasm, it was the reality of the blood trying to get through the tight place. And that's when Ed Kosnik pulled together, when he was a resident, a series of papers saying maybe you ought to raise the blood pressure and expand the volume. And it wasn't very damn scientific, it was anecdotal, and I didn't think it would be accepted, but it was. And, then we followed that along until we were expanding volume and lowering hematocrit and playing with viscosity and, of course, blood gases and all that, without hypertension unless you were forced to it. And, evolved to the Swan-Ganz catheter, which is slightly better than the poor man's version, which is a central venous line. And that, I think, has made a real big difference across the board. People are still searching the Holy Grail or the holy herb that is going to make the vessels relax and expand, you know? And we do big studies that show it makes that much difference. [Hunt, MD makes a small pinch with his fingers, meaning just a tiny amount] The thing that's made the big difference, to me, is getting away from the iatrogenic mistake, assault of hypotension, hemoconcentration, bedrest and all that. Because now everybody says, of course, we fill up the tank and then we give them the magic drug. Well, I think the filling up the tank is probably— Speaker King, MD: Makes a big difference. Speaker Hunt, MD: It's like those early days—we ought to mention Bert Silverstone, who was supposed to be here today and who's had an illness that's postponed him. We played around with carotid occlusion and we infarcted a bunch of people. And Bert developed a very sophisticated system of external coating with a latex spray put on with an artist's airbrush, and then reinforced with spatial epoxy. And, it was better than nothing, but it was a good thing that it was obsoleted by better technique. Speaker King, MD: You made another contribution that has intrigued everyone, which was a spin off from the things you've been telling us. How did you come upon the notion of this Tolosa-Hunt syndrome and where did Tolosa creep in? Speaker Hunt, MD: Tolosa—well, in the first place, in one of our aneurysm papers and it applies to this too, I quoted John Hunter's statement that the surgeon is like an armed barbarian who attempts to get by force that which a civilized man would obtain by stratagem. In other words, just because you know how to cut doesn't mean that that's the first thing to do. But shortly after I left Barnes, my wife, actually, developed double vision and then retro-orbital pain. We got on an airplane, flew back to Barnes, thinking, of course, that it was a posterior communicating aneurysm. Did an angiogram and it was normal. Did everything else you could think of and it was normal. All the neurologists, Levy and O'Leary and so forth, Sarah Henry, of course, was in charge, Doctor Schwartz. And it got worse, and it went to almost a panophthalmoplegia with a little numbness of the forehead. Slowly got better, had a minor recrudescence in that spring, and then got well and stayed well indefinitely. Well, you know, we thought, first, is this MS, and is this an aneurysm, and is this a cancer? And it wasn't any of them. And then we saw another handful of cases like that. We, on a hunch, treated it with steroids, and they got well. They got dramatically better, overnight, on corticosteroids. And so we postulated that this must be a periartoritis, or something, in the cavernous sinus, but we couldn't find it in the literature. Speaker Hunt, MD: And Houston Merritt, the great neurologist from Columbia, he was a visiting professor. We showed him a case on the ward one day, and he said, "Sure, that's that periarteritic thing in the cavernous sinus, "[inaudible] syndrome" or something, if you like. But we said, "We can't find it in the literature." He says, "You haven't read my textbook, it's in my textbook." Well, we read his textbook, and it wasn't in any textbook. But obviously, with his massive experience, he was familiar with it. He just forgot to put it in his textbook. So we thought, maybe we ought to write this up. And we wrote up the thing under the title of "Painful Ophthalmoplegia due to Indolent Inflammation in the Cavernous Sinus," which we might have been doing as an invitation to an eponym. And it lay there in the Journal of Neurology for a while until the neuro ophthalmologist from Florida—I hosted at the Cushing society one time—and he talked about neuro-ophthalmology. At the end, he said, "There's one more thing I want to tell you boys, and that is, there was this foolish paper that came out, and I don't know why the editors even accepted it, about some kind of thing." And he says, "You know, it's real." Well, he wrote the next paper and called it the Tolosa syndrome, which is where it got the eponym. Eduardo Tolosa was Barcelona. Speaker King, MD: Neuropathologist? Speaker Hunt, MD: No, he's a neurosurgeon, he was head of the Neurological Institute of Barcelona. He published, in the midst of this, just before we published this, it was the final stimulus, a case report in the British Journal of Neurology, Neurosurgery and Psychiatry of a case that fit our criteria: that had had an exploratory craniotomy with no findings, who died post-operative, cause unspecified, and who, at autopsy, showed the lesion we had postulated. And I wrote to him and he sent me the autopsy slides, and that's in our first article. And since then, there's been a lot of playing around with it. And it does exist, and we haven't the slightest notion about what causes it either way, but you shouldn't operate on it. Speaker King, MD: Very productive outcome from a good clinical observation. Speaker Hunt, MD: Yeah. Speaker King, MD: What do you think has been your major—you pick one—what would you pick as your major contribution in neurosurgery over the last 40 years? Speaker Hunt, MD: From a personal standpoint, living through it. Speaker King, MD: [Laughs] Surviving it. Speaker Hunt, MD: I don't know, I've had some interest in postgraduate education, and I'm never sure how much of it you fed to me. But the breakfast seminars, I think we got about the same time, but I think you had the idea first, and I had a program chair that implemented them—the idea being to do it. I have always thought that there is a place for critical clinical observation by a person who knows the literature and knows what's going on in the laboratory, even though he's not doing it himself. And I think that, to a significant degree, that's what made the contributions we've made to aneurysm. It hasn't been real fancy, and we haven't discovered any magic herbs, but the common-sense approach of life hands and don't make them worse, I think that was maybe useful. Speaker King, MD: Certainly your grading system has become very widely adapted for many uses and has been a great contribution. Speaker Hunt, MD: Yeah, that's great for the vanity. Speaker King, MD: Very practical way, it's been very good. Where do you think neurosurgery is likely to head in the next—? Speaker Hunt, MD: Let me go back one, because we did get the spinal cord injury center, it's been going almost 18 years now. And things that I learned from the Barnes experience, O'Leary and Bishop and the others, and from the likes of you and Sid and Bill and other contemporaries, were the importance of having respect and affection between the basics scientists and the clinicians. And there's a tendency for them to look at us as thugs and for us to look at them as worthless twiddlers of their thumbs, none of which is true. But, we spent a lot of time in the course of workings that which developed the neuroscience program at Ohio State, and they understood that, like the old Hippocrates thing, you know, "The occasion is immediate, judgment: difficult, and experiment: perilous," that we can't afford to be neat about our systems. We have to act, and we develop respect for their saying, "I'm not drawing a conclusion until I have hedged—until I have circumscribed the problem." And it's the blending of those two attitudes. So as they're not just playing with human physiology or animal physiology for the hell of it, they're doing it to help human beings, and we're trying to do the same thing, sometimes as armed barbarians. But, I think that might have been at Ohio State, not nationally, because I've never been a good benchman, might have been a major contribution there, and I carried it from St. Louis. Speaker King, MD: Where do you think neurosurgery is likely to head and in what important ways in the next few years? Speaker Hunt, MD: God knows. The, you know, the real blue sky stuff is whether or not the surgeon has a role in such things as the abiotrophies, parkinsonism. Are we going to find some way of putting the appropriate chemicals into the brain to stop that, or Alzheimer's disease, or is that so far down the line? But tissue transplant may mean something. We're learning more and more about things in the central nervous system that can throw out fibers and proliferates—primitive stuff. Certainly, we are taking a much broader interest in two public health problems. The biggest—numerically biggest one—is spine. But occlusive vascular disease—a lot more common than aneurysm and brain tumors. And we've had a little stumble there as to whether or not paying attention to big vessel occlusivascular disease means anything. And then people keep thinking of new things that they can do with new knowledge or refining the old—epilepsy, for example. And probably, the most interesting things will be something we haven't thought of. Speaker King, MD: Very likely. Speaker Hunt, MD: Very likely. Speaker King, MD: In any event, as long as the field still has people that have the kind of foresight, ingenuity that you've expressed in the last 40 years, I'm sure our future will be bright. Speaker Hunt, MD: I haven't got much insight or foresight, but I had a lot of fun. I'm awful glad I did it. I'm glad I'm not doing it anymore. I've turned 70, and it's hard. Speaker King, MD: If you were starting over? Speaker Hunt, MD: It's hard. Oh, I'd do it again, sure. Speaker King, MD: Can't think of anything else that might be better? Speaker Hunt, MD: Anything else would be kind of boring. Speaker King, MD: Very good, thank you very much, Bill. [LAUGH] [Text on screen: Sponsored by The American Association Of Neurological Surgeons] [Text on screen: Copyright 1992 by the American Association of Neurological Surgeons. Any duplication without written permission of the American Association of Neurological Surgeons is prohibited.] [MUSIC]