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Murray, T. Jock MD

Bookshelf: Book Review


Harvey Cushing: A Life in Surgery. By Michael Bliss. 610 Pages. University of Toronto Press 2005

Michael Bliss, the author of Harvey Cushing: A Life in Surgery, says that Harvey Cushing was the first neurosurgeon. I was initially taken aback by this statement, thinking of Rickman Godlee, William Macewen, Victor Horsely and others who did groundbreaking earlier operations on the nervous system, but Bliss explains that none of these forerunners were full-time neurosurgeons. It was Cushing who made neurosurgery a specialty, and trained a whole generation of leaders in the field.

Harvey Cushing (1869–1939) was born into a prominent Cleveland family, in the shadow of three previous generations of physicians. His career was always smoothed by the cushion of independent wealth. At Yale, he was a good student and athlete, clear in his sense of direction, moving on to Harvard for medicine and to the Massachusetts General Hospital for surgery. Even when he became a resident in surgery at Johns Hopkins, he hadn't yet considered neurosurgery. That came slowly when he developed an original surgical approach to the treatment of trigeminal neuralgia and experimented with cocaine nerve blocks.

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Bliss indicates that things were lackadaisical at Johns Hopkins Hospital when Cushing arrived as a surgical resident in 1896, even though we think of Hopkins as an exciting center of medical educational reform at that time. The residents were not very busy and Cushing thought the operating room (OR) procedures were sloppy. His chief was the Professor of Surgery, William Halsted, who, despite his great reputation, seemed disinterested and often absent.

When he did operate, Cushing saw him as slow, indelicate, and casual about the OR procedures. The local joke was that his patients had already healed by the time Halsted finished the operation. The Chief was not unhappy that his energetic and talented resident took command and did much of the work, whipping the OR and resident staff into shape. It was only years later that Cushing learned that Halsted was addicted to cocaine.

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In 1900 Cushing went to England. There, too, he was disturbed by what he saw as unimpressive operative procedures and callous treatment of patients by the consultants. William Osler was there on a visit and introduced him to the leading medical men. Cushing had had little previous contact with Osler at Hopkins, but became a lifelong admirer and eventually his first biographer. He returned to Baltimore unsure about what position he should seek but after his appointment focused on neurosurgery. He moved into a house next to Osler, and when he married, his neighbor Osler cut an opening in the fence so the couple could use his garden house.

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The pattern of Cushing's career could be seen early. He was demanding of himself and everyone else, autocratic, cold, uncompromising, critical, insistent on every detail, even writing out the menus for all his patients' meals. He was not going to allow anything adverse to affect the care of his patient. That this was all in the interest of his patients was evident in his low postoperative infection rates, his remarkable surgical results, and his warm, kindly interest, and care of his patients.



He might seem critical and vicious with his assistants but he would not hesitate to assist a patient lying in a pool of vomit. His patients saw a surgeon with a warm touch and time to talk. The bruised assistants were surprised to find him charming and generous when he entertained them at his home on the weekends.

Cushing knew he did not have the background, skill, or interest to do the medical aspects of neurology, but he also had no intention of being a handmaiden of the neurologists, a position many others accepted if they risked surgically entering the nervous system.

General surgeons who occasionally performed neurosurgical procedures found it a sobering and unnerving experience, usually followed by a dismal outcome. Cushing took on the field with enthusiasm, single-mindedness, courage, and dedication. He was perhaps the first American surgical superstar, as famous abroad as he was at home, recognized by the profession but also adored and courted by the press, which he disdained. He was not above self-promotion within the profession but did not believe in seeking public attention.

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His career in Baltimore and later in Boston was marked by a steadfast commitment to expanding the field of neurosurgery, especially the approach to brain tumors. He was brilliant as a surgeon, not an inventor or a deep thinker, but a highly skilled workman, pushing ahead with better ways to do the day's work.

Just when Cushing was on the top of his field, known worldwide for his role as the pre-eminent neurosurgeon, he donned a military uniform when the US entered World War I. The touching story is often told that Cushing was at the medical station as Osler's only son, Revere Osler, was dying of shrapnel wounds despite attempts to save him. The Oslers were comforted that their young friend was at their son's side when he died.

In his later years he continued to work, but was slowed by failing health. He no longer played tennis because he smoked cigarettes, which led to the painful peripheral vascular insufficiency of Buerger disease. It was said he played tennis as if he were in the operating room, pushing and berating his doubles partner, as he would have treated his assistants; his competitive spirit took over. Although he could be cooperative with his colleagues in surgery, Cushing's rivalry with his former student, the Johns Hopkins surgeon, Walter Dandy, makes interesting reading.

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In 1926 Cushing was awarded the Pulitzer Prize for the biography, The Life of Sir William Osler. He was offered many positions related to the history of medicine after his retirement at Harvard and later Yale. Although he was conscious of his legacy, he preferred to finish writing about his 2,000 brain tumor operations and a monograph on meningiomas, and adding to his impressive library of rare books on surgery and anatomy, which he bequeathed to Yale. He died of a myocardial infarction in October 1939.

I am sure Bliss enjoyed writing the life of Cushing after spending years writing his own widely lauded biography of Sir William Osler, who was as saintly as his reputation suggested. Cushing is a more delicious combination of the saint and the sinner. Cushing's personality encompassed all those features common in the dominant surgeons of a century ago – a capacity for backbreaking work, high energy, enthusiasm, competitiveness, single-mindedness, as well as occasional immature pettiness and sometimes downright meanness. But from this dedication and hard work he established neurosurgery, and current members of the specialty owe him a great debt.

Michael Bliss is particularly adept in capturing not only the essence of the individual but also the nature of patient care, including medical and surgical practice in the age of Cushing. His understanding of patients, the diseases they suffer, the professional controversies, the state of surgical practice in America, United Kingdom, France, and the rest of Continental Europe, as well as the intimate details of each surgical operation is impressive.

Harvey Cushing: A Life in Surgery is a fitting companion volume for Bliss's biography of Sir William Osler: A Life in Medicine. Academic and historical works are not so often page-turners but I think all neurologists and neurosurgeons will find this book hard to put down.

©2006 American Academy of Neurology