Harvey Cushing: a life in surgery Michael Bliss Toronto: University of Toronto Press; 2005 593 pp $50 (cloth) ISBN 0-H020-H950-X
In the first three decades of the 1900s, Harvey Cushing (1869–1939) was a cosmic force in the special field of neurological surgery and a commanding figure in American medicine.
Author Michael Bliss gives us a brilliant and highly readable re-creation of the life and work of Cushing, who is generally recognized as the founder of modern neurosurgery. For this task, Bliss trawled an immense sea of Cushing archives — over three hundred scientific and historical articles and a dozen monographs by Cushing, endless reams of his letters, journals, travel diaries, sketchbooks, and scrapbooks, photos, intimate family papers and memorabilia and, from Cushing's twenty years of surgical cases at Harvard's Brigham Hospital, 50 000 pages copied from patients' records and about 800 jars of brains. All in all, a collection “wonderfully rich,” Bliss coolly remarks, “perhaps uniquely so in the medical world.” The resulting biography is solidly referenced and annotated by forty-five pages of scholarly back-notes.
Born in Cleveland, Ohio, the tenth child of a doctor, with physicians in three preceding generations, Cushing became the peripatetic Ivy League man, with his father footing the bills. He attended Yale, where he was an eager but erratic shortstop; Harvard Medical School from which he graduated MD cum laude; then Johns Hopkins Hospital, where he had the good fortune to be exposed to the meticulous hemostatic surgical ritual of William Halsted, one of the first American surgeon-scientists. After a decade at Hopkins, Cushing was appointed Chief of Surgery at Harvard's newly opened Peter Bent Brigham Hospital and over the next twenty years he consolidated his neurosurgical career. His work was interrupted by two sessions of intense military surgery overseas in World War I. Those war years, as for so many survivors, exacted a severe toll on his health. Despite that, over the next decade, he extracted from his voluminous war diaries the story of the Harvard-staffed American Base Hospital No. 5, finished a Pulitzer prize winning biography of Sir William Osler and published six more outstanding monographs in neurosurgery, including the record-breaking Intracranial Tumors based on his 2000 verified cases.
On retirement from Harvard in 1932, Cushing moved back to Yale to focus his efforts as a writer and to indulge his love of books. There, he worked over his long surgical experience on meningiomas and in 1936 he published what became one of the most famous texts in neurosurgery.
Cushing, by his driven obsession and his innovative talents as a researcher, artist, author, medical historian and statesman, left an indelible legacy at all these medical schools and their hospitals. He taught more than a hundred young neurosurgeons, many of them toiling for one year on his demanding clinical service, some spending a second year in the experimental laboratory. These disciples then fanned out across the United States or back to Europe, to spread the Cushing gospel.
Cushing had strong Canadian connections. At Hopkins he was the protégé and friend of William Osler, who strongly supported young Cushing's struggles to start a neurosurgical practice. In February 1904 Osler asked Cushing to see a patient in Montréal who had been suffering from bouts of facial pain. Cushing took this opportunity to report to the Montreal Medico-Chirurgical Society the results from his first twenty cases of relieving the ferocious pain of trigeminal neuralgia by total removal of the Gasserian ganglion. Cushing had developed his anatomical method by dissection at 30 autopsies. The operation was extremely difficult and although it did relieve the pain, the consequences were severe — half the face became insensible leading sometimes to keratitis and blindness and, if the motor root was damaged, to a skewed jaw. To Cushing's chagrin, a year after he had proudly published his technique, the neurologist William Spiller and surgeon Charles Frazier in Philadelphia described how they divided the nerve behind the ganglion, a much simpler operation that enabled selective division of the nerve without a ganglionectomy. In a brief report a few years later, despite his vested interest in the ganglion operation, Cushing quietly revealed that he had adopted their approach after his first 28 cases — a blow no doubt to his surgical pride, but a boon for his patients.
Canadians are especially indebted to Cushing for two of his students, Wilder Penfield and Kenneth McKenzie, who established the two major schools of neurosurgery in Canada, at Montréal and Toronto. Penfield and his associates at the Montreal Neurological Institute in turn trained scores of young neurosurgeons from the United States who returned to become leaders in American neurosurgery. In 1922, Cushing spoke at the opening of McGill's Biological Building, emphasizing the importance of bedside teaching (introduced by Osler at Johns Hopkins) as compared to laboratory exercises. In 1929 he attended the opening of the Bibliotheca Osleriana designed to house Osler's gift of 8000 rare books. At Cushing's final visit to Montréal in 1934, on the invitation of Wilder Penfield, he presented one of his finest addresses at the opening of the Montreal Neurological Institute. He graciously paid homage to Osler for his influence in directing the Rockefeller fortune toward medical research, recognized the valuable spirit of exchange between the medical profession of the United States and Canada and gave his blessing to his student Wilder Penfield and the staff for the future of the Institute. Following Osler's example in Montréal, Cushing decided to leave his books to Yale University, where, with those of Arnold Klebs and John Fulton, the famous Medical Historical Library at Yale was founded.
There is much else of interest in this fine sweeping biography — Cushing's relations with his wife Kate Crowell Cushing and her wrenchingly poignant letters protesting his single-minded focus on surgery at the neglect of the family; Cushing's many overseas tours during war and peace; the tragedies and high romance involving his children that included three daughters who married and remarried into the rich and famous, and in the latter part of Cushing's life, worldwide recognition for his enormous accomplishments to neurosurgery and to medicine at large.
At the time of Cushing's sixtieth birthday in 1929 he wrote Wilder Penfield in Montréal in regard to the problem of training a neurosurgeon.
We may be setting the standard too high, too comprehensive, but it is worth striving for. … The length of time it would take for a proper grounding in neuropathology, psychiatry, neurophysiology, etc., plus surgery, except for the occasional genius, is prohibitive. The art is long and the life short.