Harvey Cushing: A Life in Surgery

For decades professional medical historians considered the biography to be outdated as a genre. However, in recent years there has been a revival of interest in the lives of outstanding individuals. Michael Bliss, a professor of history at the University of Toronto, first published William Osler: A Life in Medicine (review BMJ 2000;321: 1087). He sees a Cushing biography as a sequel to the Osler biography: “Each would stand alone, but together the two volumes would be a biographical study of the rise of North American medicine and surgery.”

Figure 1.

Michael Bliss

Oxford University Press, £23.99/$40, pp 608 ISBN 0 19 516989 1

Rating: ★★★★

Bliss's biography of Cushing revolves around several metaphors. There are numerous references to sport. Neurosurgery is a team game, and Cushing is compared to a “star player, star coach, and general manager, all in one.” Every operation was like a championship set: “He played tennis the way he operated, and he operated the way he played tennis.” Cushing described the first world war as a football game and life in general as a sports event (“Life all round is a kind of sporting event and the best any of us can do is to try continually to improve our game,” he wrote to his son Bill). He gave up his surgical practice after hitting a record number of 2000 removed brain tumours. Cushing at the end of his career is likened to an ageing athlete who “collapsed like an exhausted runner.”

Bliss notes that “the rise of American medicine in general and neurosurgery in particular was a product of American Puritanism, American democracy, and American wealth.” He views Cushing's life as an example of applied Puritanism: “Cushing had been the puritan as perfectionist surgeon—no germs, no bleeding, no sloppiness, no shortcuts.” Cushing called himself “merely a handicraftsman” and privately deprecated surgical contemporaries who pretended to be philosophers.

God-like Cushing was the creator of neurosurgery, Bliss claims. He indeed had a great impact on shaping the specialty, and trained many surgeons from North America and western Europe. The results of his brain tumour surgery were considered a gold standard throughout the world, and he founded the Society of Neurological Surgeons. But Cushing was not the only one to practise neurosurgery in the first decades of the 20th century. Other names include Charles Frazier and Ernest Sachs from the United States, Fedor Krause and Otfrid Foerster from Germany, Antoine Chipault from France, and Ludwig Pussep from Russia.

Bliss admits that “Cushing had been a surgical innovator without being particularly inventive.” Most instruments and techniques he used were initially suggested by others. These include monitoring blood pressure with an inflatable cuff invented by Scipione Riva-Rocci, electrosuction introduced by Fedor Krause in 1908 and later adapted by Cushing, and electrocoagulation developed by W T Bovie in the 1920s. H Schloffer used the transsphenoidal approach to pituitary tumours in 1907, two years before Cushing.

Cushing was remarkably prolific at his writing desk, as well as in the operating room. It has been estimated that in the 1920s he committed to paper between 5000 and 10 000 words a day, assisted by several female secretaries, typists, stenographers, medical artists, and photographers, called “Cushing's harem.” His total literary output comprises 13 books and 330 scientific articles. The recipient of 23 honorary degrees, an honorary member of 60 scientific societies, and the author of 16 prize lectures, Cushing was named in 1931 by William Welch as “the most influential man in the medical world today.” In 1939 the New England Journal of Medicine labelled him as “perhaps the foremost physician produced in the United States.”

But what was the quality of Cushing's research? According to Walter Dandy (Cushing's former resident at Johns Hopkins), he “was not a real scientist. All of his physiological efforts failed miserably because he tried to prove what he preconceived and he preconceived badly...”Was Dandy perhaps wrong? Bliss does not produce any evidence in Cushing's support.

Much of the book presents a Jekyll and Hyde personality, “hustling Harvey,” as Grace Osler nicknamed Cushing. He was charming and selfish, sentimental and racist, devoted to patients and sadistic to his residents, arch-Victorian in his cultural habits and ultramodern in clinical practice, and addicted to work and tobacco. Cushing was ruthless in his pursuit of knowledge. He “did not use consent forms either for operation or for autopsies.” When a patient's relatives refused permission for an autopsy, Cushing would offer them money from his own pocket. Otherwise he would bribe a priest or an undertaker to allow the clandestine removal of postmortem specimens by one of his residents.

Figure 2.

Cushing was devoted to patients, but sadistic to his residents

Credit: NLM/NIH

Money was not an issue for Cushing. His hospital salary was insufficient to cover the wages of his personal staff. The Cushings' annual income ($50 000, which is roughly equivalent to $750 000 (£396 000; €582 000) in current purchasing power) mostly came from their parents' estates and trust funds. Patients of moderate means were asked to pay the equivalent of their monthly income. Fees for physicians and their families were waived.

Bliss's book is aimed at a lay audience. It is clearly written, but the author should have gained some minimal knowledge of human anatomy. That might have prevented him referring to the spinal column as “the body's main nerve canal” or describing the cerebellopontine angle as a place “where cerebellum meets the pons at the upper end of the spinal cord.” According to Bliss, the pituitary gland is “a little nut of an organ, weighing about half of a gram.” In reality, it is three times heavier. Despite these minor criticisms this is an excellent book.