Portal de Periódicos da CAPES

Harvey Cushing: A life in surgery

2006; Elsevier BV; Volume: 41; Issue: 3 Linguagem: Inglês

10.1016/j.jpedsurg.2005.12.065

1531-5037

John G. Raffensperger,

Health and Medical Research Impacts

Michael Bliss, who has previously published The Discovery of Insulin and William Osler, a Life in Medicine has written an extraordinary biography of Harvey Cushing, who, 100 years ago, laid the foundations for modern neurosurgery. Professor Bliss used material from the Cushing papers at Yale University, personal correspondence, and the diaries of his assistants to trace the life of this great surgeon from his birth in 1869 until his death in 1939. These sources provided the author with greater insight into Cushing's personal life and professional values than previous biographers.Harvey Cushing was a third-generation physician born to a family of New England Puritans who migrated to Cleveland Ohio in the mid-1830s. His father and grandfather were successful physicians, and family members on both sides were well educated and financially secure. He had a liberal education with Latin, Greek, literature, and history and was interested in architecture but, during his third year at Yale, turned to medicine. Cushing played on the Yale baseball team, rowed, did gymnastics, and was elected to Scroll and Key, an honor society. In a college play, starring as Miss Pocohantus, he entered the stage with a double back handspring. At Harvard medical school, Cushing excelled in anatomy and skipped lectures to do hospital work. He gave ether anesthetics during his first year and, even before a formal course in surgery, assisted at operations. He almost gave up medicine after a woman died during an operation for a strangulated hernia while he administered the anesthetic. This was perhaps the first time he knew anger and despair when a patient died. In 1927, when he lost Gen Leonard Wood during removal of a recurrent brain tumor, he blamed himself for not doing the operation in 2 stages. Throughout his life, he became angry and depressed when patients did poorly. At one time, he thought of suicide but bounced back from episodes of depression with physical exercise, reading, travel, and heavy cigarette smoking. During his optional fourth year of medical school, he worked as an outpatient physician, saw patients at the Children's Hospital, and delivered babies in the homes of poor people. Today's medical educators should take note of Cushing's broad general education and his early exposure to clinical responsibility.No one had heard of the “80-hour week” when Harvey Cushing was a surgical intern at the Massachusetts General Hospital in 1895. He reduced fractures and dislocations, sutured lacerations, took care of gunshot wounds, and assisted at all kinds of surgery. He witnessed an abdominal operation on a 2-day-old baby, gave ether anesthetics, kept careful records, and was constantly on call. After one long continuous stint of work, he said, “Had a great twenty four hours.” Even as an intern, Cushing was independent and did not hesitate to criticize his superiors when they had bad results. One time, after an attending man recommended an amputation, he saved the patient's leg by draining a tubercular abscess.In 1896, he became an assistant surgical resident under William Stewart Halsted at the new Johns Hopkins Hospital. In one of his many interesting digressions, Professor Bliss describes the hospital, the university, and the outstanding physicians who instituted a completely new system of medical education at Hopkins. At first, Cushing was disappointed with Halsted, who was slow and fussy in comparison with the fast Boston surgeons. After a few months, he settled down, did outstanding research work, and published the first of many papers in which he established the connection between typhoid fever and cholecystitis. He became Halsted's senior resident, reorganized the surgical service, introduced x-rays, insisted on careful anesthesia records, and pioneered early operations for patients with intestinal perforation because of typhoid fever. Cushing was in charge of the surgical service during Halsted's many long absences and even operated on some of the “Chief's” private patients in their homes. He was on duty, night and day, 7 days, and still found time to take German lessons, do literary work, and play tennis. While still a resident, he operated upon Halsted's wife after an accident, and later, Halsted operated upon Cushing for appendicitis. He did some of the first intestinal resections and the first splenectomy at Hopkins. Near the end of his residency, he became interested in surgery of the nervous system, and after practicing on thirty cadavers, in 1899, he performed a gasserian ganglionectomy on a patient with trigeminal neuralgia. He opened the skull with a hammer and chisel under chloroform anesthesia. The operation was successful.In the summer of 1900, Cushing spent 14 months touring Europe and observing surgery. He was disappointed with the surgeons and appalled at the apparent disregard for patients. He said this about German surgery: “The patient was something to work on, interesting experimental material, but nothing more.” While in Switzerland, his interest in the brain was cemented while doing research on the relationship of intracranial pressure with systemic blood pressure.Upon his return to Hopkins, Cushing became an associate in surgery in charge of the neurologic cases and, at the age of 33, married his long-time fiancée. During the next decade, he operated upon patients with trigeminal neuralgia, brain tumors, and pituitary disorders; removed blood clots from the brains of newborn babies; and performed subtemporal decompressions to relieve the symptoms of inoperable brain tumors. He commenced the pattern of intense surgical activity, writing, speaking, and research, which characterized his life. Working with open drop ether or local anesthesia, he achieved amazing results because he was a “crotchety perfectionist” and a slow careful operator who observed the minutiae of surgery. He was often stymied by bleeding and instituted the use of warm moist cotton pledgets and silver clips to control hemorrhage. Later, at Harvard, he was one of the first surgeons to use electrocautery. In 1910, he operated upon Gen Leonard Wood, an American hero, for a brain tumor. There was so much bleeding that he dosed the skull and, 4 days later, using local anesthesia, reoperated and removed a huge tumor. It was during this time that he formed a lasting friendship with William Osler, the great physician.In 1912, he was called to be the chief surgeon at Harvard's new Peter Bent Brigham hospital. Professor Bliss provided us with interesting background material on the Harvard medical school and Bostonians. Cushing did not easily fit into the Harvard pattern. His work was interrupted when, at age 46, he led Harvard's volunteer medical unit to France to help the British medical service during the early days of the First World War. He meticulously operated upon head wounds in a rat-infested, muddy tent hospital and was one of the first to use a magnet to retrieve shrapnel fragments and suction to debride brain tissue. Later, when America entered the war, he went back to France and operated almost continuously during the great battles of 1917. Professor Bliss again described for us one of the saddest strangest episodes in the history of war and medicine. Revere Osler, son of Sir William Osler and, on his mother's side, a great, great, great grandson of Paul Revere, was severely injured by a shell burst during a German offensive. Almost by chance, Harvey Cushing and 3 other of the most skilled American surgeons were in the area. They operated but were unable to save the 21-year-old soldier. What a tragic waste of human life; Revere was William Osler's only child.When Dr Cushing returned from the army, his legs were numb and he can hardly walk, but at the age of 50 years and in poor health, he returned to intense surgical and literary work at the Peter Bent Brigham Hospital. He operated upon increasing numbers of patients with brain tumors with steadily improving results. Despite gangrenous toes because of smoking, he left his hospital bed in a wheelchair and, in 1931, operated upon his 2000th tumor case. Shortly after that case, he retired to become a professor at Yale. At the time, he had a gastric ulcer and painful feet; his health improved when he gave up smoking. He died with a myocardial infarction in 1939 at the age of 70 years.Cushing's stupendous literary output reached a peak with the publication of his 2-volume biography of Osler in 1925, which won a Pulitzer prize. There were innumerable papers, textbooks, and lectures that provide insight to his thoughts on medical education and practice. He sought a balance between science and the art of medicine, feeling that even during the 1920s the pendulum had swung to far toward science and research and away from the clinical care of patients. He anticipated one of today's thorny ethical problems when he wrote that surgeons should not prolong life unless the life was worth living. In a 1926 graduation address to Jefferson Medical School, he said, “If a doctors life may not be a divine vocation, then no life is a vocation and nothing is divine.” While at Yale, he published his war diaries and his last book, a 741-page volume on meningiomas, which was released in 1938.We surgeons can learn from Cushing's personal life. One of his more serious imperfections was his meanness to assistants, but then, he did not hold a grudge. He was jealous of competitors, especially in matters of priority, but he wrote letters of congratulation when his former students excelled. He was above all kind and sympathetic with patients and personally changed dressings, cleaned patients, and helped with bedpans. Unfortunately, his single-minded devotion to surgery estranged him from his family. His wife frequently went on vacations by herself, and his family rarely accompanied him on his many medical travels. He was separated from them for long periods of time, and when he was home, he spent more time in his study than with the children. His oldest son died in an alcohol-related car crash, and his second son flunked out of Yale, perhaps with a nervous breakdown. One of his 3 daughters married a son of Franklin Roosevelt. None of the “fabulous Cushing sisters” attended college, and their first marriages ended in divorce. During his last years, Cushing was often alone and in poor health.This book answers the question “what makes a great surgeon.” First, there was his extraordinary medical family, and second, as evidenced by his athletic activities, near-perfect hand-eye coordination and his determination to win at all costs. In an age when many surgeons focused on speed, he was an exquisitely careful technician. He could afford a prolonged period of training because his father provided financial support and he avoided the distractions of marriage until completion of his training. He was independently wealthy and did not have to worry about collecting fees. He was curious about all things, driven, and can ignore fatigue, but most of all, Harvey Cushing was a great humanist who put his patients first before everything else in his life.Harvey Cushing: A Life in Surgery is an extraordinary book. Buy it and read it but do not let it gather dust on your bookshelf. Pass it on to your resident or a medical student. Michael Bliss, who has previously published The Discovery of Insulin and William Osler, a Life in Medicine has written an extraordinary biography of Harvey Cushing, who, 100 years ago, laid the foundations for modern neurosurgery. Professor Bliss used material from the Cushing papers at Yale University, personal correspondence, and the diaries of his assistants to trace the life of this great surgeon from his birth in 1869 until his death in 1939. These sources provided the author with greater insight into Cushing's personal life and professional values than previous biographers. Harvey Cushing was a third-generation physician born to a family of New England Puritans who migrated to Cleveland Ohio in the mid-1830s. His father and grandfather were successful physicians, and family members on both sides were well educated and financially secure. He had a liberal education with Latin, Greek, literature, and history and was interested in architecture but, during his third year at Yale, turned to medicine. Cushing played on the Yale baseball team, rowed, did gymnastics, and was elected to Scroll and Key, an honor society. In a college play, starring as Miss Pocohantus, he entered the stage with a double back handspring. At Harvard medical school, Cushing excelled in anatomy and skipped lectures to do hospital work. He gave ether anesthetics during his first year and, even before a formal course in surgery, assisted at operations. He almost gave up medicine after a woman died during an operation for a strangulated hernia while he administered the anesthetic. This was perhaps the first time he knew anger and despair when a patient died. In 1927, when he lost Gen Leonard Wood during removal of a recurrent brain tumor, he blamed himself for not doing the operation in 2 stages. Throughout his life, he became angry and depressed when patients did poorly. At one time, he thought of suicide but bounced back from episodes of depression with physical exercise, reading, travel, and heavy cigarette smoking. During his optional fourth year of medical school, he worked as an outpatient physician, saw patients at the Children's Hospital, and delivered babies in the homes of poor people. Today's medical educators should take note of Cushing's broad general education and his early exposure to clinical responsibility. No one had heard of the “80-hour week” when Harvey Cushing was a surgical intern at the Massachusetts General Hospital in 1895. He reduced fractures and dislocations, sutured lacerations, took care of gunshot wounds, and assisted at all kinds of surgery. He witnessed an abdominal operation on a 2-day-old baby, gave ether anesthetics, kept careful records, and was constantly on call. After one long continuous stint of work, he said, “Had a great twenty four hours.” Even as an intern, Cushing was independent and did not hesitate to criticize his superiors when they had bad results. One time, after an attending man recommended an amputation, he saved the patient's leg by draining a tubercular abscess. In 1896, he became an assistant surgical resident under William Stewart Halsted at the new Johns Hopkins Hospital. In one of his many interesting digressions, Professor Bliss describes the hospital, the university, and the outstanding physicians who instituted a completely new system of medical education at Hopkins. At first, Cushing was disappointed with Halsted, who was slow and fussy in comparison with the fast Boston surgeons. After a few months, he settled down, did outstanding research work, and published the first of many papers in which he established the connection between typhoid fever and cholecystitis. He became Halsted's senior resident, reorganized the surgical service, introduced x-rays, insisted on careful anesthesia records, and pioneered early operations for patients with intestinal perforation because of typhoid fever. Cushing was in charge of the surgical service during Halsted's many long absences and even operated on some of the “Chief's” private patients in their homes. He was on duty, night and day, 7 days, and still found time to take German lessons, do literary work, and play tennis. While still a resident, he operated upon Halsted's wife after an accident, and later, Halsted operated upon Cushing for appendicitis. He did some of the first intestinal resections and the first splenectomy at Hopkins. Near the end of his residency, he became interested in surgery of the nervous system, and after practicing on thirty cadavers, in 1899, he performed a gasserian ganglionectomy on a patient with trigeminal neuralgia. He opened the skull with a hammer and chisel under chloroform anesthesia. The operation was successful. In the summer of 1900, Cushing spent 14 months touring Europe and observing surgery. He was disappointed with the surgeons and appalled at the apparent disregard for patients. He said this about German surgery: “The patient was something to work on, interesting experimental material, but nothing more.” While in Switzerland, his interest in the brain was cemented while doing research on the relationship of intracranial pressure with systemic blood pressure. Upon his return to Hopkins, Cushing became an associate in surgery in charge of the neurologic cases and, at the age of 33, married his long-time fiancée. During the next decade, he operated upon patients with trigeminal neuralgia, brain tumors, and pituitary disorders; removed blood clots from the brains of newborn babies; and performed subtemporal decompressions to relieve the symptoms of inoperable brain tumors. He commenced the pattern of intense surgical activity, writing, speaking, and research, which characterized his life. Working with open drop ether or local anesthesia, he achieved amazing results because he was a “crotchety perfectionist” and a slow careful operator who observed the minutiae of surgery. He was often stymied by bleeding and instituted the use of warm moist cotton pledgets and silver clips to control hemorrhage. Later, at Harvard, he was one of the first surgeons to use electrocautery. In 1910, he operated upon Gen Leonard Wood, an American hero, for a brain tumor. There was so much bleeding that he dosed the skull and, 4 days later, using local anesthesia, reoperated and removed a huge tumor. It was during this time that he formed a lasting friendship with William Osler, the great physician. In 1912, he was called to be the chief surgeon at Harvard's new Peter Bent Brigham hospital. Professor Bliss provided us with interesting background material on the Harvard medical school and Bostonians. Cushing did not easily fit into the Harvard pattern. His work was interrupted when, at age 46, he led Harvard's volunteer medical unit to France to help the British medical service during the early days of the First World War. He meticulously operated upon head wounds in a rat-infested, muddy tent hospital and was one of the first to use a magnet to retrieve shrapnel fragments and suction to debride brain tissue. Later, when America entered the war, he went back to France and operated almost continuously during the great battles of 1917. Professor Bliss again described for us one of the saddest strangest episodes in the history of war and medicine. Revere Osler, son of Sir William Osler and, on his mother's side, a great, great, great grandson of Paul Revere, was severely injured by a shell burst during a German offensive. Almost by chance, Harvey Cushing and 3 other of the most skilled American surgeons were in the area. They operated but were unable to save the 21-year-old soldier. What a tragic waste of human life; Revere was William Osler's only child. When Dr Cushing returned from the army, his legs were numb and he can hardly walk, but at the age of 50 years and in poor health, he returned to intense surgical and literary work at the Peter Bent Brigham Hospital. He operated upon increasing numbers of patients with brain tumors with steadily improving results. Despite gangrenous toes because of smoking, he left his hospital bed in a wheelchair and, in 1931, operated upon his 2000th tumor case. Shortly after that case, he retired to become a professor at Yale. At the time, he had a gastric ulcer and painful feet; his health improved when he gave up smoking. He died with a myocardial infarction in 1939 at the age of 70 years. Cushing's stupendous literary output reached a peak with the publication of his 2-volume biography of Osler in 1925, which won a Pulitzer prize. There were innumerable papers, textbooks, and lectures that provide insight to his thoughts on medical education and practice. He sought a balance between science and the art of medicine, feeling that even during the 1920s the pendulum had swung to far toward science and research and away from the clinical care of patients. He anticipated one of today's thorny ethical problems when he wrote that surgeons should not prolong life unless the life was worth living. In a 1926 graduation address to Jefferson Medical School, he said, “If a doctors life may not be a divine vocation, then no life is a vocation and nothing is divine.” While at Yale, he published his war diaries and his last book, a 741-page volume on meningiomas, which was released in 1938. We surgeons can learn from Cushing's personal life. One of his more serious imperfections was his meanness to assistants, but then, he did not hold a grudge. He was jealous of competitors, especially in matters of priority, but he wrote letters of congratulation when his former students excelled. He was above all kind and sympathetic with patients and personally changed dressings, cleaned patients, and helped with bedpans. Unfortunately, his single-minded devotion to surgery estranged him from his family. His wife frequently went on vacations by herself, and his family rarely accompanied him on his many medical travels. He was separated from them for long periods of time, and when he was home, he spent more time in his study than with the children. His oldest son died in an alcohol-related car crash, and his second son flunked out of Yale, perhaps with a nervous breakdown. One of his 3 daughters married a son of Franklin Roosevelt. None of the “fabulous Cushing sisters” attended college, and their first marriages ended in divorce. During his last years, Cushing was often alone and in poor health. This book answers the question “what makes a great surgeon.” First, there was his extraordinary medical family, and second, as evidenced by his athletic activities, near-perfect hand-eye coordination and his determination to win at all costs. In an age when many surgeons focused on speed, he was an exquisitely careful technician. He could afford a prolonged period of training because his father provided financial support and he avoided the distractions of marriage until completion of his training. He was independently wealthy and did not have to worry about collecting fees. He was curious about all things, driven, and can ignore fatigue, but most of all, Harvey Cushing was a great humanist who put his patients first before everything else in his life. Harvey Cushing: A Life in Surgery is an extraordinary book. Buy it and read it but do not let it gather dust on your bookshelf. Pass it on to your resident or a medical student.