Top Doc

1.

Late on a Friday afternoon in May 1984, seventy-five-year-old Betsey Whitney, the last of the three Cushing sisters whose photos had appeared on so many society pages earlier in the century, sat in rapt attention as her father’s many contributions to medical science were described to an audience of about 150 fascinated listeners. The occasion was the annual Meeting of the Associates of the Yale Medical Library, and the speaker was Dr. Jeremiah Barondess, professor of medicine at Cornell and, coincidentally, her own personal physician.

Flanked by her two daughters in the high-vaulted, balcony-rimmed Medical Historical Library, Mrs. Whitney was surrounded on all sides by shelves containing hundreds of the valuable books collected by her father during his lifetime. Two floors of stacks lay below, holding many hundreds more from his collection, adding up to thousands. To enter the library, the three women had passed through the two-storied Cushing Rotunda, presented to the university by the Yale class of 1891, in honor of their most distinguished classmate. As they were being escorted through that lofty—in both senses of the word—space that has been a source of inspiration to several generations of medical students and faculty, the three women paused to look up at its circular walls, which displayed fourteen steel crests representing the European honorary degrees awarded to Harvey Cushing. No graduate of the Yale School of Medicine would disagree that the symbolic focal point of the two-hundred-year-old institution is that magnificent rotunda.

Sitting near Mrs. Whitney was a friend of many years, Elizabeth Thomson, a former editor of the Journal of the History of Medicine and Allied Sciences and one of Cushing’s biographers. Though Mrs. Whitney had often traveled to the New Haven suburb of Hamden to visit Miss Thomson, she would later tell her that she had never come close to grasping the full range of her father’s vast accomplishments until that day, as she listened to Dr. Barondess and heard others describe his work. He was for the most part a distant and even imperious figure to his own family, frequently off doing something that seemed far more important than being at home with his wife, Kate, and their five children.

What was it that Harvey Cushing had been doing in all those years of busy inattention to those who should have been closest to him? Betsey Whitney was well aware, of course, that her father was commonly referred to as the father of neurosurgery, and that he had, during an unimaginably productive career, operated on the seemingly impossible number of two thousand patients with tumors of the brain. She also knew, though hardly to the extent that she became aware of it that day, that he was a pioneer in the research that elucidated the functions of the pituitary, the small structure lying at the base of the skull that has so strong a controlling influence on other hormonal secretions of the body that it is commonly known as the master gland. And she had since childhood heard tales of his legendary technical prowess in the operating room. But as the story of his career unfolded during Barondess’s talk and the ensuing discussion, she came to realize, she later said, that the sheer magnitude and originality of his contributions had elevated him to a level of accomplishment matched by few men in the entire long history of surgery.

It was Harvey Cushing who, while still in his early thirties, introduced the notion of routinely monitoring the blood pressure during operations, something that had never been done before. This innovation was presented at about the same time that he undertook the difficult treatment of tic douloureux—a debilitating form of facial neuralgia—by the exquisitely delicate maneuver of removing the mass of nerve tissue at the very edge of the brain, called the Gasserian ganglion, through which the agonizing pain passed.

There was a reason he could do this successfully when others had not dared to make the attempt, and it was the same reason for which he was soon thereafter able to overcome the brain’s reputation as an organ so dangerous to operate upon that the great majority of patients died after attempts to do so, or were considerably worsened. This was his development of precise techniques to control the intense bleeding that usually accompanied such operations, as well as his methods of preventing or dealing with the swelling of the brain that they caused. Much of his success was owing to minutely meticulous technologies for dissecting and handling tissue, and the painstaking ways in which he accurately controlled the multitude of small blood vessels in the area of the operation.

The new methods meant that his patients lived, while the patients of others died; he taught a generation of young surgeons to operate as he did, and they in turn became the teachers of those that followed. No neurosurgeon of today can escape the influence of the Cushing approach to the brain that he or she has been taught, without which all efforts to treat the brain would be doomed to failure.

For such towering contributions, Harvey Cushing was laden with honors by a grateful profession and even a grateful world, and was celebrated during his life in ways that his children knew about only in part. But the work and the worldliness separated him from other rewards much closer to home, though he seemed scarcely to notice what was missing. The story of his daughter’s incomplete knowledge of all that her father had been is a metaphor of sorts for the way he chose to live his life. It provides the background for Michael Bliss’s absorbing chronicle of the career of one of the greatest medical innovators ever produced by the US—or any other country. In some ways, Cushing exemplifies a familiar kind of gifted, driven, single-minded, and enormously ambitious person. In others he was a unique figure at a unique historical moment, who combined inborn talents and fortunate circumstances in ways that were so distinctive one could, in his presence, feel engulfed by the man’s radiating energy.

Such a person is difficult to live with. From at least his late teens, Cushing seems to have been increasingly aware of his remarkable gifts, whether natural or acquired. He lived as though determined not only to foster his brilliance but also to guard it against any possibility that it might not reach the fullness that was to be its destiny. Not only that, but he recorded every step of his lifelong efforts to enlighten the medical science and practice of his era. He seems to have known from the beginning that he would grow up to be Harvey Cushing: everything was documented, everything was kept.

As a result we possess recorded evidence of one of the most extraordinary lives any biographer might wish to study. Cushing was the first resident in a Johns Hopkins program that would become the model upon which every other surgical training plan in the United States would be built; he was the founding professor of surgery at Harvard’s Peter Bent Brigham Hospital, one of the world’s leading medical research and clinical institutions; he served his country bravely and indefatigably as the commanding officer of US Army Base Hospital No. 5 in the combat zones of France during World War I; he won the Pulitzer Prize in 1926 for his biography of William Osler, America’s greatest medical teacher; his collection of rare books became the core of one of the foremost libraries of medical history in the world.

As a working surgeon, he introduced a series of diagnostic and therapeutic techniques that profoundly affected surgery; he was not only the pioneer researcher into the physiology and surgery of the pituitary gland, but developed the first safe methods of operating on it. As for postoperative treatment, Bliss writes,

Cushing virtually invented the concept of intensive care in an age before the intensive care unit. Patients were observed on the operating table for hours after recovery, sometimes in the operating room for days. Special nursing was supplied to charity patients out of a special fund, and in Cushing’s final years special nurses were hired to oversee the whole neurosurgical ward. “Unquestionably many lives have been saved in this way,” he wrote, “for less experienced nurses or junior house officers can hardly be expected to appreciate the significance of symptoms which indicate that something is going wrong with a patient recently operated on for brain tumor.”

In addition to all of this, his was among the most colorful of the many charismatic medical personalities who became well-known public figures during the first decades of the twentieth century, a period when the idealized image of the physician was widely circulated in America.

But the very vastness of achievement and the thoroughness of record-keeping pose a problem for the biographer. With so many letters written and received, so many histories of patients, so many newspaper clippings, so many diary entries, so many annotated photographs and pen-and-ink sketches drawn by Cushing, so many anecdotes and comments by others, so many personal scribblings in the margins of book pages—with such a plenitude of available material, how is a clear narrative to be constructed?

I know about these difficulties because I have been studying Cushing’s life for almost thirty years, sometimes deliberately and sometimes accidentally. I’ve come across many of my discoveries while looking into the holdings of the Yale Medical Historical Library, which is part of his heritage. I’ve also done research on some of his accomplishments in the university’s Sterling Library, where so much of his archive is stored. His renown looms over the school where I have spent the past half-century; I wrote much of my first book—a biographical history of medicine—in the reconstructed Cushing office that contains many of his personal effects and memorabilia, some of them in the desk I worked at, its drawers still crammed with all kinds of stuff he left in them on the day he fell victim to the coronary occlusion that killed him at the age of seventy. Both Elizabeth Thomson and Madeline Stanton, Cushing’s loyal secretary and later director of the library, who figures so prominently in Michael Bliss’s book, were women whom I knew well; they both had much influence on my writing and thinking.

It is precisely for thes e reasons that I applaud Bliss’s magisterial accomplishment. Somehow, he has been able to find a way through the mass of Cushingiana, and show the reality of a brilliant and deeply flawed man. For all of his greatness, Harvey Cushing was not a person easily liked, and few have written of him with affection. He could be, and often was, imperious, insensitive, and on occasion downright cruel, especially to assistants judged to be delivering anything less than the perfection he demanded of them. But it was not his vanity that drove him; nor was it his self-absorption, though he had plenty of both. Rather, it was the intensity of the mission he set for himself very early in his career, which was, quite simply, to become the best at everything he tried, if that goal could be attained by hard work. Anything or anyone in his way was pushed aside or ignored if they were not part of the process in which he meant to excel as no surgeon had excelled before him. Several generations of American neurosurgeons took him as a model and, in one way or another, they are his direct professional heirs.

Bliss writes tellingly of the ethic of unremitting work in neurosurgery, which was such a striking feature of Cushing’s heritage. After a passage describing the puritanical streak that contributed to Cushing’s zealous pursuit of perfection, he says:

A second problem was Cushing’s addictive personality. Addicted to tobacco, addicted to work. A driven man, lacking a sense of balance in life, perhaps knowing that he lacked it…. He worked too much and too hard. He tried to be too many things—surgeon, researcher, teacher, author, administrator. His family, among others, paid a price. Later generations of neurosurgeons may also have paid a price for believing that their specialty required the stamina and genius of macho supermen, that they had to work like Cushing and other overachievers, relaxing differently perhaps but usually not relaxing at all.

Bliss does not attempt to excuse Cushing’s excesses in this regard, nor does he treat his subject as a hero, as did his first biographer, the neurophysiologist John Fulton. Fulton had worked closely with his friend and mentor in neuroscience and came to see him as unassailable, his more obnoxious characteristics merely the peccadilloes of genius and hardly worth comment. Bliss does not criticize Cushing, nor does he praise him unduly. What he does so well, and for the first time despite all the previous essays and memoirs and the two earlier biographies, is to present the man in full. What Bliss has given to his subject is what Cushing himself, or any of us, would ask of a biographer: understanding.

2.

Bliss’s book shows a remarkable grasp of the voluminous sources bearing on Cushing’s personal and professional life and the state of contemporary medical knowledge and what might be called its cultural background. Five generations of Cushings had been physicians; the pioneering and ultimately very prosperous family came from New England and settled in Cleveland in the Western Reserve. The Yale of 1887 seemed the natural college for a son of the rising American aristocracy, who distinguished himself there as a baseball player and as a student. He went on to the Harvard Medical School and then began his internship at the Massachusetts General Hospital. Shortly after the former Yale football captain William Halsted started the Hopkins surgical training program, Cushing applied and was accepted into it in 1896.

It was a heady time. Johns Hopkins, a Baltimore merchant and banker, left half his $7 million estate to found a university and the other half to found a hospital. When the medical school opened in 1893, it was to be the scene of a great experiment in education, with a faculty of a caliber previously unknown in any other American institution of higher learning, all dedicated to research and clinical work. The school became a source of innovation, scientific discovery, and new pedagogical approaches that made it the envy of medical schools everywhere and a model of teaching and study for the next generations. Hopkins provided the perfect atmosphere for a talented young man just beginning to become fascinated with the workings of the human body and the ways in which its diseases might be treated surgically.

Cushing proved to be not only a fine technician in the operating room, but one intent on improving every aspect of patient care, both during surgery, and, as we have seen, pre- and postoperatively as well. Intellectually stimulated by a year spent studying at several European clinics in 1900–1901, he began to turn his attention to neurological research and the problems of operating on the brain, a field just coming into its own. Bliss succinctly describes what happened as a result of his new interest: “Having looked at the brain, Cushing in the next few years learned how to gain access to it, relieve it, and let it heal. In doing this he founded neurosurgery.”

Bliss describes in fascinating detail how Cushing concentrated exclusively on his new specialty and thus gradually made himself into

the first surgeon in history who could open what he referred to as “the closed box” of the skull of living patients with a reasonable certainty that his operations would do more good than harm…. He became America’s and then the world’s leading [neurosurgical] enthusiast and guiding star.

The process began at Hopkins and continued after Cushing was appointed the Mosely Professor at Harvard in 1912, when he was forty-two. He continued to teach his techniques to young surgeons, with such effectiveness that the twenty-five trainees he brought into the field became the elite academic neurosurgical cadre that would spread his methods and surgical philosophies of meticulous preoperative evaluation and postoperative care to the group that followed them into the ranks, and add even further to his reputation for decades to come. He founded, in fact, an international school of neurosurgeons well beyond the limits of his own country, as residents came to him from various European countries. During his twenty years in Boston, his exploits in the laboratory, the operating room, and—in 1917–1918—as an intrepid front-line military surgeon brought him acclaim and gratitude. His medical papers were written with such literary flair, as were his descriptions of battlefield surgery (to be brought together into a book published in 1936), that none of their readers were surprised when he not only took on the task of writing the biography of his mentor, William Osler, the first professor of medicine at Hopkins, but went on to win the Pulitzer Prize for nonfiction.

In his thirty years at Hopkins and the Brigham, Cushing worked relentlessly at his craft. He invented techniques, devised new instruments and procedures, and attempted operations never before conceived of. Applying to the brain the scrupulous attention to detail he had learned from Halsted, his operative results were so remarkably good that they continued to be better than those who followed him into the field, including his own students. He wrote such a flood of articles and monographs for the medical literature that Bliss estimates his daily output, year after year, to have been in the astonishing range of five thousand words handwritten or dictated to secretaries.¹ He was a whirlwind of productivity despite being in constant demand as a speaker and making frequent journeys to medical meetings and clinics in the United States and abroad. At the First International Neurological Congress, held in Berne in 1931, William Welch, the founding dean at Hopkins, said that Cushing had become “the most influential man in the medical world today.”

None of this left time for family, or even for fully sharing his triumphs with his wife, Kate. The distance between them became greater over the years, and even after he accepted Yale’s offer of an obligation-free chair in neurology following his somewhat unwilling retirement from Harvard in 1933, he seems to have made little effort to improve matters. Cushing was a man who forgot his second wedding anniversary; almost from the beginning, his thoughts were elsewhere. The gradually deteriorating situation is documented in plaintive letters written by Kate to her preoccupied husband, which provide clear glimpses into corners that Cushing himself would certainly have preferred to leave in darkness.

He constantly professed his love to his wife and children, though always from afar, whether the distance was physical or emotional. He seems not to have had the time or the inclination for anything but his career. He kept telling himself and Kate how difficult his work was and how stressful to him the distance between them. From time to time, his letters would include expressions of guilt, but they don’t sound very convincing, except perhaps as attempts to stave off recrimination.

No wonder that Betsey Cushing was in such awe in the library on that afternoon in 1984 hearing for the first time, after so many decades, of the full magnitude of his accomplishments: they were his alone, hardly to be shared with the wife or the children who continued to love him even as he appeared to them as an imperious autocrat whose unbending will determined the atmosphere of the household from which he was so frequently absent. Of the many virtues of Michael Bliss’s book, his skillful weaving of the domestic scene into the narrative is perhaps the most revealing, and certainly the most original of his additions to previous Cushing biographies. “The Cushing children,” he tells us in one of his many sentences that explain a great deal in only a few words, “were being raised in the shadow, if not exactly the presence, of a stern, disapproving father.”

And yet, the strain of being Harvey Cushing was, in fact, as great as he described it to Kate, even if he sometimes used it as an excuse to avoid personal responsibility for her and the children. In another of his pithy sentences, Bliss tells us that some of the surgeon’s trainees “wondered how Cushing could carry on, fiercely determined to control his world, apparently almost friendless, respected by many, liked by a few, and loved, it seemed, by no one.” But he was, of course, loved, in the way children love their father despite any chill in their relations with him, and also as a wife still loves her unfeeling husband.

Passages from one of the letters Kate wrote to Harvey describe in her usual articulate fashion the changes that had already occurred in their marriage of eight years, when Cushing was contemplating a move to Harvard from Johns Hopkins:

You never speak but to criticize. You couldn’t have realized it. I have wrastled with Billy and Betsey all summer. I have put my whole mind and all my energy into looking after the children mentally morally and physically—not one word of commendation did you give me—nothing but little critical remarks and you thought me very touchy and ill tempered I think, when I was trying to bear them… I couldn’t talk to you Harvey—you weren’t interested….

Everything is dust and ashes to me unless I have your interest your sympathy and help. I don’t lean heavily on you. I don’t lean heavily enough—and this separation business isn’t safe. Those long silent dinners—when no one is there—not the silence of understanding, but the silence of constraint…. You don’t realize how little you were at home all last winter and spring. I didn’t realize how Willy and I missed your coming. I can’t stand it Peaches [in spite of everything, Harvey and Kate continued to call each other by their mutual pet name] this winter if it’s like that. I try to fill up my life as other people do, with women friends and with the children—but its awfully dry bones when you grow more and more absorbed and silent—more uninterested and indifferent. Why I’d be a different woman if you ever gave me a word of commendation for anything—a sympathetic pat on the back.

The appendix to John Fulton’s immense 1946 biography of Harvey Cushing contains four closely typed, small-print pages of what the author calls Degrees and Honors, amounting by my calculation to 153 items. Most of these involved a trip away from Baltimore, Boston, or New Haven, often to a European university, and they took a great deal of time that Cushing might better have spent at home. But even had he remained closer to the cities in which he lived, Cushing would have no doubt used the saved days and weeks as an opportunity to work.

Kate rarely accompanied her husband on these journeys, nor would she have wanted to. He had so effectively closed her off from his professional life and the social relationships growing out of it that it would be too much even to claim that she rode as a backseat passenger in the vehicle of his ever-accelerating career. She paid an immense price for this, and she knew it; her anguish attests to it. But Cushing himself, ever pursuing the greatness he saw so clearly in himself, seems never to have had any idea of his own sacrifice.

Only six years ago, Michael Bliss published a biography of William Osler² that exceeds in quality and literary style even the one for which Cushing won the Pulitzer Prize. In the preface to that book, he describes how, for all his trying, his research had revealed nothing to so much as weaken the reputation of his subject as a veritable saint of medicine and private life. With the present volume, he has found a subject with many failings. It is Bliss’s great accomplishment that he has made accessible not only the science, medicine, and professional atmosphere of Cushing’s career, but also the character and personality of the man justly praised for so many years as a medical innovator. He has made good on the aim he announces in his preface to

follow Walt Whitman, who wrote that the poet “drags the dead out of their coffins and stands them again on their feet… He says to the past, Rise and walk before me that I may realize you.”