Book Review

The Legacy of Harvey Cushing: Profiles of Patient Care

N Engl J Med 2008; 358:316-317January 17, 2008

Article

The Legacy of Harvey Cushing: Profiles of Patient Care
Edited by Aaron A. Cohen-Gadol and Dennis D. Spencer. 568 pp., illustrated. New York, Thieme, 2007. $129.95. ISBN: 978-1-58890-389-1

Harvey Cushing has been called the father of neurosurgery, and as a testament to his singular importance, the American Association of Neurological Surgery was founded in 1931 as the Harvey Cushing Society. Not surprisingly, several biographies of Cushing review his life and family, his many important contributions to neurosurgery, and his impact on society. The Legacy of Harvey Cushing is entirely different, and it will appeal not only to those who work in the fields of neurosurgery and neurology, but also to many people who work in the broad area of medicine. It is wonderful in many ways.

The Cushing Brain Tumor Registry originated at Johns Hopkins Hospital in Baltimore and subsequently moved to the Peter Bent Brigham Hospital (now the Brigham and Women's Hospital) in Boston before coming to its current home at Yale University in New Haven, Connecticut. The clinical data and insights that were gathered from Cushing's cases and were further organized by his colleagues Louise Eisenhardt and Percival Bailey constitute the rich trove that led to the publication of this comprehensive volume, which was edited with care and affection by Aaron A. Cohen-Gadol and Dennis D. Spencer. I think the book could as easily be subtitled Profiles in Courage of Patients and Their Surgeon.

Photograph of Harvey Cushing from the Johns Hopkins Hospital Album, 1903–1904.

The book is organized into sections according to anatomical areas or certain types of neurologic problems. Instead of simply providing a review of diagnostic and surgical phenomena, however, each section comes alive because it is made up of individual cases that are taken from the Brain Tumor Registry. Each case includes, when available, a photograph of the patient; an admitting history and physical exam that are summarized from the records; and, most revealing, the operative note, typically dictated by Cushing and including his comments and drawings about the case. Perhaps anticipating the value that his observations would have to posterity, he does not hesitate to discuss his findings, his techniques, his mistakes, and precisely what he learned from each patient. Letters from patients or their families that provide information about long-term outcomes are often included. As I read each case, I felt as though I were actually sitting in the hospital, seeing the patient, reviewing the chart on rounds, and listening to Cushing impart his wisdom. The data, descriptions, examinations, and images are a true wonder.

We tend to be impressed with what the field of medicine can do for patients now. Imagine the field almost 100 years ago, before sophisticated anesthesia, antibiotics, modern imaging techniques, and a century of experience. Diagnoses were based in great part on the subtleties of the history and the physical exam, with the aid of simple radiography and, only later, ventriculography. Physicians had to have the courage to make decisions and take action on this paucity of information. Patients, in turn, had to have the courage to trust their physicians to act with skill and compassion on their behalf. That reciprocal courage is clearly evident in the faces of the patients whose photographs are included in the book, as well as in Cushing's dictations about his decision-making process and surgeries.

A rare personal side of Cushing is also presented in this book. Previously, I had the image of a tyrant who ran his service with a dedication that left no room for anything but a 24-hour workday and a level of perfection that left nothing unknown or undone. I had heard the stories of someone who was critical of weakness, aloof, unkind, egotistical, and mean. These case scenarios reveal a very different side of the man. His sensitivity toward and compassion for his patients are clear. While he was the pioneer in neurosurgery, performing operations that might have been unthinkable to lesser talents, he demonstrated a concern for his patients that I feel was paramount and authentic. He was candid both about what he achieved and about cases in which he believed he had done the wrong procedure or otherwise erred. I found no instance in which he blamed fate or his colleagues for an imperfect outcome. Rather, his self-examination and self-criticism were frequent and unsparing. It is clear that he had a tender bedside manner and a total devotion to his patients that matched, if not exceeded, his pride in his many surgical achievements.

Cushing's accomplishments are legendary: he described the physiology of some pituitary functions, decreased the mortality of cranial surgery by 69% to less than 10%, won a Pulitzer prize for his biography of William Osler, classified brain tumors with Bailey, applied the technique of electrocautery to neurosurgery, and standardized preoperative and postoperative care.

This book will be respected for its clear documentation of the courage of both patients and surgeons, the importance of examination and localization, the use of staged procedures for safety, the caring quality of a surgeon who practiced 100 years ago, and the innovations that were made during surgery. The volume will be cherished for revealing the less familiar Cushing — the perfectionist with the constantly questioning mind who reviewed pathology before, during, and after surgery, who engaged in perpetual self-reflection, and who believed that the quality of his patients' survival was more important than its length.

The Legacy of Harvey Cushing gives the reader a firsthand look into case reports that, as stated by Cohen-Gadol in the preface, became “the diary of neurological surgery in its infancy.” I loved this book and did not want to put it down. I believe it will be a treasure to any person who is interested in the history of medicine, and it will have special significance to those who practice neurology and neurosurgery.

Kalmon D. Post, M.D.
Mount Sinai School of Medicine, New York, NY 10029
kalmon.post@mountsinai.org