Saturday, December 14, 2013

Things you probably didn't know about Harvey Cushing, pioneering neurosurgeon

Stranded on a tropical island with Harvey Cushing. Sort of.
Harvey Cushing was not a vet but a trail-blazing brain surgeon after whom the endocrinopathy Cushing’s syndrome is named. We treat Cushing’s, or hyperadrenocorticism, medically (with very few exceptions), but the man himself is still renowned for his surgical skills. Thanks to the work of Canadian historian Michael Bliss, Cushing was my ever-present companion in the Cook Islands. I'm not sure that the real-life Cushing would have approved of the bars we sat in or the casual island dress code, but in his time he was an adventurer of the bravest sort.

Bliss also wrote abiography of the physician William Osler, a mentor and neighbour of Cushing’s. In fact, Cushing wrote the first biography of Osler and the man didn’t do things by halves. The first draft was one million words long. He was a puritan, a workaholic, and a bit of a grump by all accounts (sometimes he role-models what not to do), yet Harvey Cushing: A Life in Surgery is a book I found hard to put down.

Here are ten things I learned about Dr Cushing.

Cush, as he was known, struggled with uni – like just about every vet and medical student in history. 

An entry from his diary in second year: “June 14, 9.30: Anguish. Will go to Materia Medica exam w. despair depicted on my face & shame in my soul. I am not sufficiently bright or well memoried to take such subjects & know anything about them.”

When he was an undergraduate, surgery wasn't the respectable profession it is today - but that changed during his career.

In the 1890s, when Cushing graduated, surgery remained a frontier, the realm of cowboys and butchers. As Bliss writes: “When all else failed, the surgeon with his knives and saws and blood-stained frock coat was called in to strap down the patient, give everyone whisky, take some himself, and go to it. Now, though [ie when Cush graduated] the surgeons came armed not only with anaesthesia but with the ability to limit infection through the anti- and aseptical…As surgery became relatively painless and germ-free, it was transformed in one generation from a cut, run and pray business, stinking of pus and gangrene, into an almost routine, ‘medical’ procedure. Surgeons quickly began to extend their range from the surfaces of the body and its major orifices into its previously sacred cavities. Surgery worked – not just in the crude way that, say, amputation worked, but in more conservative, less heroic ways: to repair broken and ruptured organs and to save limbs and tissue that would otherwise have been lost.” P85.

In the past, the best surgeons were the fastest – often also the roughest. Cushing was famously slow and delicate. He had been mentored by Halstead whom, despite being a hopeless cocaine addict, was a meticulous, slow surgeon with exceptional tissue handling skills that veterinary surgeons are still taught today.

When Cushing started out, most operations were performed literally on the table – the dining room table of the patient. Halstead’s generation apparently believed (possibly rightly) that patient’s homes were less septic than hospitals back then.

He put his life in the hands of his very unreliable mentor.

Despite knowing his mentor’s weaknesses (Halstead would often flee halfway through surgery), on September 28, 1897, Halstead had to remove Cushing’s appendix, just days after Cushing had lost one of his own patients to a ruptured appendix. The team had only done a handful of appendectomies, and Halstead had repeatedly expressed his distaste for working inside the abdomen. Cushing wrote a will of sorts and the op went ahead – uneventfully. Days later the wound became infected and broke down, and had to be resutured. “We have been bragging of our summer record of 200 cases or more without suppuration,” he wrote home. “I have broken the series.”

On the topic of infection, Cushing copped a needlestick one morning which became infected. The patient whose germs he inoculated himself with died. “What serious things we dabble in at times,” he wrote. He recovered without incident.

Cushing was a harsh, brutally honest self-critic who wasn't shy about sharing his failures. 

He kept meticulous statistics about operative outcomes – and even published about his failures. In one case report he wrote: “It is difficult to record fatalities due to operations, which ordinarily have a successful termination, without attempting on some grounds or another to excuse the unhappy outcome. There is none to offer in this case…Whatever may have been the underlying condition, the operation was the immediate cause of death and should have been abandoned at the time of the patient’s beginning failure” p160. As Bliss points out, Cushing was more publicly critical of himself than “any surgeon could be in today’s litigious world.”

Cushing carried out a lot of animal experiments, mostly on dogs, to the protest of the antivivisectionist movement. 

According to Bliss, in order to make this practice less offensive, Cushing invited residents of Baltimore to refer sick animals to his assistants in the lab and developed a quasi consulting veterinary practice. “One of Baltimore’s most militant antivivisectionists was won over, he claimed, when they removed a disfiguring tumour from her pet poodle.”p197.

Despite punching in long days in surgery, he wrote 5000-10000 words every day. 

He had an army of secretaries (who nicknamed themselves “the harem”) who did a huge amount of work for him, but even on impossibly exhausting days he would write several thousand words in his detailed diaries.

Another blissful moment with Harvey Cushing.
Cushing and his contemporaries struggled with the same curricular controversies hounding veterinary schools to this day.

He loathed politics but working in university teaching hospitals meant butting heads over medical curricula, amongst other things. He felt that pre-clinical sciences were taking over the curriculum at the expense of clinical work, when “90 per cent of the students wanted to learn how to practice medicine, not to do research” (p394).

Cushing, whose dad Kirke was a general practitioner, always sang the praises of the “good country doctor”, who could show up hospital specialists running suites of tests. “Careful studies of our patients are not to be superseded by snap diagnoses; yet the incident illustrates…the over-emphasis laid on the accumulation of often unessential laboratory data, and the under-emphasis on what may be learned by a trained observer from a thorough bedside study of the patient…I do not believe that students can begin to think in terms of the patient too early in their course, nor too early begin to interpret and record what they can see, hear, and touch – perhaps even smell and taste – at the bedside.” P395. [Fortunately, tasting isn’t a technique routinely employed in current veterinary or medical practice].

He performed major, successful brain surgery minutes after hearing of the death of his son.

Cushing was a workaholic who famously neglected his family, much to his wife Kate’s chagrin. On June 12, 1926, his son William was killed in a car accident along with several others. Cushing took the call at work as he was prepping to remove a tumour from a young woman. He phoned his wife, went into the operating theatre, performed the surgery successfully and told the team after. Some may have seen this as a reflection of his incredible ability to focus; others might have read it as detachment from his family.

Cushing was performing brain surgery before any kind of imaging became available, without technology that most of us take for granted. 

He felt that a good surgeon, apart from requiring excellent tissue handling, had some sort of ‘x-factor’, surgical judgement – which even the experienced could not always reliably harness. “When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted nucleation of a pathologically favourable tumour to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session – all this takes surgical judgement which is a matter of long experience and which can scarcely be transmitted by the written word.

Surgical judgement, indeed, is a more or less inspirational quality which is variable and elusive, all surgeons being conscious of having it in hand on some occasions, of losing it on others. It is a good deal like a game which even the best and most consistent player foozles for some unaccountable reason at certain times. The surgery of brain tumours may be likened without being trivial to a form of major sport which is played against all invisible but utterly relentless antagonist quick to take advantage of every misplay and faulty move.”p457. He was often brutal and unethical in his pursuit of the post mortem, in one case bribing a funeral director for access to a brain – but this sort of post-hoc imaging was vital and he made full use of it to refine his practice.

He was a prolific smoker, and realised only too late the damage this habit had wreaked on his circulation. 

As he was in hospital having toes amputated due to gangrene, consultants would come in and grab a cigarette before examining him. “There is no question whatever but that tobacco is extremely damaging to the neuro-vascular system,” he wrote. “It is unfortunate that the victims of the habit are often doctors and still more often highly-strung surgeons who are loath to acknowledge to other lay-habitues the damaging effect of tobacco…There seems to be at present no possible legislation to prevent the radio advertising of tobacco as a source of ‘chemical consolation’.” P508. 

For anyone remotely interested in surgery or the history of medicine, this book is a brilliant read.