Editorial: Harvey Cushing

Abstract

Placing any major surgeon’s achievement in the context of the complex history of his specialty is bound to be difficult and perilous, the more so when the surgeon in question is a prima donna, not inclined toward meticulous or generous acknowledgement of the work of predecessors. The great strength of Dr. Carey’s paper1 is its account of how, in his reports of his battlefield surgery in 1917, Cushing incorporated contributions made by a number of Continental surgeons, notably Barany and Velter, without giving them explicit credit. The Europeans, after all, had been treating brain wounds since the start of their war in 1914. The Americans were late entrants to the conflict and to the surgical problems it posed. Cushing’s apparent reluctance to acknowledge the work of his predecessors can be seen as a case study of the very broad tendency of Americans to believe that nothing particularly important or innovative had happened in the war until they came along and won it. History is now inclined to notice how many lessons the American forces fighting in France had to learn from their allies, and their enemies. Even Cushing came to recognize some of the wisdom, both military and surgical, accumulated by the men who had served far more time in the trenches than the Yankee doughboys and their medics. One of the glories and frustrations of researching history is to find that exercises in contextualizing events can themselves be contextualized. It is somewhat surprising that this paper makes no reference to innovations in neurosurgery before World War I, almost as though no intracranial work had been performed. But of course, many of the techniques used in wartime had been pioneered earlier, some of them in fact by Cushing himself. For many years before the war he had been disdaining any contact between fingers and brain tissue, had been completely shaving patients’ heads, had mastered bone flap techniques, experimented with local anaesthesia, and practiced primary closure, among other techniques. How would the story of wartime neurosurgery read if we traced all the peacetime influences on Cushing’s continental associates? Aside from being malignly influenced by his ego and his arrogance, Cushing was perhaps genuinely conflicted about his relationship to his predecessors. As Carey notes,1 he did, often enough, recognize that his work was unoriginal, especially in any given particular. It was in perfecting the complete experience, the total approach to the surgical problem, from shaving to suturing and everything in between, that Cushing achieved a whole that was greater than the sum of its parts, resulting in what appears to have been a great leap forward in outcomes (assuming that we can trust statistics from that era; Cushing appears to have been unusually rigorous in his use of statistics, but there is considerable room for doubt). To use an inappropriate metaphor, Cushing achieved his good results through an approach characterized by perfectionist overkill. Similarly, his 126-page 1918 paper on his work at Passchendaele was a kind of publishing overkill, the uses of which Cushing well understood. Is it any surprise that this massive and comprehensive article would have been so often cited and so influential as English-speaking surgeons confronted brain wounds in later conflicts? It is not so clear, however, that to have published an extremely influential text on the subject necessarily made Cushing the “originator of brain wound care.” Dr. Carey1 draws this phrase from a 1990 article about craniocerebral injuries in fighting between Israelis and Lebanese. Is he setting up a straw man? To my knowledge no one writing primarily about Cushing’s place in the history of neurosurgery has made a claim for the war work that is nearly so sweeping. In the context of his total contributions to neurological surgery, Cushing’s battlefield experiences in World War I appear to have been derivative and perhaps secondary. It is an important corrective to note how he structured reports of his accomplishments in ways that appeared to slight predecessors and competitors. At the same time, much more could be said about the remarkable dedication with which this senior and aging surgeon (48 years old in 1917) risked his health and his career to serve his country in wartime. He did not shirk and he did not complain, except about the incompetence and laziness of people around him. A case can be made that Cushing’s long hours of work under primitive conditions on one of the bloodiest battlefields in history were his very finest.