Harvey Cushing: A Historical Vignette
Scott Kutz, MD and Patrick O'Leary, MD
Departments of Neurosurgery (SK) and Surgery (PO)
Louisiana State University Health Sciences Center; New Orleans, Louisiana

Harvey Cushing, the man who was to become known as the father of neurosurgery, was born in Cleveland, Ohio on April 8, 1869. At this time, the region was fondly known as the Western Reserve.(1) His father, grandfather, and great grandfather before him were all general practitioners of medicine.(1) Cushing was the youngest of ten siblings. Prior to college he attended a manual training school, which was a precursor to the technical high schools of today. In this environment he learned basic carpentry, woodturning, forging, metal work, mechanical drawing, and machinery. (1) Many of these talents would stand him in good stead in years to come.

During the years 1887-1891, Cushing attended college at Yale. In addition to his full course load, he was very active in social clubs and college athletics, most notably baseball and tennis. He excelled in the latter. This was much to the dismay of puritanical father who felt college athlectics were inherently evil. This philosophical difference led to several heated correspndences between them. The younger Cushing performed well scholastically despite his outside activities, but his true potential was yet to become evident.

After Yale, Cushing attended Harvard Medical School from 1891-1895. An older brother had already received his medical degree from Harvard. At this time medical school was only three years with a fourth year if elected. During his summer holidays and in his electe fourth year Cushing served as an extern at the Boston Children's Hospital and Massachusetts General Hospital (MGH).


Cushing (far left) at MGH

It was during his elective time that his first major contribution to medicine was developed. At this time, students often provided the ether anesthesia for the surgeons with whom they were studying. Early in Cushing's externship he had a patient die whom he was anesthetizing. Dissatisfied with the lack of patient monitoring routinely performed, he and fellow student Amory Codman developed the first continuous record for recording pulse and respiration. This was in 1895. These were the only intraoperative vital signs routinely obtained at that time. The record they produced is very similar in appearance to the anesthesia record of today. Cushing graduated cum laude in June 1895. In what later came to be recognized as his typical behavior, he did not attend his own graduation ceremonies because he was caring for patients at the hospital.(1)

Without a substantial break, he began his internship at MGH. The mysterious X-ray had just been described by Roentgen and rumors of this discovery had reached Boston. Cushing was involved in the introduction of this technology into the clinical realm at MGH. The young doctor was fascinated with this new diagnostic tool and was among the first clinical researchers in this arena. Upon completion of his internship, he was summoned to Baltimore to serve as assistant resident to William Halstead at the recently established Department of Surgery at John Hopkins.(1) Cushing brought the use of x-rays with him to Hopkins. Halstead was enthusiastic about and supportive of his work. His training at John Hopkins proved to be very influential on his future practice. He learned meticulous surgical technique from Halstead while modeling his intellectual pursuits after William Osler, who at that time was chairman of the Department of Medicine and was recognized even by his contemporaries as one of the intellectual giants of medical history. Osler's influence first became evident in Cushing's adoption of Osler's hobby of collecting ancient medical books. Both became medical bibliophiles of note and both subsequently donated libraries to academic institutions.

In addition to his house officer duties, Cushing engaged in several important research projects. Among these were some of the first human experimentation with nerve block anesthesia for operation using the rather newly isolated compound, cocaine.(1) In addition, he studied typhoid disease and developed a pioneering approach to surgical management of perforations of the esophagus secondary to infection by this organism. Several papers on bacteriology were published as a result of his work.(1) In 1900, he reported with Livingood that the stomach and small intestine could be sterilized by fasting.(7) This would ultimately prove important in the preparation of patients for intestinal procedures. He also studied Raynaud's Disease, hibernation, and predicted the routine use of positive-pressure endotracheal anesthesia twenty years before it became fashionable.(6) He was the first to describe in the literature the tolerance of the heart to surgical manipulation, a concept it would take the medical community more than two decades to accept. Cushing's technical prowess was demonstrated by the successful suturing of the thoracic duct without leakage (1898) while still a resident.(7) This was the earliest known successful accomplishment of this feat.

At the insistence of Osler and after he had been at Hopkins for four years, Cushing toured the medical community of Europe for fourteen months. With Osler's help he was able to study with some of the greatest surgeons and researchers in Europe at that time. First he studied under Horsley, one of the early European surgeons with a neurosurgical focus. Others with whom he worked included Hartmann, Roux, Kocher, Kronecker, and Sherrington. A particularly long time was spent under Kocher and Kronecker in Berne, Switzerland. With Theodor Kocher he discovered that elevated intracranial pressure was associated with an increase in the blood pressure to a level slightly above the pressure exerted against the medulla.(5) This principle came to be known as the Cushing Reflex. With Hugo Kronecker he found that a lack of calcium and potassium in normal saline caused irreversible damage to nerve-muscle preparations. When applied to the clinical situation this led to the development of physiologic salt solutions.(5) With Sherrington, Cushing was able to participate in the epic cortical localization experiments that made Sherrington famous.(5) On his part, Sherrington was extremely grateful to Cushing for his contribution to the laboratory as a seasoned researcher. Toward the end of the European tour, Cushing stopped in Pavia, Italy, where he saw the Riva-Rocci device in use. This was the first sphygmomanometer. He recognized the utility of the instrument and brought it to the United States upon his return. He later introduced the instrument into regular use in his operating room despite other surgeons' contemporary belief that a physician's trained finger on a patient's pulse was of more use than the data produced by the "confound contraption."
In October of 1901 Dr Cushing returned to John Hopkins, transformed from student to teacher. One of his major accomplishments in his new capacity was to establish the Old Hunterian Experimental Surgical Laboratory for medical students. This laboratory allowed students and residents to learn and practice proper surgical technique on animal models before applying these procedures on their patients. A great deal of important research would be produced by the laboratory. In 1912, after refusing many offers for prestigious posts around the country including his alma mater Yale and Case Western Reserve in his childhood hometown, he became the Moseley Professor of Surgery of Harvard University at the Peter Bent Brigham Hospital. Harvey Cushing focused exclusively on neurologic surgery. It was at this time that he began to train residents in neurosurgery. From 1911 to 1932, he trained 22 assistant residents in neurosurgery. All became full professors or chiefs of major neurosurgical services.(7) There is no doubt that Harvey Cushing is the father of modern neurosurgery. During these times his energy was unequaled by anyone. He was to contribute an 80 page chapter on surgery of the head to Keon's text Surgery. In 1907, Cushing submitted 800 pages with over 200 hand-drawn illustrations.(5)

At the start of World War I, Cushing was instrumental in forming a Harvard medical regiment. He was selected to serve as its head and the unit was stationed at a base hospital in France.(1) Work was grueling, with each physician responsible for the care of more than 80 patients. During peak times, Cushing performed up to eight craniotomies a day.(4) During this time, he developed a classification for head trauma which is still is use today. At the end of his service in 1918, he developed what was at the time called vascular polyneuritis, better known today as Guillain-Barre syndrome. He never fully recovered.(3) Shortly thereafter he developed bilateral femoral artery occlusion and suffered from severe claudication for the rest of his life.(1) His condition was not aided by the fact that he was intensely addicted to cigarettes and was never able to quit smoking.
Following the war, Cushing settled into civilian practice again as chief of surgery at Harvard. Following the death of William Osler, he spent from 1920-1924 writing his biography. The tome was critically acclaimed and won the Pulitzer Prize in literature in 1925.(1)


Download a larger version of title page of Cushing's Pultizer Prize winning book on Osler

From 1918-1928 he published 6 books and almost 100 scientific papers, addresses, and reports.(3) When these works were analyzed, it was estimated that he wrote more than 10,000 words per day. This was in addition to his busy schedule that included clinical and administrative duties.
It was during this period that he described the association of pituitary basophilic tumors with the clinical syndrome now known as Cushing's disease. He also described the association between the disturbance of nerve centers at the base of the brain and stomach complications known as Cushing's ulcers.(7) In 1931 Cushing performed his 2000th confirmed brain tumor operation. His lifelong contributions to this field led to an association of neurosurgeons which was named the Harvey Cushing Society (now known as the American Association Of Neurological Surgeons or AANS).(1)
Upon retiring from Harvard, Dr. Cushing accepted a professorship in neurology at Yale where he established a brain tumor registry of his 2000 tumors and donated his personal library to the formation of the Yale Medical Library.(1) Harvey Cushing died on October 7, 1939, secondary to cardiac arrest, ironically while lifting a heavy volume of a Vesalius anatomy text, a favorite item in the collection he so loved.(1)

The accomplishments of Harvey Cushing are an inspiration to the medical profession. His inexhaustible energy and his painstaking attention to detail made him a superior surgeon, author, teacher, and scientist. These traits combined with his unyielding devotion to the care of his patients made him a legendary physician.(2)

References:

  1. Fulton J: Harvey Cushing, A Biography. Springfield, Il: Charles C. Thomas. 1946.
  2. Greenblatt SH: The image of the brain surgeon in American culture: The influence of Harvey Cushing. J Neurosurg 75:808-8111, 1991.
  3. Horwitz NH: Library: Historical perspective. Harvey Cushing (1869-1939). Neurosurgery 39:1062-1067, 1996.
  4. Lepore FE: Harvey Cushing, Gordon Holmes, and the neurological lessons of World War I. Arch Neurol 51:711-722, 1994.
  5. Modlin IM, Shin JH: Harvey Cushing: First guest at "The Divine Banquet of the Brayne". Surgery 113:438-455, 1993.
  6. Moore FD: Harvey Cushing: General surgeon, biologist, professor. J Neurosurg 31:262-270, 1969.
  7. Sweet WH: Harvey Cushing: Author, investigator, neurologist, neurosurgeon. J Neurosurg 50:5- 12, 1979.