Harvey Williams Cushing

Surgeon

• Born: April 8, 1869
• Birthplace: Cleveland, Ohio
• Died: October 7, 1939
• Place of death: New Haven, Connecticut

American neurosurgeon

Cushing was the founder of modern neurosurgical procedures, introducing into general medicine and surgery the determination of blood pressure and the continuous recording of vital signs during surgery. He made fundamental discoveries about the disorders of the pituitary gland and had a profound influence on the training of surgeons in the United States.

Areas of achievement Medicine, physiology

Early Life

Harvey Williams Cushing was born the tenth and last child to Henry Kirke Cushing and Betsey Williams Cushing. His father, grandfather, and great-grandfather were all physicians. He had a happy, secure childhood, the family comfortably provided for by his father, a highly regarded practitioner and professor at the Cleveland Medical College. Cushing grew up lean and handsome, with finely chiseled features and considerable athletic ability.

Cushing enrolled at Yale University and, despite his father’s urging not to participate on athletic teams, earned a varsity letter in baseball, the sport he loved most. Not until his senior year did he seriously entertain the idea of a medical career; in 1891, after he was graduated, he entered the Harvard Medical School, as had his brother Edward earlier. His academic performance at Harvard, in contrast to his record at Yale, was outstanding. His excellent artistic ability enabled him to draw anatomical structures with fidelity and sketch patients to note symptoms and general appearance, which he continued to do throughout his career as part of the case histories of his patients.

Harvard students received their clinical training at Massachusetts General Hospital, where Cushing made his first major contribution to medicine. He had to administer ether to a woman prior to surgery; when the surgeon opened the abdomen, the patient died. The anguished Cushing thought of leaving medical school, remaining only after being reassured by the surgeon that the patient was in such bad condition that she probably would have died anyway. With a fellow student, Ernest Codman, he investigated the administration of ether, realizing that it was done with no awareness of the depth of anesthesia. The students devised a chart whereby the surgeon and anesthetist could tell at a glance the vital signs of the patient, a major contribution to the safeguarding of the patient during surgery.

Cushing interned in surgery at Massachusetts General Hospital. Following Wilhelm Conrad Röntgen’s discovery of X rays in 1895, Cushing introduced the clinical use of X rays at the hospital, which he then carried to Johns Hopkins University upon accepting a residency under the foremost surgeon in the United States, William Halsted.

Johns Hopkins was the preeminent American medical school, and in Halsted it had a masterful, innovative surgeon. Cushing had learned in Boston that speed was the first essential in successful surgery; under Halsted, with the new German asepsis methods to prevent infection and with anesthetics to provide the gift of time, he learned to perform long, painstaking operations with the gentle handling of tissue.

Cushing advanced rapidly, doing much of the surgery between 1896 and 1900, as Halsted became increasingly ill. He performed the first removal of the spleen in the United States; he also extended the use of cocaine, introduced by Halsted as a local anesthetic, to amputations at the shoulder and hip. During 1898-1899, he concentrated on a surgical approach to the treatment of tic douloureux by excising the ganglion from which the sensory nerve to the face arises. His success he reduced mortality by 50 percent brought him his first fame. Sufferers of this excruciatingly painful malady came to him from all over the country. During these years as resident, he learned much, proved himself, and did so many operations, including innovative ones, that it was clear he had a bright future ahead of him.

Cushing combined the temperament and sensitivity of the artist with the patience and method of the scientist. A charming and engaging person, he could also be domineering and critical as a surgeon. His associates admired him for his skill and brilliance, but his tongue-lashings upset them. The most revered clinical teacher in the United States, William Olier, warned him that his future at Johns Hopkins depended on his controlling his temper and tongue.

Cushing had been seeing Katharine Stone Crowell, a Cleveland neighbor, for several years. A close relationship developed, but marriage, as she understood and accepted, would have to wait until his future was more assured.

Life’s Work

Based on a few experiences in Boston and his tic douloureux work, Cushing decided to specialize in neurosurgery. With recommendations from his professors, he went to Europe (1900-1901) to learn from its outstanding medical scientists. In Bern, he worked with the Swiss Nobel laureate Emil Theodor Kocher, the foremost surgeon in Europe, known to Cushing for his treatise on the lesions of the spinal cord. In Pavia, while on a one-month trip to medical centers in Italy, he was introduced to the sphygmomanometer, the blood-pressure device invented by Scipione Riva-Rocci and in routine use at the hospital there. He sketched it, was given a model of the inflatable armlet part, and, on his return to Johns Hopkins, introduced blood-pressure determination into surgery and general medicine. In England, he assisted another Nobel laureate, the neurophysiologist Charles Sherrington, who at that time was exploring the motor cortex of the brain.

From 1901 to 1912, Cushing was on the surgical faculty of Johns Hopkins, becoming the first American full-time neurosurgeon, engaging in surgical research and animal experimentation, and developing hitherto unthinkable brain operations. On June 10, 1902, he married Katharine Crowell. Their deep love made for a strong marriage, despite his having to sacrifice much of his family life to his profession. They had five children; in 1926, his firstborn, William, was killed in an automobile accident. His daughter, Betsey, married James Roosevelt, the son of Franklin D. Roosevelt (and later married John Hay Whitney); another daughter, Barbara, married William Paley of the Columbia Broadcasting System.

The problems facing the neurosurgeon in the early years of the twentieth century were formidable. There had been removal of brain tumors in Europe and the United States with occasional success, but the methods were those of general surgery, and survival was unusual. Cushing succeeded in developing methods of locating the sites of tumors based on diagnostic signs and physiological research, along with surgical techniques delicate enough to make brain operations feasible. The number of his operations increased yearly, with corresponding reductions in mortality, to levels achieved by no others in his lifetime (from nearly 100 percent when he began to less than 10 percent).

From 1909 to 1912, he was at a peak of activity in clinical and experimental work. In 1910, he invented the silver clip to control hemorrhage, a revolutionary step in lowering the death rate and opening the way to more extensive operations on tumors that were previously inaccessible. The disorders of the pituitary gland, located at the base of the brain, came under scrutiny. He introduced the terms “hypopituitarism” and “hyperpituitarism” for the abnormal secretion of the pituitary and the conditions of dwarfism, gigantism, and acromegaly that result. These conditions were fully studied physiologically, clinically, and surgically, and were the subject of a major monograph on the disorders of the pituitary gland in 1912, with remarkable case illustrations and histories.

Cushing had become internationally famous. Many offers from universities came; he turned them all down, reluctant to leave Johns Hopkins and its excellent facilities. In 1912, however, he decided to return to Harvard, with an opportunity to plan a new teaching hospital, the Peter Bent Brigham Hospital, under the control of the Harvard Medical School; Cushing would be the surgeon-in-chief and professor of surgery. He aroused controversy by wanting clinical work for medical students to begin immediately, at the expense of course work. He was scornful of teachers who lived in ivory towers and refused to make reference to the clinical applications of what they taught. The controversy that developed reflected the historical background of medical education, which had been one of course work and examinations and not of laboratories and teaching hospitals. Cushing was, in fact, the first clinical teacher to give full time to the work of a teaching hospital.

During World War I, Cushing organized a Harvard volunteer unit in 1915, to serve at a Paris military hospital. From 1917, he was a lieutenant colonel at a base hospital in France, operating eleven to eighteen hours daily and drastically reducing mortality, by 50 percent, in serious head and brain injuries. A 1918 paper on wartime brain injuries made a major contribution to neurosurgery and was used as a reference work by surgeons in World War II. In October, 1918, Cushing suffered a disabling attack of an undiagnosed illness with symptoms of fever, double vision, and numbness in the feet; it would flare up and cause increasing disability later in his life.

Resuming his Harvard career after the war, Cushing continued to improve and expand the field of neurosurgery. He wrote monographs on the different kinds of tumors and their classification, natural history, and treatment. The medical community regarded him as the foremost American surgeon, and he found himself training assistants and students from all over the world.

Cushing also became an accomplished writer. At first an awkward and labored stylist, he honed his skills by writing and rewriting daily, and he became an outstanding example of the physician-writer. Following the death of William Osler in 1919, he wrote Life of Sir William Osler (1925), a study not only of Osler’s career but also of the development of medical education during Osler’s lifetime. Full of wit, love, and understanding of his dear friend, it brought to life his individual qualities and won for Cushing the Pulitzer Prize in 1926.

Cushing had to keep track of all of his patients, since neurosurgery had no past history. He requested that they write him on every anniversary of their operation. While he needed to know their subsequent history for the sake of medicine, he also had a sincere interest in their welfare. Letters came from most of them he eventually performed more than two thousand brain tumor operations as well as birthday and Christmas cards with statements of gratitude and news of important events in his patients’ lives; he had made every one of them his personal responsibility, and each knew that he or she was special to Cushing.

Cushing’s days of surgery ended in 1931. Plagued by ill health, he nevertheless continued to contribute to medicine especially with his identification of the disease now known as Cushing’s syndrome, following a brilliant study of patients with painful adiposity of the face and increased basophilic cell activity in the pituitary gland.

In 1932, the year of his retirement from Harvard, thirty-five young associates formed the Harvey Cushing Society with his permission (later named the American Association of Neurological Surgeons). From 1933 to 1937, he was professor of neurology at Yale. An avid collector of medical classics, he left his library of about eight thousand items to Yale. The Historical Library, as a wing of the new Yale Medical School, opened two years after his death.

In retirement, Cushing resumed the role of physician-writer-biographer, focusing on Andreas Vesalius, a Renaissance physician, and producing an extraordinary biobibliography of the famed artist-anatomist. By the end of the summer of 1939, the project was nearly complete. In October came a fatal heart attack. Friends finished the project, which was published in 1943, on the four hundredth anniversary of Vesalius’s famous treatise on human anatomy.

Significance

Cushing founded the modern discipline of neurosurgery, based on meticulous history-taking, examination, diagnosis, and painstaking operative technique. After visiting Italian surgeons and witnessing their techniques, he introduced their methods of determining blood pressure and the continuous recording of vital signs during surgery, practices so vital to patient care that surgery without seems unthinkable. He wrote the classical descriptions of the history of various types of tumors and developed the surgical treatment of the previously inaccessible pituitary gland. He trained a generation of surgeons, gifted students who came to him, then spread his methods worldwide. He made laboratory and animal experimentation essential to surgical advance. Finally, exercising a critical influence on medical education, he played a major role in the awakening of American medical schools to the demands of research and clinical training in the development of a proficient medical profession.

Bibliography

Bliss, Michael. Harvey Cushing: A Life in Surgery. New York: Oxford University Press, 2005. A detailed account of Cushing’s personal and professional life based on the author’s use of newly discovered collections of personal and family papers, diaries, and patient records.

Cartwright, Frederick F. “The More Recent Specialties: Brain, Lung, and Heart.” In The Development of Modern Surgery. New York: Thomas Y. Crowell, 1968. Cartwright provides a lucid historical account of modern surgery, examining Cushing’s predecessors and his work in the context of surgical knowledge of the time.

Fulton, John F. Harvey Cushing: A Biography. Springfield, Ill.: Charles C Thomas, 1946. This is still the definitive biography. More than seven hundred pages long, it presents Cushing’s life and career based on the personal knowledge of a longtime associate and using Cushing’s unpublished notes and letters.

Singer, Charles, and E. Ashworth Underwood. “Some Modern Surgical Advances” and “The Pituitary.” In A Short History of Medicine. 2d ed. New York: Oxford University Press, 1962. The authors give a good overview of the development of neurosurgery and endocrinology, and of Cushing’s contributions to these areas.

Thomson, Elizabeth H. Harvey Cushing: Surgeon, Author, Artist. Rev. ed. New York: Neale Watson Academic, 1981. Written for both general readers and physicians and making use of the John F. Fulton biography, this is more than a shorter version of the Fulton book. Thomson provides illuminating material on Katharine Cushing, her influence on her husband and children, and on Cushing’s relationships with his patients. A book of wide appeal.

Walker, A. Earl, ed. A History of Neurological Surgery. 1951. Reprint. New York: Hafner, 1967. For the more advanced reader. The dominance of Cushing in this discipline is reflected in many of the twenty-eight chapters, each written by an expert in neurosurgery.