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|NI FEATURE: JOURNEY THROUGH THE EONS - COMMENTARY
|Year : 2016 | Volume
| Issue : 6 | Page : 1125-1128
Harvey William Cushing: The father of modern Neurosurgery (1869–1939)
Kalyan B Bhattacharyya
Department of Neurology, RG Kar Medical College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||11-Nov-2016|
Kalyan B Bhattacharyya
Department of Neurology, RG Kar Medical College and Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhattacharyya KB. Harvey William Cushing: The father of modern Neurosurgery (1869–1939). Neurol India 2016;64:1125-8
This phenomenal neurosurgeon from the United States of America is universally acclaimed as the “father of modern Neurosurgery.”Among all the great neurosurgeons, the palm goes to him without a shadow of doubt for advancing incontrovertible evidence about the feasibility of intracranial surgical intervention in order to relieve the symptoms in a patient suffering from tumor of the brain. In the beginning of the twentieth century, when Neurosurgery was by and large considered a luxury of working on the improbable, he devised a number of surgical techniques for operating on the brain, and his innovative works established him as one of the foremost leaders in the field. Under his stewardship, Neurosurgery became a new, organized, and autonomous surgical discipline.
Cushing was born in Cleveland, Ohio. He was the tenth child of his parents and his father was a puritanical doctor. He attended the Cleveland Manual Training School, and it is often said that he honed his manual dexterity as a surgeon in the precincts of this institute., Later, he entered Yale College, Harvard Medical School, and interned at the Massachusetts General Hospital. After his graduation in 1891, he joined the Harvard Medical School and received his MD degree in 1895. Thereafter, he became a surgical house officer at the Massachusetts General Hospital, Boston, and collaborated with EA Codman, whose description of an imaginary triangle in the X-ray of the long bones in osteosarcoma made him familiar with generations of medical students, and who devised the first ever anaesthetic chart, “the ether chart.”In 1896, he became the Assistant Resident under William Stewart Halstead, the much celebrated surgeon famed for devising the time-tested operation for carcinoma of the breast in Johns Hopkins Hospital, and worked for 4 years under his supervision. Cushing subsequently worked out an arrangement with Halstead whereby he handled the neurological cases admitted in the wards. He was not impressed with the centre and in a letter to his father, he wrote, “…architecturally, most monotonous. Rows of unbroken brick fronts are as alike Streptococci…The hospital is a very sloppy place and the work of everyone most unsystematic, i.e., on the surgical side. Dr. Halstead has only operated once this month and rarely appears. Hope things clear up or I can't stand it.”
In 1900, Cushing set out for Europe and spent some time with Sir Victor Horsley in London, Theodore Kocher in Switzerland, and thereafter, with Sir Charles Scott Sherrington in Liverpool, where he worked on intracerebral pressure and localization of cerebral centers in anthropoid apes, respectively., His association with Kocher was the turning point in his career, and it was in his laboratory that he met Victor Krönecker, the physiologist, and started working on the effects of raised intracranial tension on respiratory rate, pulse rate, and blood pressure which was to earn him world-wide reputation. The reflex earned the eponymous name, the Cushing's response. With Sherrington, he worked on the effects of electrical excitability of the cerebral cortex in primates. Incidentally, Sir William Osler had been visiting the United Kingdom at that time, and following their meeting, a firm friendship grew between these two extraordinary neuroscientists that was to last till Osler's death in 1919. He returned to Johns Hopkins Hospital in 1901 and worked there till 1912. During this period, his primary interest lay in the surgical removal of the pituitary gland, and he operated on a 14-year-old girl, who was obese and sexually immature and complained of headaches and visual failure. At postmortem, she was found to have a large pituitary cyst. At the end of his tenure, he wrote a classic “The pituitary body and its diseases,” which was published in 1912. Thereafter, he was appointed as Moseley Professor, Harvard Medical School, and later, joined the staff of the army at the time of World War I and worked in France. In 1911, he was appointed surgeon-in-chief at the Peter Bent Brigham Hospital in Boston, and then as professor of surgery at the Harvard Medical School in 1912. In 1913, he was made an honorary Fellow of the Royal College of Physicians of London, the only surgeon ever to receive this honor, and the very next year, he was elected a Fellow of the American Academy of Arts and Sciences. He returned to Boston in 1919 and worked there till 1932 when he retired from service. In his later years, he was appointed to the chair of director of studies in the history of medicine at Yale University.
Cushing started using the scalpel on the brain in 1902, and by 1931, operated on an awesome number of more than 200 verified cases of brain tumor. The volume and variety of his contributions to neurosciences simply takes one's breath away. A short list shall include:
- Standardized neurosurgical techniques and reduced mortality from a staggering 35–40% to a rather nominal, less than 8%
- Wrote books on different aspects of Neurosurgery such as the pituitary gland, tumors of the acoustic nerve (a classic), classification of gliomas, intracranial tumors, including meningiomas (a term that he actually coined)
- Contributed vastly toward the control of hemorrhage during surgery and devised tools such as pneumatic tourniquets, hemostatic clips (Cushing's clip), and an electrocautery
- Classified brain tumors morphologically along with Percival Bailey, his closest associate, and Louise Eisenhardt
- Introduced the use of X-rays for diagnosing intracranial pathology
- Advocated decompression as a palliative measure for inaccessible tumors
- Advocated meticulous approximation of galea aponeurotica during closure of operative wounds. Personally, he felt this was his greatest contribution to Neurosurgery
- Described the changes that occur in the pulse rate, respiratory rate, and blood pressure with rise in intracranial pressure (Cushing's phenomenon or response)
- Cushing's law: Increase in intracranial pressure causes compression of the cerebral blood vessels, and therefore, cerebral ischemia
- Described Cushing's syndrome and Cushing's disease. This work was published as “The Basophil Adenomas of the Pituitary Body and Their Clinical Manifestations,” in 1932
- Bailey-Cushing's syndrome: A syndrome with unsteadiness in balance, disturbed coordination of the body in space, though with good coordination when lying or with body well braced
- Cushing's symphalangism: A syndrome of symphalangism with fusion of the mid-phalangeal joints, fusion of elbow and carpal and tarsal bones, and absence of the normal articular folds
- Cushing's syndrome I: Glucocorticoid excess syndrome in which the hypersecretion of glucocorticoids is secondary to hypersecretion of adrenocorticotrophic hormone from the pituitary gland
- Cushing's syndrome II: A syndrome of multiple tumors of the spinal nerve roots and auditory nerves
- Cushing's syndrome III: A syndrome of bitemporal hemianopsia and associated primary optic atrophy
- Rokitansky-Cushing ulcer More Details: Gastrointestinal hemorrhage, complicating head injury
- Neurath-Cushing syndrome More Details: A syndrome combining the features of prepubertal adiposogenital dystrophy and gigantism.
Arguably, Cushing's greatest contribution came with his introduction of the device for recording blood pressure in North America. He once visited Italy in 1896 and met the physician Scipione Riva-Rocci who introduced the system of recording blood pressure by inflating a balloon cuff over the hand that could record the systolic blood pressure. Cushing brought back a sample of Riva-Rocci's sphygmomanometer and blood pressure measurement became a vital sign in clinical practice. This system of recording blood pressure survived till the Russian physician Nikolai Korotkov included diastolic blood pressure measurement in 1905 with his modern sphygmomanometer, which also replaced the mercury manometer with a smaller, round dial manometer.,,,
However, Cushing's works in the field of endocrinology did not match up to the sterling standards he set for himself in neurosciences in spite of the fact that he wrote the masterly treatise on the pituitary gland. He was biased about some of his observations on the pharmacological activities of the posterior pituitary gland. He almost obsessively believed that hormones from this gland entered the circulation through cerebrospinal fluid. He persistently believed that obesity following hypophysectomy was due to the absence of posterior pituitary hormones, and could not accept the views of Percival Bailey and Frederic Bremer, his co-workers, that even a puncture wound of the hypothalamus could lead to the triad of obesity, diabetes insipidus, and hypogonadism. He even went to the extent of opposing the publication of such papers from his center, and even later, he could not be persuaded by the truly scientific works of Gustav Roussy and Vincent Camus to change his views that such features could be the resultant effect of hypothalamic injury. Much later, however, he thought otherwise, and in the course of his Lister Lectures, he declared that Bailey and Bremer were correct in their observations, and wrote that their work provided “a veritable bouleversement of our cherished preconceptions.” During his tenure in the American Army at the time of World War I, Cushing had his share of troubles as well. As a Colonel with the Harvard Unit, serving in the British Expeditionary Forces, he harshly criticized one British surgeon in a private letter to his wife that was intercepted by French censors and sent to the British government. He was kept in suspension by the threat of court-martial, till the matter was settled by his transfer from the offended British command to an American one. However, here during his tenure in France, he experimented with the use of electromagnets to extract fragments of metallic missiles that were lodged within the brain.
It should, however, be remembered that Sir William Macewen (1848–1924) of Glasgow was the first recognized practitioner of modern Neurosurgery. However, he did not devote much of his time and energy to this field. In 1888, he published his report on 21 operations with 18 recoveries, thus, proving the possibility of operating safely on the brain. In 1886, Victor Horsley (1857–1916) was appointed surgeon to the National Hospital for the Paralysed and Epileptic at Queen Square, London. This was the first ever neurosurgical appointment anywhere in the world, and though in 1 year he performed 10 cranial operations, he had no beds under his command and used to operate only when invited to do so. All along, Cushing believed that the chief task of a neurosurgeon was to remove as little as possible from a lesion and not to jeopardize the functional status of the patients. He was quick to realize that, in those primitive days of Neurosurgery and neurosciences in general, when very little therapeutic modalities were available, it would be prudent to save the organ rather than try to remove the entire bulk of the tumor, which could result in an unacceptable and troublesome neurological deficit. His attitude toward the approach of neurosurgical intervention is well exemplified by the case of Major General Leonard Wood, Chief of the Staff of US Army, who suffered from a large meningioma and Cushing was summoned to operate on him in 1910. The patient returned within a month to his work and served admirably throughout the World War I, and ultimately, was appointed as Governor, Philippines. This quiet and conservative approach to Neurosurgery was not appreciated by his most gifted pupil, Walter Edward Dandy, who advocated belligerent and aggressive surgery in order to try to remove large volumes of the lesion to cure the patient of the disease. The master and the pupil hardly ever saw eye to eye and soon Dandy left his mentor to work elsewhere. However, as a general rule, most neurosurgeons throughout the world prefer to adopt a more conservative approach to Neurosurgery, and there is little doubt regarding the statement that Anderson and Haymaker made in their book, Founders of Neurology, “As in his younger days he vowed he would, Cushing, perhaps more than anyone else, guided Neurosurgery through its formative years and established it as one of the great specialties.”,
Cushing was a colorful person and there are many facets to his electrifying personality. A handsome man, he was tall and lean and his features were sharp and chiselled. His voice was compelling and almost always a cigarette would be found between his fingers. Michael Bliss, a Canadian historian, wrote “Cushing was a slow, meticulous operator who understood that with anesthesia, you could take your time as a surgeon and make sure that you didn't have bleeding or infection. This enabled him to come and go through the cranium virtually at will… What surgeons marveled at with Cushing was that, without X-rays, he was able to work from just signs and symptoms. It was remarkable that he was able to locate as many tumors as he did.” He was liked by his patients for his sympathetic attitude and had all the time in the world for listening to them. Often, he used to tell his pupils “A physician is obliged to consider more than a diseased organ, more than the whole man–he must view the man in his world.”On the contrary, he was a much dreaded surgeon in the operating theatre, and on many occasions, he would have made the student nurses weep, for which he apologized later. He was mercurial by temperament and a martinet who extracted every ounce from his students and assistants and always expected the best from them. Franklin Newell wrote, “As house officer, I was his junior and suffered severely in that position for a year. He was an extremely hard man to work with, whether one was over him or under him, as his tremendous ambition for success made it impossible for him to allow anyone else to get any credit for work done. As you know, when he wanted to be, he was one of the most charming people in the world, but working with him I found that he couldn't tolerate anyone else in the limelight,”while Hugh Cairs, a leading neurosurgeon in Oxford and London wrote, “Gallipoli and the battle at Marne were as nothing compared to the clinical stress of one year as Cushing's neurosurgical resident.” John Fulton wrote, “As an investigator Harvey Cushing had conspicuous faults as well as obvious virtues. In the papers on posterior pituitary secretion, he had been led astray, but despite an imposing array of evidence to the contrary, he never really admitted that he had been wrong; in addition, he unfortunately caused a number of his junior associates to waste valuable time and effort in attempting to establish his original contention. It was a curious foible in a man who had achieved so much in so many directions.” Conrad Jacobsen, Cushing's associate, was equally critical of him and wrote,”As a research man he was of the deductive type of mind. Some investigators gather their data and try to draw their conclusions from them. He was inclined to have a theory and then use all of his efforts and ingenuity to prove the validity of it... Cushing's interpretation of certain facts which were produced experimentally under his direction undoubtedly has been rather too enthusiastic and has been and will be questioned. When he was reminded of these facts by some of his contemporaries, he usually remarked: 'I never expected to settle these things; I had set others thinking about them and this is the main purpose, after all.” As a writer, he was fastidious to a fault and it is often said that he would write and rewrite his articles ten times before he would ultimately send them for publication. And even when they were published, he was not always happy and argued with the editors that his style had been restructured, punctuations altered, and character of English changed. When the journal, Brain, published his series of Cavendish Lectures in 1922, a number of figures were omitted and Cushing felt that others were printed badly. Soon thereafter, Cushing chose to publish the lectures privately in Boston., He was a vocal advocate for reforms related to the curriculum of postgraduate education and stressed upon conducting training based on broader perspectives. On the other hand, the humourous side in his character is well-portrayed in an incident, where in his early days in Johns Hopkins University, he once exchanged notes with William MacCallum on Paris and casually remarked “Let us meet at the top of the Eiffel Tower ten years from now on July the 4th, at two in the afternoon and continue this conversation.” Curiously enough, MacCallum remembered to go to Paris on that appointed date and reached the top of the tower and found no one. A guide suggested that he should go up the iron staircase before leaving and when MacCallum went there, he was greeted by a smiling Cushing who said “Well, Willey, I had almost despaired of you getting here.”, His phenomenal work on the biography of Sir William Osler published in 1926 earned him the prestigious Pulitzer Prize and his short biographies on Andreas Vesalius and Luigi Galvani were no less comprehensive.,
Cushing received accolades from all around the world and some of them included the Distinguished Service Medal, Companion of the Bath, Officier de la Légion d'Honneur, and Order of El Sol del Perú. He was a member of the American Philosophical Society, the National Academy of Sciences and the American Academy of Arts and Sciences, and Fellow of the Royal Society of London. Following his suggestion in 1919, the Society of Neurological Surgeons was formed, and in 1931, with Cushing's permission, the Harvey Cushing Society was created by a group of young neurosurgeons, which is now called the American Association of Neurological Surgeons. He published 13 books and 300 scientific articles in his life and his large collection of books and papers have been donated to the Yale medical Library. As a gesture of esteem for the institution, he bestowed a plaster cast of his hands to the Royal College of Surgeons, which is on display there, and in 1988 United States Postal Service issued one postage stamp in his honor. He died in 1939 following an attack of myocardial infarction in Connecticut, while he had been working on the monograph of Vesalius, the father of modern anatomy, and was trying to lift a heavy folio volume containing his writings., Rudolph Kleinert and Bad Reichenhall wrote that an autopsy performed following Cushing's death revealed a concealed colloid cyst in the third ventricle. John Fulton wrote an authoritative book, “Biography of Harvey Cushing,” that is consulted by all medical historians as the reference volume on Cushing, and E Sabbatini, FE Lepore, and LF Haas, among others, have written exhaustive biographical accounts on him. Henry Viets wrote an account of personal interactions with Cushing that makes interesting reading.
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