The Legacy of Harvey Cushing Open Access

It is a formidable task for any biographer to record all of the achievements of Harvey William Cushing, commonly known as the Father of American Neurosurgery. Regarded as the leading neurosurgeon of the 20th century, Cushing was a tireless investigator, dedicated teacher, prolific writer, gifted artist, and ardent bibliophile. His name is known to every medical student and is immortalized in the well-known Cushing syndrome, Cushing disease, Cushing reflex, and Cushing ulcer. Cushing also left a lasting legacy in pathology with his work on the pituitary gland and brain tumors.

Cushing launched neurosurgery as a distinct discipline and firmly established it as a separate specialty. Every phase of Cushing's career has been the subject of intense scrutiny, with extensive biographies detailing his college days at Yale, medical training at Harvard, surgical residency at Johns Hopkins, and the years at Peter Bent Brigham and Yale. There are also several well-known biographies of Cushing, including those written by John F. Fulton, Elizabeth H. Thomson, and Justin F. Denzel.

Born on April 8, 1869, in Cleveland, Ohio, Cushing was the youngest of 10 children, 7 of whom survived to maturity. His great-grandfather, grandfather, father, and older brother Ned were physicians. Cushing attended Yale College in New Haven, Conn, and graduated from that institution in 1891. While at Yale, Russell Chittenden encouraged in Cushing an interest in physiological chemistry.

Cushing greatly admired his father and his brother Ned. He followed in the family tradition and embarked on a medial career, joining Harvard Medical School in Boston, Mass. Cushing attended Harvard from 1891 to 1896 and received his medical degree in 1895. He completed his internship at Massachusetts General Hospital.

During his medical school years, Cushing was a keen and observant student, who was able to recognize the importance of new developments. Ether anesthesia had come into vogue, and medical students were called upon to administer it. One patient anesthetized by Cushing died, which disturbed Cushing so much that he wanted to quit medicine. Brooding over the tragedy and hoping that such deaths could be prevented if vital signs were monitored, he embarked on a new venture with fellow student Ernest Amory Codman. Together, they developed a record of anesthesia that documented pulse and respiration. This “ether chart,” as it came to be called, worked well and revolutionized anesthesia practices.

Cushing was also impressed with Roentgen's x-rays and was one of the first to recognize their diagnostic potential. While still at Massachusetts General Hospital, Cushing personally took radiographs, made the emulsions, and developed the films. His first formal report on the use of x-rays came in 1897, wherein he described 2 cases of gunshot wounds of the spine in which the bullet was localized through the use of x-rays.

In 1896, Cushing joined the Johns Hopkins Hospital in Baltimore, Md, as an assistant resident in surgery. He remained at Johns Hopkins until 1912. His supervisor and mentor was the legendary William Halsted. Halsted's surgical technique, which emphasized gentle tissue handling, precise hemostasis, and attention to minute details, would leave an indelible mark on Cushing, who emerged as a meticulous and extremely competent surgeon. Cushing's careful approach to brain tumor surgery led to very low infection rates, superb operative results, and a substantially lower mortality rate.

Sir William Osler, the first professor of medicine at Hopkins, also profoundly influenced Cushing. Osler and Cushing became good friends, and Cushing adopted many of Osler's traits, including a love of books. Cushing's deep admiration and respect for his mentor and friend would culminate in a biography of Osler, titled The Life of Sir William Osler, which won the 1926 Pulitzer Prize.

Cushing spent the 1900–1901 academic year in Europe, where he was profoundly influenced by some of the greatest minds in medicine and surgery. In Switzerland, he encountered the famous surgeon Theodor Kocher and physiologist Hugo Kronecker, and performed the basic work on the Cushing reflex (the rise of blood pressure with an increase in intracranial pressure). In 1901, Cushing's epoch-making report on the regulation of blood pressure in the setting of increased intracranial pressure was published. Cushing stated that “a simple and definite law may be established, namely, that an increase in intracranial tension occasions a rise in blood pressure which tends to find a level slightly above that of the pressure exerted against the medulla.”

In Europe, Cushing also assisted physiologist Charles S. Sherrington of Liverpool, England, with mapping the motor cortex of apes. While traveling in Pavia, Italy, Cushing encountered the Riva-Rocci pneumatic cuff for measuring blood pressure, which he brought back to Harvard. As a result, blood pressure measurement was added to the ether chart. In 1903, Cushing read his first formal paper on routine determination of blood pressure during surgery and in the clinic. While his paper was met with initial skepticism, time would prove him correct, and the sphygmomanometer would become an integral instrument in medicine.

On returning from Europe, Cushing started surgical practice at Johns Hopkins after getting the commitment from Halsted that he would be allowed to focus on the “neurological side.” Cushing established a very successful neurosurgical practice at Johns Hopkins. In 1910, he reported a mortality rate of only 13% for brain tumors. Halsted also assigned Cushing to direct the Hunterian Laboratory, where surgical investigations were performed.

Early in his career, Cushing was asked to contribute to the new 5-volume edition of Surgery, edited by William Williams Keen. Cushing prepared an impressive monograph of 276 pages and 154 illustrations, entitled Surgery of the Head. Published in 1908, this work became the single most important neurosurgical text at the time and firmly established Cushing's reputation as a neurosurgeon.

After Johns Hopkins, Cushing joined the Peter Bent Brigham Hospital in Boston, where he became surgeon-in-chief. Cushing remained here from 1912 to 1933. Cushing carried out more than 2000 brain tumor operations while at Brigham.

Cushing made many original contributions to neurosurgery, notably in the realm of brain tumors. He was able to localize tumors accurately and safely resect them. With Percival Bailey, he developed a pathogenetic classification of gliomas. Cushing was also known for gasserian ganglionectomy for trigeminal neuralgia and transsphenoidal surgery for pituitary tumors. Later, he turned to an intracranial approach for pituitary tumors. Other notable contributions by Cushing include innovations in hemostasis, including use of muscle fragments and the “silver clip,” palliative decompressions for inoperable tumors, as well as innovations in electrosurgery. Cushing also advocated the use of physiological solutions in surgery and demonstrated the detrimental effect of pure sodium chloride on muscle and nerve preparations. He used radium for the treatment of gliomas, but was not favorably impressed with the results of brachytherapy. He also described ulceration of the stomach, which frequently occurred with intracranial tumors (Cushing ulcer).

Cushing demonstrated that intracranial hemorrhage in a newborn was not necessarily a hopeless situation that always culminated in cerebral palsy. In a 1905 report of 4 infants with subdural hemorrhages who were operated on, Cushing described successful recovery in 2 cases.

Between 1908 and 1912, Cushing devoted himself to the study of the pituitary gland. The discovery of the pituitary gland as the controller of the body's hormonal balance was an important milestone in endocrinology. Cushing recognized the states of hypopituitarism and hyperpituitarism, and he had a keen interest in acromegaly and dwarfism. In 1912, he published the monograph The Pituitary Body and Its Disorders. Cushing described basophilic adenomas of the pituitary associated with Cushing disease and described Cushing syndrome—the clinical effects of hyperadrenalism.

In 1915, shortly after the outbreak of World War I, Cushing served in the Harvard Unit at Neuilly, France. From 1917 to 1918, he was chief of a base hospital. One of Cushing's major contributions while at the base hospital was to define a logical and systematic approach to the care of wounds involving the nervous system.

In addition to his Pulitzer Prize–winning biography of Osler, Cushing left behind a rich legacy of masterful writings. A prolific writer, he produced several books and monographs, and some 300 publications.

Cushing took a keen interest in medical history and visited antiquarian bookstores. He was encouraged in this venture by Osler, whose collection was housed at McGill University in Montreal, Canada, while Cushing's collection was housed at Yale. Cushing was particularly interested in the work of Andreas Vesalius.

Cushing married Kate Crowell in 1902, and the couple had 4 children. Their son, William, died in a car accident. Their 3 daughters went on to prominent social positions.

Max Brödel, the medical artist at Johns Hopkins, encouraged Cushing to develop his artistic talent. Immediately after an operation, Cushing would sit down to drink tea and make sketches from a surgeon's perspective. These drawings conveyed invaluable information about the operation and became an integral part of his surgical reports.

Cushing retired from Harvard Medical School in 1933. He then was named Sterling Professor of Neurology at Yale University and also served as medical historian. He remained at Yale until 1937.

A compelling facet of Cushing's illustrious personality was his habit of maintaining meticulous records of all his patients, including hospital notes, detailed follow-up, and the pathology specimens and slides. This veritable treasure, including the Cushing Tumor Registry, was transferred to Yale. Cushing spent his years at Yale writing and reviewing his vast clinical experience. He coauthored a major work with Louise Eisenhardt on meningiomas. He also summarized memoirs from his war experience in the publication, “From a Surgeon's Journal.”

Cushing was an able administrator and effective teacher. He played a pivotal role in neurosurgical training. Cushing believed that a properly trained neurosurgeon must also be a clinical and experimental neuroscientist, and have a good command of clinical neurology, neuropathology, and neurophysiology.

A consummate surgeon and teacher, Cushing died on October 7, 1939, of a coronary occlusion, yet he continues to inspire generations of physicians. He has been justly hailed as the “Neurosurgeon of the Century.”