Crushing, Harvey Williams

Crushing, Harvey Williams

(b. Cleveland, Ohio, 8 April 1869; d. New Haven, Connecticut, 7 October 1939)

neuosurgery, neurophysiology.

Cushing was the sixth son and the tenth child (seven lived to maturity) of Henry Kirke and Betsey Maria Williams Cushing. Henry Kirke Cushing, a third generation physician, combined a large practice with the professorship of midwifery, diseases of women, and medical jurisprudence at Cleveland Medical College and was also for many years a trustee of Western Reserve University. Reserved with his children, he left much responsibility for their upbringing to his wife, a gracious, highly intelligent women quite capa ble of the task. He imposed strict discipline in his household and provided comfortably for physical needs—generously for education. One son entered the law, another geology; two became physicians. They attended the Presbyterian church public schools in Cleveland, and eastern universities for their college and post-graduate training.

Handsome and of wiry grace, Harvey Cushing maintained his slight figure through life by moderate participation in sports—varsity baseball in college, tennis in later years. His health was good except for an undiagnosed illness during World War I that affected his legs and later caused pain and increasing disability. Four years at Yale nurtured an abiding loyalty to his alma mater, largely through the close friendships formed there and maintained and treasured all his life. Enrolling at Harvard Medical School in 1891, he became the fifth Cushing to enter medicine. He received his M. D. cum laude in 1895 and became a surgical house officer at the Massachusetts General Hospital, Boston, then assistant resident at the newly founded Johns Hopkins Hospital (1889) on the service of William S. Halsted, then pre-eminent among American surgeons.

Stimulated by William H. Welch, William Osler, Howard Kelly, and Halsted, Cushing’s restless and inquiring mind and enormous capacity for work found full expression. Their interest in medical history spurred him in his collection of medical books; he was also encouraged by his father, who passed along volumes from his own library that also often carried the signatures of his grandfather and great-grandfather. From 1896 to 1911 Cushing progressed to associate professor of surgery. After a year abroad (1900–1901), he began to move toward neurological surgery. He became the first American to devote full time to its development.

In 1902 Cushing married Katharine Stone Crowell, a Cleveland childhood friend; they had five children. The situation in his father’s household was repeated in his: he spent long hours at the hospital, then devoted evenings to writing. Yet many house officers and students remember the warm hospitality of a friendly family and Dr. and Mrs. Cushing as gracious hosts. Their elder son, William, a Yale student, was killed in an automobile accident in 1926, and Cushing’s sorrow was deepened because he had only begun to know him.

Several universities, including Yale, offered him professorships; he chose Harvard. Moving to Boston in 1912, he served as Moseley Professor of Surgery and chairman of the department at Harvard Medical School, and as surgeon-in-chief of the Peter Bent Brigham Hospital from 1913—when it opened—until his retirement in 1932. During World War 1 he was briefly in France in 1915 and again from 1917 to 1919, as chief of Base Hospital No. 5. As he gradually solved the problems of brain surgery, patients and young physicians came to his clinic from all over the world. The results of his labors are recorded in 330 books and papers, some devoted to medical history. He was a talented writer; his biography of William Osler was awarded a Pulitzer Prize in 1926. Cushing returned to Yale as Sterling Professor of Neurology (1933–1937) and there published selections from his war diaries, completed an extensive monograph on the meningiomas, and made plans for leaving his library of some 8,000 items, many of great rarity, to Yale University. He persuaded two friends with fine collections, Dr. Arnold C. Klebs of Switzerland and Dr. John F. Fulton, a Yale physiologist, to join him, together with other friends with smaller collections.

Cushing was awarded honorary degrees from nine American and thirteen European universities; several decorations: Distinguished Service Medal, Companion of the Bath, Officier de la Légion d’Honneur, and Order of E1 sol del Perù and many prizes and awards. He was a member of the American Philosophical Society, the National Academy of Sciences, and the American Academy of Arts and Sciences; a foreign member of the Royal Society; and a member (often honorary or foreign) of more than seventy medical, surgical, and scientific societies in the United States, South America, Europe, and India. Some thirty-five of his young associates formed the Harvey Cushing Society in 1932; it is now called the American Association of Neurological Surgeons and has more than a thousand members.

Macewen of Glasgow accurately diagnosed and located a brain tumor in 1876, and after 1900 Horsley of London performed some successful operations. In America, Cushing’s contemporaries, Charles H. Frazier of Philadelphia and Charles A. Elsberg of New York, were starting to study the nervous system, Frazier particularly concerned with relief of pain, Elsberg with surgery of the spinal cord; both worked with neurologists. Cushing’s greatests contributions were in the broad field of intracranial tumors; he took full responsibility for diagnosis, localization, treatment, verification of pathology, and follow-up of his patients.

His extraordinary achievement (based on a series of more than 2,000 verified cases of tumor) of reducing mortality from almost 100 percent to less than 10 percent would have been impossible without early and continuing recourse to the experimental laboratory. He was responsible for establishing the Hunterian Laboratory at John Hopkins in 1905 and also the Laboratory of surgical Research at Harvard. Not only did they afford a place for his own investigations, but his course in operative surgery for students, begun in 1902, was basic to another of his important contributions-the training of a generation of surgeons who have extended the boundaries of neurosurgery. Form these laboratories came more than 325 papers by his pupils.

Early in his career Cushing employed his considerable talent for drawing-as illustrated in diaries of trips, class notes, and sketches of clinic patients at Harvard-in the recording of important aspects of operations. These were sketched on the patient’s record immediately afterafter surgery. During his apprenticeship in general surgery, he studied physiological, bacteriological, and biochemical problems as well. Disturbed by deaths caused by inadequate knowledge of volatile anesthetics, he devised an ether chart on which temperature and respiration were recorded during operations. Later, he experimented with local anesthetics, using them successfully in amputations and hernia operations. He became adept at the surgical handling of perforation of the gut in typhoid cases among soldiers in the Spanish-American War. He carried out experiments on bacterial flora in the abdomen and demonstrated that in the fasting dog they were reduced practically to zero except for a pocket in the cecum harboring colon bacillus. Finding that pure sodium chloride solutions were injurious to nerve-muscle preparations, he worked out a physiologically balanced substitute, which, as Cushing’s solution, is still used at the Peter Bent Brigham Hospital. Attempting experimental surgery of the thorax and heart, then clinically unheard-of, he studied chronic valvular lesions in the dog and commented"on the possibilities of future surgical measures in man directed toward the alleviation particularly of the lesion characterizing mistral steno,” In opening the thorax he discovered the need to maintain lung inflation and used “direct inflation of the lungs by opening the trachea, as commonly used in a physiological laboratory…,”He thus anticipated the now routine use of positive-pressure endotracheal anesthesia.

Certain technical problems had to be solved before brain surgery could be successful. In Switzerland in 1900–1901 Cushing studied the blood pressure-spinal pressure problem and demonstrated in a classic experiment that as the spinal fluid pressure of a dog is increased, there is initially a vagal effect with brady-cardia followed by a high rise in arterial blood pressure. This finding started physiologists such as Walter Cannon on years of further study; for Cushing it made possible safer craniotomies. He took hack to America a model of the first blood pressure apparatus and was instrumental in its adoption. The management of hemorrhage was most important, and for this Cushing devised silver clips still used to control bleeding. In 1925 he introduced electrocautery in brain surgery and was able to call back many patients whose tumors he had not dared earlier to attack.

One of his earliest interests, tumors of the hypophysis (pituitary gland), resulted in his most enduring work and offered endocrinologists many provocative ideas for imploration. A contemporary surgeon describes Cushing’s work in physiology and endocrinology as that of the natural or intuitive biologist, one who acquires enough general understanding of the natural arrangement of things to sense how things unknown are ordered. The sudden insights of his endocrinological research had this quality of brilliance and enabled him to progress in less than thirty years from the consideration of the peripheral ductless glands to the surgically exposed, diagnosed, examined, and removed pituitary. Cushing early observed that the “hypophysis and the ductless glands in general so influence the function of every organic process that they overlap into every individual specialty.” His monograph on the pituitary (1912), based on fifty cases, elucidated this influence, especially the effects of undersecretion (hyperpituitarism), over (hyperpituitarism), and recognition of clinical signs of such malfunction. In 1930 he made the brilliant connection between a reported case of basophile adenoma and his own patients who suffered from painful adiposity of the face and body. In solving this baffling question he recognized a new disease entity that was called pituitary basophile or, commonly, Cushing’s disease.

As his experience in the diagnosis and treatment of tumors intracranial increased, he was able, together with his two associates Pervcical Bbailey and Louise Eisenhardt, to describe the gliomas, blood-vessel tumors, and the meningiomas. He had already completed before Wold Wa I an authoritative monograph on tumors of the nervus acusticus. His military contributions included a 50 percent reduction in mortality from compound head wounds and elucidation of surgical principles hardly altered to this day.

Viewed in the perspective of the thirty years since his death, Harvey Cushing remains the dominant figure in neurosurgery. He set an example in the application of the scientific method to clinical problems in this developing field, especially to tumors of the brain; and the influence on succeeding generations of this broad approach will probably be his greatest contribution to medicine.

BIBLIOGRAPHY

I Original Works. Cushing’s papers, manuscript diaries, and memorabilia are in the Historical Collections of the Yale Medical Library. His vita, honors and awards, bibliography, and the papers from his laboratories by pupils are included in A Bibliography of the Writings of Harvey Cushing Prepared on the Occasion of his Seventieth Birthday April 8, 1939 by the Harvey Cushing Society (Springfield, III., 1939). His books include The Potuitary Body and its Disorders (Philadelphia-London, 1912); Tumors of the Nervus Acusticus and the Syndrome of the Cerebellopontile Angle (Philadelphia-London, 1917); The Life of Sir William Osier (Oxford, 1925); A Classification of the Tumors of the Glioma Group on a Histogenetic Basis with a Correlated Study of Prognosis, written with P. Bailey (philadelphia, 1926); Studies in Intracranial physiology and Surgery (London, 1926); Tumors Arising from the Blood-Vessels of the Brain (Springfield, III., 1928); Consecratio Mdeici and Other Papers (Boston, 1928); Intracranial Tumours. Notes upon a Series of Two Thousand Verified Cases with Surgical-Mortality Percentages Pertaining Thereto (Springfield III., 1932); Papers Relating to the Pituitary Body, Hypothalamus and Parasympathetic Nervous System (Springfield, III., 1932); From a Surgeon’s Journal, 1915–1918 (Boston, 1936);and Meninigiomas. Their Classification, Regional Behaviour, Life History, and Surgical End Results, written with L. Eisenhardt (Springfield, III., 1938).

A selection from his papers illustrating the range of his early interests includes “Laparotomy for Intestinal Perforation in Typhoid Fever,” in Johns Hopkins Hospital Bulletin, 9 (1898), 257–269; “Experimental and Surgical Notes Upon the Bacteriology of the Upper Portion of the Alimentary Canal, with Observations on the Establishment There of an Amicrobic State as a Preliminary to Operative Procedures on the Stomach and Small Intestine.” written with L. E. Livingood, in johns Hospital Reports,9 (1900),543–591; “Concerning the Poisonous Effect of Pure Sodium Chloride Solutions upon the Nerve-Muscle Preparation,” in American journal of physiology,6 (1901), 77–90; “Some Experimental and Clinical Observations Concerning States of Increased Intracranial Tension,” in American Journal of the Medical Sciences, 124 (1902), 375–400; “The Blood-Pressure Reaction of Acute Cerebral Compression, illustrated by Cases of Intracranial Hemorrhage,” in American Journal of the Medical Sciences, n.s.125 (1903), 1017–1044; “Instruction in Operative Medicine. With the Description of a Course Given in the Hunterian Laboratory of Experimental Medicine,” in Johns Hopkins Hospital Bulletin, 17 (1906), 123–134; “Experimental and Clinical Notes on Chronic Valvular Lesions in the Dog and Their Possible Relation to a Future Surgery of the Cardiac Valves,” written with J. R. B. Branch, in Journal of Medical Research, n.s. 12 (1908), 471–486; and “Surgery of the Head,” in W. W. Keen, ed., Surgery, Its Principles and Practices, III (Philadelphia, 1908), 17–276.

II. Secondary Literature. The definitive biography is john F. Fulton, Harvey Cushing: A Biography (Springfield, III., 1946).A shorter biography for the layman is Elizabeth H. Thomson, Harvey Cushing. Surgeon, Author, Artist (Newyork, 1950).Harvey Cushing. Selected Papers on Neurosurgery, ed. by Donald D. Matson, Willam J. German, and a committee of The American Association of Neurological Surgeons (New Haven-London, 1969), is the most recent reprinting of Cushing’s papers. The foreword and W. J. German’s introductory notes to sections offer useful appraisals, as does Francis D. Moore, “Harvey Cushing: General Surgeon, Biologist, Professor,” in Journal of Neurosurgery, 31 (1969), 262–270.

E. H. Thomson