Harvey Williams Cushing
- Bailey-Cushing syndrome
- Cushing's clip
- Cushing's law
- Cushing's symphalangism
- Cushing's syndrome I
- Cushing's syndrome II
- Cushing's syndrome III
- Cushing's triad
- Launois' syndrome
- Neurath-Cushing syndrome
- Rokitansky-Cushing ulcer
- Slocumb's syndrome
Biography of Harvey Williams Cushing
Harvey Williams Cushing was born in Cleveland, Ohio, the sixth son and the tenth child (seven lived to maturity) of Henry Kirke Cushing and Betsey Maria Williams Cushing. The Cushing family on the paternal side originated from Gravesend, England. Matthew Cushing, a deacon, emigrated to Boston in 1638. His great grandfather David (1768-1814) was country doctor, his grandfather Erastus (1802-1893) was also a general practitioner. His father, a stern puritanical doctor, 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 Case Western Reserve University. Reserved with his children, he left much responsibility for their upbringing to his wife, a gracious, highly intelligent woman quite capable of the task. He imposed strict discipline in his household and provided comfortably for physical needs - generously for education. Harvey’s mother came from a pioneer mid-western stock. 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.
At the age of 18 Harvey Cushing went to Yale College, where four years nurtured an abiding loyalty to his alma mater, largely through the close friendships formed there and maintained and treasured all his life. After receiving his A.B. at Yale University in 1891, he followed his brother Edward into Harvard Medical School in 1891, becoming the fifth Cushing to enter medicine. Before enrolling at Harvard he was directed by his father to abstain from smoking, drinking, boating, baseball and other forms of intemperance. In 1894, the year before graduation, he visited London for the first time, meeting Jonathan Hutchinson (1828-1913) at his rooms and Thomas Barlow (1845-1945) at Great Ormond Street Hospital.
He received his MD cum laude in 1895 and became a surgical house officer at the Massachusetts General Hospital, Boston. Here he collaborated with Ernest Amory Codman (1869-1940), with whom he had devised the first anaesthetic chart, “The ether chart” in 1894, while still a student, prompted by the death of a patient during surgical procedure. This gave brief details of the patient and the operation and allowed both the anaesthetist and the surgeon to follow the condition of the patient throughout the operation by recording pulse, respiration and temperature. This innovation led to a considerable reduction in mortality rate from anaesthesia. Cushing and Codman now collaborated on the clinical use of X-rays, whose discovery had only been made in December the previous year by Röntgen. Even at this early stage in his career Cushing’s driving energy and his taskmaster attitude to his junior were becoming apparent.
In 1896, at the age of 27, Cushing went on to become assistant resident at the newly founded Johns Hopkins Hospital where for four years he worked under William Stewart Halsted (1852-1922), the pre-eminent among American surgeons. Cushing was unimpressed both by the city of Baltimore and the hospital - "the hospital is a very sloppy place and the work of everyone most unsystematic, i.e. on the surgical side. Dr. Hallsted has only operated once this month and rarely appears. Hope things clear out or I can't stand it" - an extract from a letter he wrote home. He lived. However, next door to William Osler and a great friendship developed. The first professors at the newly established medical school were men of extraordinary high calibre, among them, besides Osler, was William Henry Welch (1850-1934) in the chair of pathology, and Howard Atwood Kelly (1858-1943) in charge of obstetrics.
Stimulated by these men, 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.
In 1898 Cushing had his first experience of military medicine and in surgery in dealing with soldiers, mostly suffering from typhoid fever, who were evacuated to Baltimore during the Spanish-American war in Cuba. From this resulted two of his early papers, on the treatment of typhoid perforation of the intestine.
After completing his time at Johns Hopkins, Cushing went to Europe and in Bern where he experimented under the direction of Theodor Kocher (1841-1917) on the relationship between systolic blood pressure and cranial pressure. In Bern he also worked with Hugo Kronecker (1839-1914) on the effects of raised intracranial pressure and noted the rise in blood pressure that accompanies it. From Bern he went to England, working with Victor Horsley in London, and during a month in Liverpool took part in Sir Charles Scott Sherrington's (1857-1952) experiments on the ape motor cortex. Perhaps the most important aspect of his visit was that William Osler, too, was spending the summer of 1900 in England, and it was during this period that Cushing began the firm friendship with Osler that was to continue until Osler’s death. Much of the success of this European visit was due to the numerous introductions that Osler could make for his young colleague. On this trip Cushing also visited surgical centres in France, Germany and Italy.
After spending the year 1900-1901 in Europe, Cushing in 1902 returned to Johns Hopkins, where he ran courses in surgical anatomy, and organized an experimental surgical laboratory in which junior students carried out operative surgical procedures on dogs. It was at this time that he began to move toward neurological surgery, particularly turning his attention during the next three years to patients with pituitary tumours. He was the first American to devote full time to the development of neurological surgery.
In 1902 Cushing married Katharine Stone Crowell, a Cleveland childhood friend. They had five children: William Harvey, Mary Benedict, Bestey, Henry Kirke and Barbara. The situation in his fathers 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.
Cushing’s first experience of pituitary disease was in 1901, when he carried out a decompression of a girl aged 14 who had complained of headaches and visual failure. She was fat and sexually immature. At post mortem she was found to have a large pituitary cyst, In the same year, Alfred Fröhlich (1871-1953) reported a similar case from Vienna, a boy of 15 with headache, failure of vision, obesity and sexual immaturity. The patient was operated on by Anton von Eiselsberg (1860-1939), who drained a cystic tumour of the pituitary. Fröhlich syndrome passed eponymously into medical terminology. In this work it has been entered as Babinski-Fröhlich syndrome, named for Joseph Babinski (1857-1932) who described the condition in 1900, one year before Fröhlich.
Pity the pituitary
In March 1909 Cushing carried out his first operation for acromegaly. The patient was a 38-year old farmer referred by Charles Mayo. The approach to the pituitary was via a frontal flap opening the frontal sinuses. The patient made a remarkable recovery and lived until 1930. This was only the second successful case, the first having been operated by Herman Schloffer (1868-1937), then professor of surgery at Innsbruck, in 1907. Between 1909 and 1911, Cushing collected 46 patients with lesions involving the pituitary and most of these were subjected to surgery. The dangers and difficulties of these early operations are demonstrated by the fact that of three patients in this series with acromegaly who were operated upon, two died.
Cushing was associate Professor of Surgery at Johns Hopkins from 1903 to 1912. In 1910 he had accepted the appointment as Mosley Professor of Surgery and chairman of the department at Harvard Medical School, and Surgeon-in-Chief at the Peter Bent Brigham Hospital on the Harvard Medical School campus. He entered his new tenure when the new school opened in 1913, and remained until his retirement in 1932. The first patient to enter the surgical service – a woman with varicose veins of the legs – was admitted on January 27, 1913.
During World War I he was briefly in France in 1915 at the military hospital established at Neuilly outside Paris in the converted Lycée Pasteur, and again from 1917 to 1919 as chief of Base Hospital No. 5. During this time he had a brush with the military hierarchy. As a Colonel with a Harvard Unit serving with the British Expeditionary Forces, in a letter to his wife which was intercepted by French sensors, he made some harsh criticism of a British surgeon. The letter was handed over to the British government and he was threatened with a court martial. The matter was smoothed over eventually by him being transferred to an American command.
In 1936 he published From a Surgeons Journal, 1915-19 of his experiences in World War I which gives poignant descriptions of the wounded and a sad account of the death of Osler's only child Revere, at whose side he stayed until he died. He comments on the irony of a grandchild of the famous American patriot, Paul Revere, being buried wrapped in a Union Jack.
The roaring twenties
The 1920’s were a particularly fruitful period for Cushing. His clinical output was prodigious, and he trained a series of remarkable men, both from the USA and Europe, who themselves and, in turn, through their trainees spread the Cushing technique throughout the world. Among the most distinguished of those from the USA was Walter Edward Dandy (1886-1946), who introduced ventriculography and the radical excision of acoustic tumours.
Cushing's perhaps most important work in the 1920’s was in the problem of haemorrhage. One of the major technical problems that Cushing had to overcome in the development of surgery of the central nervous system was haemorrhage. The scalp itself is particularly vascular. In 1910 he developed a small silver clip (Cushing’s clip). Suction was introduced to deal with bleeding in deeply placed recesses of the skull. Most important, however, was his work on the application of electrical coagulation to neurosurgery. A large part of this was done with the physicist Dr. William Bovie. In 1926 he used the high-frequency current to remove a vascular myeloma invading the scalp. A previous attempt by Cushing to excise the tumour had failed because of haemorrhage. On this occasion, Cushing’s operation notes read,
”With Dr Bovies help I proceeded to take off most satisfactorily the remaining portion of the tumour with practically none of the bleeding which was occasioned in the preceding operation. The loop acted perfectly and blood stilling was almost complete but whether we would venture to use anything of this kind in the brain tissue itself I am at a loss to know because almost certainly it would cause convulsion.”
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 labours are recorded in 330 books and papers. In 1932, at the retirement age of 63, Cushing retired as Mosley professor, after occupying the chair for 20 years. He was replaced by Elliott Carr Cutler (1888-1947), who had been one of the early members of Cushing's house staff at the Bingham. In 1933 Cushing moved to Yale as Sterling Professor of Neurology from (1933-1937) and also was made Director of Studies in the History of Medicine. There he 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. The establishment of the Medical Library at Yale in 1941 was largely due to the efforts of Cushing and his friends, Dr. Arnold Carl Klebs (1870-1943) of Switzerland and John Farquhar Fulton (1899-1960), a Yale physiologist. Calling themselves “The Tritarians” these three great figures of twentieth-century medicine, together with other friends with smaller collections, gave their extensive library collections to Yale to form the nucleus of one of the great medical historical libraries of the world. John Fulton later received the Pulitzer Prize for his biography of Cushing.
The list of Cushing's honours, honorary doctorates and other distinctions fills several pages. He 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 El Sol del Perú; 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, 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
In 1939, as a surgeon, he was made an Honorary Fellow of the Royal College of Physicians in London. Cushing wrote and thanked. This is from a letter written by the secretary of the Royal College in reply to Cushing's letter:
"I had a fleeting glance at your welcome reply to the President, and saw that you were interested to know whether a surgeon had ever before enjoyed the honour. No, the distinction is yours alone. King Edward VII, when Prince of Wales, was elected an Honorary Fellow in 1897; and in 1928, to mark the auspicious occasion of the Tercentary of the publication of Harvey's De motu cordis, the College elected four Honorary Fellows, namely, Lord Balfour, Lord Rutherford, Professor Pavlov and Professor Wenckebach. Of these, professor Wenkebach is happily with us. You are the only other Honorary Fellow.
It will be an additional interest to you to know that, including yourself, only six individuals have enjoyed the distinction of Honorary Fellowship in the course of two and a half centuries."
The four honorary fellows referred to are the then former British foreign minister Arthur James Balfour, 1st Earl of Balfour (1848-1930), the physicist Ernest Rutherford (1871-1937), the Russian experimental physiologist Ivan Petrovich Pavlov (1849-1936), and the Dutch-born Austrian internist Karel Frederik Wenckebach (1864-1940).
Greatest of neuro surgeons
In the USA Cushing is generally recognised as a pioneer, maybe the greatest in neuro surgery. Although he improved and developed several surgical procedures, there is no particular "Cushing surgical procedure", but it is obvious that he, more than any other, proved the feasibility of intracranial surgery. Besides, he was exceptionally considerate to his patients, which came from all over the USA and from Europe, some of them prominent figures. He seems to have spent an enormous lot of time on his surgical activities, for periods operating every day, and, to the despair of his staff, not infrequently even on Saturdays and Sundays.
Cushing contributed to the study of blood pressure during surgery and developed the method of local anaesthesia during surgery. He improved techniques and introduced, among others, the transphenoidal method of operation. His most brilliant achievements, however, were in the treatment of brain tumours, operations that had previously almost invariably led to the death of the patients. Cushing's neurosurgical skills reduced the rate of mortality at brain surgery from some 90 % to approximately 8 %, skills brilliantly demonstrated when, in 1910, he was called upon to operate on Major General Leonard Wood, Chief of Staff of the U.S. Army, to remove a large meningioma. The general returned to his official duties within a month and served throughout World War I and finally became Governor of the Philippines.
Cushing’s 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 Johns 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. From these laboratories came more than 325 papers by his pupils.
Cushing was highly estimated by his colleagues in neuro surgery, and at the gatherings of the Harvey Cushing Society, established 1932, brought together several of the world's greatest neuro surgeons.
In September 1926, occasioned by Cushing receiving the prestigious Cameron Prize for 1924-1925, and giving his three obligatory lecture at the University of Edinburgh, London Hospital gazette wrote:
"There can be few more interesting figures in the surgical world of today than Professor Harvey Cushing. Starting out some twentyfive years ago to specialize in the surgery of the brain, Dr. Cushing rapidly attained a position of great distinction. The way in which it was done can be gathered from a study of his Cameron Lectures, now issued in book form ... His distinction is - and it is a distinction which places him for all time in the front rank of scientific investigators, and his almost unique position among surgical specialists - his distinction is that he has regarded and studied his specialty from every conceivable angle ... Here is the right kind of specialist fit to join such former Cameron Prizemen as Pasteur, Lister, Horsley. Si sic omnes!"
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 bradycardia 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 craniotomes.
In 1901 Cushing visited the University of Pavia, where he met Scipione Riva-Rocci (1863-1937) and became familiar with Riva-Rocci’s apparatus – the mercury sphygmomanometer. He took back to America a model of the apparatus, and was instrumental in its adoption.
The management of haemorrhage 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 tumours he had not dared earlier to attack.
The man and the physician
With his patients Cushing was almost charming, friendly and compassionate, never in a hurry of any kind. To his fellow workers, however, Cushing could be an extremely exasperating and hard task master. His sarcasm and stormy outbursts occurred most frequently in the operating theatre when he would reduce student nurses to tears (sometimes he apologised).
One frequently told story about Cushing is that during his Johns Hopkins days when exchanging stories on Paris with William George MacCallum (1874-1944), Cushing casually remarked "let us meet at the top of the Eiffel Tower ten years from now on July 4th at 2.00 in the afternoon, and continue this conversation". The incident was not mentioned again. MacCallum went to Paris and went to the top of the Eiffel Tower but could not find Cushing; he then noticed an iron staircase which went up to the very top; on clambering up, he was greeted from a small lookout with "Well, Willy, I had almost despaired of you getting here."
In his time, the Mecca of neuro surgery was in his clinics. His social circle and his correspondence with colleagues all over the world were intense - the majority of them also being his students. Numerous travels helped to uphold the contact.
Cushing's unique position in medical establishment is even more conspicuous when judged from his circle from outside neuro surgery. He was visited by Ivan Pavlov (1849-1936), Theodor Kocher (1841-1917), Archibald Vivian Hill (1886-1977) and Lord Charles Sherrington (1857-1952), all recipients of the Nobel Prize for Physiology or Medicine, and he also visited some of them in their own countries. His correspondence with them often lasted for many years. Fulton's detailed account of Cushing's circle in this respects reads like a "Who is who in science?". His broad knowledge of many fields of medicine, maybe most of all the history of medicine, contributed to this standing.
Even outside medicine he devoted himself to wide interests giving incitements to visits and correspondence. He was an excellent illustrator, leaving a large collection of drawings of people he had met. He was also an accomplished writer, and many consider his book Life of Sir William Osler (1925) his most brilliant work. It is one of the finest works in medical biography, and won him the Pulitzer Prize for 1926. He was also a great collector of books, and his large and valuable book collection, particularly on the history of medicine, was to become the basis for the Historical Library at Yale. This was taken over by John Fulton after the death of Cushing.
Cushing died while working on a monograph on the 1600th century anatomist Andreas Vesalius, in which he took a great interest through most of his active life. The heart attack which killed him was triggered as he lifted a heavy folio volume of Vesalius's work.
Handsome and of wiry grace, Harvey Cushing maintained his slight figure through life by moderate participation in sports - baseball in college, tennis in later years. Cushing contracted influenza during the pandemic of 1918 and thereafter suffered from chronic disability, which prevented him from taking more than a few steps at a time.
Cushing died on October 7, 1939 at the age of 70 of myocardial infarction. Autopsy showed a posterior coronary occlusion, complete occlusion of the femoral artery on both sides and, in line with the belief that doctors often develop the disease in which they have specialized, a 1 cm colloid cyst of the third ventricle.
A 1988 United States stamp and postcard feature a portrait of Harvey Cushing, the first person in the United States to use X rays for the diagnosis of neurological problems.
"His death was not the end. Harvey Cushing, like a truly great teacher, had merely turned over his work to his pupils in clinics and operating rooms the world over.
“He was recognised as perhaps the ablest man in his class at the medical school and was an extremely hard worker. 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.”
Franklin S. Newell, who served under Cushing at the Massachusetts General Hospital, and later became professor of obstetrics at Harvard. 1942.
“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'."
Cushing's associate and admirer, Conrad Jacobsen, on Cushing as a research scientist.
"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."
«To the medical profession, if not to the community in general, The Dispensary [by Samuel Garth, 1661-1718] must always remain of historic import, commemorating as it does the first attempt to establish those out-patient rooms, which since have become such a universal charity.»
Quoted by Mary Lou McDonough in Poet Physicians
«We are tending to become a standarized country, and it is perhaps on standardization that industrial progress is founded. But standardization of our education system is apt to stamp out individualism and defeat the very ends of education by leveling the product down rather than up. The qualities that really count in this world are quite beyond pigeonholing, quite beyond measurement by scales, tape, or mental tests, quite beyond rating by any known system of examination, all of which fail in giving us an estimate of that most precious of all qualities, personality.
The capacity of the man himself is only revealed when, under stress and responsibility, he breaks through his educational shell and he may then be a splendid surprise to himself no less than to his teachers.» Consecratio Medici, Ch. 1.
«Who have made the greatest gifts to their fellow man? Those who have left an idea that has supplied, like the utterances of Christ, what minds have yearned for? Those who have added to his physical comforts and have found ways to lessen hunger and want? Those who have added to his conveniences and devised means to lighten his labor? Those who have, like Lincoln, freed him from bondage and like Lister released him from the horror of suppuration? One answer certainly can be made: that only when the gift requires self-denial and only if the giver be one that walketh uprightly, and worketh rigteousness and speaketh the truth in his heart, will he, like Saint Francis, come to be canonized and forever blest.»
Consecratio Medici, Ch. XIV.
«A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world.»
Quoted by René J. Dubos in Men Adapting, Ch. XII.
There is only one ultimate and effective preventive for the maladies to which flesh is heir, and that is death.»
The Medical Career and Other Papers, «Medicine at the Crossroads.
«In spite of all the discouraging things they are permitted to learn about the units composing society, the doctor and the priest continue to have not only hope for but faith in their fellow men, and expect them, in spite of their frailties, to be unselfish and honest till they prove themselves otherwise; whereas in trade, politics, and the law, we are told, a man is primarily taken to be self-seeking until he proves the contrary.»
The Medical Career and Other Papers, «Medicine at the Crossroads.
«Why not put the surgical age of retirement for the attending surgeon at sixty and the physician at sixty-three or sixty-five, as you think best? I have an idea that the surgeon’s fingers are apt to get a little stiff and thus make him less competent before the physicians cerebral vessels do. However, as I told you, I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work. Then, of course, many of us may get vascularly speaking, a little inelastic well on this side of sixty, or may remain in this respect as youthful at seventy as are others at fifty. This is all a lottery of inheritance and habits, and I shall be very glad, for one, to have legislated to stop active work at sixty.»
Letter to Dr. Henry Christian, November 20, 1911.
«In these days when science is clearly in the saddle and when our knowledge of disease is consequently advancing at a breathless pace, we are apt to forget that not all can ride and that he also serves who waits and who applies what the horseman discovers.»
Consecratio Medici, Ch. 1
We thank Roberto Knerich for correcting an error in the original entry.