Harvey Cushing' Author, Investigator, Neurologist, Neurosurgeon

Harvey Cushing' Author, investigator, neurologist, neurosurgeon WILLIAM H. SWEET, M.D., D.Sc. Massachusetts General Hospital, Boston, Massachusetts i AM pleased and honored to have been given December, 1901, a 14-year-old girl complaining of the opportunity to speak to you on the headaches and loss of vision. She was undersized, theme of Harvey Cushing's accomplishments in obese, and sexually immature, incidental observations the fields of surgery and neurology and the far broader whose relation to an intracranial tumor was not then sphere of literature and human relations. Following known. His operative decompression of the brain, first his death on October 7, 1939, the Editorial in the New on one side and then on the other, relieved the head- England Journal of Medicine stated, "Imbued with ache, but the vision worsened. Thinking the patient great vitality and enormous energy he became the might have a cerebellar tumor he exposed this region foremost surgeon of his day, a master-teacher, a and the patient died 6 weeks later. The autopsy profound and prolific investigator and the most ac- revealed a huge cyst in the pituitary region called complished medical writer in our country. TM I shall by Hopkins' famous pathologist, Popsy Welch, a discuss seriatim the justification for these encomiums. "teratoma." Today it is more precisely classified as a The tremendous esteem he had achieved outside of craniopharyngioma (pp. 137-138). 47 Countless such this country was intimated by his election to Honorary humbling experiences did not deter this man from a Fellowship in Britain's Royal College of Physicians. relentless determination to try to solve all the relevant This rare distinction had, according to the Secretary problems. Cushing soon learned that at about the of the Royal College) s come to only five other in- same time Fr6hlich in Vienna had in a similar case dividuals in the course of 21/2 centuries: two purely suspected a pituitary tumor, and had persuaded a political figures, two basic scientists, and one internist. Viennese surgeon to operate. The cystic tumor was It was the capstone, 6 months before his death, of an drained, and although the operation was too late to incessant series of recognitions, which included 105 save vision the patient survived. Cushing perceived honorary fellowships, memberships, prizes, lec- from such accounts that vast increases in knowledge tureships, and decorations from the world's medical, were required in the pathology of intracranial scientific, and more general learned societies and processes, in the symptoms they produced, and in the national governments. In addition, he received 24 entire technique of pre-, intra- and postoperative honorary degrees from the world's universities, 14 of management. Dr. Manuelidis will discuss the steps them outside of this continent. A particularly apt Cushing took in regard to pathology. I will try to sum- award was that from St. Bartholomew's Hospital, marize his general surgical, neurological, and neuro- London, in 1922 of "Honorary Perpetual Student" surgical achievements. Although these came at a rapid (pp. 3-7). 4 Professors Denny-Brown, Manuelidis, and clip, the pace of improvement in surgical mortality I have the congenial task of telling you how he earned was painfully slow. these accolades. Thoracic surgery in the 1930's and cardiac surgery in the 1950's were, by virtue of the broad range of knowledge of the relatively simple structures afflicted "The Foremost Surgeon of His Day" and the perfected ancillary techniques, comparatively I think his peculiarly distinctive contribution was to ripe plums ready to be picked by several thoughtful be the first physician to concentrate his total clinical courageous surgeons around the world at about the effort on the surgery of the nervous system and to same time. In the first decade of this century this was achieve such success thereat as directly to induce true on no count with respect to neurosurgery. Sir Vic- many other capable persons to enter the same field. tor Horsley preceded Cushing in a serious effort to He began to focus his efforts on the brain and establish neurosurgery as a speciality. However, pituitary gland at a time when so little was known Cushing was the first man in the world who, laboring about their diseases that the grossest errors were made full-time, morning, afternoon, evening, and night, to in their treatment. One example will suffice. He saw in try to solve surgically the multitudinous diseases J. Neurosurg. / Volume 50 / January, 1979 5 W. H. Sweet afflicting the brain, achieved methods that continue to 154 illustrations. Its appearance in 1908 in Keen's be emulated. Volume 3 led to the recognition of neurological sur- The precision of all aspects of his care from the time gery as a clearcut field of surgical endeavor? ~ This the patient entered the hospital until he was dis- systematic treatise on the technique of neurological charged has become the indispensable foundation surgery was widely quoted and reprinted by the upon which the rest of us have tried to build. It was United States Surgeon-General for use in World War not, however, until the final year of Cushing's 11 years I. The year of its appearance marked the first time on the faculty at the Johns Hopkins Hospital and an assistant resident surgeon at Hopkins, George Medical School that an assistant resident surgeon J. Heuer, was assigned to work with Cushing. working with Cushing went into neurosurgery himself; His service was the most demanding in the hospital. that man was Walter Dandy, the year was 1911-1912. To begin with, there was the protracted detailed During the first years, the high mortality rates after history to be obtained from both patients and intracranial operations were publicized by a reporter relatives. In addition to the time-consuming neuro- on the Baltimore Sun, who inserted notices about peo- logical and general physical examination, there were ple who had come long distances for operation and the special examinations such as those of the visual then a few days later recorded their death without fields. A lengthy preparation for operation was comment. '7 This reporter's actions elicited a protest followed by a meticulous procedure which was almost from the Hopkins' authorities, but the grim facts, well interminable even by Halsted's standards. A distin- known in the medical world, were perhaps the reason guished general surgeon, watching Cushing at work why Cushing had only 39 patients with intracranial in the Brigham amphitheater one day, asked him, tumors verified at operation or even at autopsy in the "Harvey, do these tumors ever recur on you during the 6 years 1902 through 1907. Many others came to operation?" For all of Cushing's career, only 1 or 2 operation but died without verification of tumor. units of blood of about 500 cc each was likely to be at Cushing's chief, the Professor of Surgery Halsted, hand for transfusions, and hemostatic electro- tried to discourage him from concentrating on neuro- coagulation did not become available in neurosurgery surgery, fearing he would starve on his $350 annual until Cushing introduced it in 1927.13 Hence operative stipend from Hopkins in 1902. Halsted is rumored hemorrhage was an ever-present specter. Cushing to have commented that he did not know whether to stopped every vestige of hemorrhage after each step in say "Poor Cushing's patients" or "Cushing's poor the operation before he proceeded to the next. Perhaps patients." it was his insistence on a totally dry and unobscured Laboratory scientists have the option and are in- field which was one of the keys to the minimal un- deed well advised to select as their field of effort one in wanted damage and remarkably superb results he which current knowledge and techniques offer the best began to attain. Indeed, it may be that the current im- chance to make a major leap forward. Thus, although provement in mortality and morbidity with the Sir Charles Sherrington as early as 1901 published ex- operating microscope is due partly to our return to tensive observations on the physiology of the cerebral Cushing's insistence on zero oozing into the field. cortex in higher apes, 36 he concentrated his main Under the microscope a trickle of blood looks like a attention on the spinal cord and nerves. His torrent. monumental work in 1906, The Integrative Action of The primitive state of our data gathering in the first the Nervous System, was based largely on studies of years of the century is illuminated by the fact that it these simpler systems?' The prerequisite knowledge was Cushing who brought the Riva-Rocci instrument was not yet adequate for intensive analysis of the for measuring blood pressure to this country in 1901. physiology of the cerebral hemispheres in animals. It The Committee on Surgical Research of the Harvard was even less adequate for the poorly controllable Medical School sent a letter to the School's surgeons studies of intracranial diseases in man. But the on February 1, 1903, commenting, "The represen- patients afflicted in the brain, the most complicated of tations by Dr. Cushing of the importance of blood the human systems, provided a stimulus of undeniable pressure observations in surgical diagnosis and treat- urgency. Of all those who picked up the gauntlet ment have produced a widespread interest in these thrown down by these fearsome diseases, Cushing was methods on investigation of surgical problems." As a for a decade the only one who refused to drop the sur- consequence of proposals in this letter, 37 surgeons at gical attack and turn for respite to some less demand- the Massachusetts General, Boston City, and Boston ing task.

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