Cushing - A brief history of HARVEY CUSHING

The 20th century was an important time for the development of neurosurgery. While there are many who contributed to the notable discoveries and advancements, there is one person who has been hailed the father of modern neurosurgery, and I'm of course talking about Harvey Cushing. Harvey Cushing was born on the 8th of April 1869 in Cleveland, Ohio. He was the fourth generation of a dynasty to pursue a career in medicine. He graduated from Yale with a Bachelor of Arts degree in 1891, before studying medicine at Harvard, where he graduated with distinction in 1895. Cushing focused primarily on neurological cases at Johns Hopkins Hospital in Baltimore, Maryland, creating an expertise that in time would prove vital to the development of the specialty that we know today. By the 20th century, general anaesthesia and the concept of perioperative infection control had contributed to great improvements in neurosurgical outcomes. Lagging behind, however, was the issue of blood loss management, a crucial factor in advancing surgical precision and neurosurgical care. Although the importance of being able to stop a bleed or promote haemostasis was recognised, early applicators, which were based on a tourniquet mechanism, were too flimsy to prove effective. Cushing introduced the pneumatic cranial tourniquet in 1904, an inflatable device similar to the arm cuff used in blood pressure measurement that we're all familiar with today. This was essentially a rubber band held down by tape with a buckle used to adjust the band's tension. Cushing would also instruct his assistants to apply manual pressure on either side of the surgical incision, helping to reduce the risk of significant bleeding. Although seemingly crude, this common sense approach, combined with a later improved version called the haemostat, was able to provide bloodless incisions on several occasions, according to Cushing. There were also clipping devices with handles like a pair of scissors. Once clamped to a flap of scalp, they were pulled to fold the scalp over and against the head. That would reduce and block blood flow and prevent any bleeding. In 1911, Cushing addressed the risk of intracranial bleeding, which is bleeding within the brain itself, with something called silver haemostatic clips. These were small u-shaped pieces of silver wire used to control bleeding within the frail vessels of the meninges, which are the outer coverings of the brain. The clip could be positioned at the opening of a vessel and clamped using special forceps, which had a grooved surface that secured it into position. These were not the only haemostatic methods that Cushing came up with. Many others involved stringents, chemicals which constrict tissues, coagulation, and also suction. They contributed not only to operative safety, but improved surgery duration, allowing more complex procedures to be carried out with lower risk. Such was the impact of these innovations, that they have become vital tools in the general surgeon's arsenal, used in almost every operation to this day. Other accomplishments away from the operating theatre. Cushing is also well known for his contributions to our knowledge of trigeminal neuralgia. This is a condition where the body of the trigeminal nerve, located deep within the face, becomes compressed, causing the patient to feel an excruciating stabbing pain in the side of the face. He devised a method of treatment called gasserian ganglion resection, where a bundle of nerve cell bodies is cut and removed, resulting in a complete lack of sensation in the face, but also pain relief. You may have also heard of Cushing through his extensive studies on the pituitary gland, and its role in controlling hormonal balance in the body. He recognised diseases such as acromegaly and dwarfism, and described the clinical effects of hyperadrenalism, otherwise known as Cushing's syndrome. Cushing's legacy also lives through his work on brain tumours. In 1901 he published a report outlining the principles of the Cushing reflex. 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. Every medical student will learn that this results in the Cushing's triad, a widened pulse pressure, lowered heart rate and irregular breathing. This is a critical sign that tells us that a patient has impending brain stem herniation, something that will prove fatal if not treated immediately. During medical school, Cushing came close to quitting. After a patient he administered ether anaesthesia to, died at his hands. From this tragedy, Cushing and his classmate Ernest Amory Codman developed the Ether Chart. This document was used to monitor vital signs, including pulse and breathing rate, during anaesthesia, and revolutionised the way that anaesthesia was practised. Cushing was clearly a passionate and talented man. Early on, he contributed to a five-volume edition of Surgery, which grounded Cushing's reputation in neurosurgery. Notably, Cushing's interest in brain tumours, particularly meningiomas and gliomas, produced several books including Classification of the Tumours of the Glioma Group, The Pituitary Body and its Disorders, Studies in Intracranial Physiology and Surgery, and Meningiomas. His talent for writing was recognised with a Pulitzer Prize in 1926, following a two-volume biography of Sir William Osler, the first Professor of Medicine at Johns Hopkins, and a dear friend to Cushing. Cushing often accompanied his publications and surgical reports with medical art. He was encouraged to develop his drawing abilities during his time at Johns Hopkins, and was often seen sketching in the operating room after surgery. It was said that he could actually draw on a blackboard with both hands at the same time. This ambidexterity is something he had in common with another father of neurosurgery, Victor Horsley. Altogether, Cushing wrote more than 300 articles and 13 books. Consistent with his teaching principles, Cushing always started his books with a discussion on anatomy, physiology, pathology and chemistry, before moving on to the specific subject. To this day, the Cushing Tumour Registry is the most comprehensive tumour archive in the history of neuro-oncology, compiling over 2,000 case studies, including specimens and meticulous clinical records. Cushing retired as Chief of Surgery at the Peter Bent Birmingham Hospital in 1932. He spent the rest of his time in New Haven at Yale, compiling all of his notes and books, and entrusted his personal collection to Yale University. Cushing contributed immeasurably to the field of neurosurgery. Although described as somewhat cold, Cushing held those who he knew well in high regard, and commanded great respect from his contemporaries worldwide. In his honour, a group of American neurosurgeons established the Harvey Cushing Society in 1905. In the same year, Cushing was appointed to direct the Hunterian Laboratory of Experimental Medicine at Johns Hopkins University, where he dedicated his time to educating young neurosurgeons in medical and experimental science. There are more videos in this series covering the whole of the history of neurosurgery, so don't forget to like, subscribe, and check out the rest of the playlist if you want to learn more about neurosurgery in general. See you next time.