Harvey Cushing: Cushing's disease.
Abstract: In 1932 Harvey Cushing published an article entitled 'Basophil adenomas of the pituitary and their clinical manifestations'. These are rare tumours of the anterior pituitary gland, at the base of the brain, with striking manifestations, which include adiposity of the face and trunk, but not the limbs, weakness, fatigue, abdominal striae, facial hair, high blood pressure and raised blood sugar. Although I spent two years in an army neurosurgical unit, I never saw a case. More frequently, the same clinical picture is produced by a benign adenoma of the suprarenal cortex, but today by far the commonest cause of this condition is seen in the patient receiving high dosage of cortisone, when we talk about the person exhibiting 'Cushingoid features'. Most readers of this journal will have seen such cases.
Subject: Hypertension
Author: Ellis, Harold
Pub Date: 09/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Sept, 2012 Source Volume: 22 Source Issue: 9
Accession Number: 309315286
Full Text: Harvey Cushing was born in Cleveland Ohio, USA in 1869, preceded by three generations of doctors. His father was a gynaecologist and Harvey's elder brother became a paediatrician. Harvey went to Yale University and then to Harvard Medical School, Boston. While still at medical school, Cushing showed his genius for clinical innovation. In those days, medical students gave most of the anaesthetics - chloroform or ether. Cushing devised the first continuous monitoring of the anaesthetised patient - he called it 'the ether chart' - which documented pulse, temperature and respiration. He added blood pressure to this a few years later when an effective sphygmomanometer was invented by Riva-Rocci.

A particular interest was the pituitary gland

In 1895, Cushing qualified MD with distinction and was appointed house surgeon at the Massachusetts General Hospital, Boston. The following year he moved to the new medical school, the Johns Hopkins, in Baltimore as resident to William Haisted, (of radical mastectomy fame). Here he developed his interest in neurosurgery, then in its earliest days. At that time there was no effective medical treatment for the agonies of trigeminal neuralgia. Cushing pioneered the operation of total removal of the trigeminal ganglion via an approach through the temporal bone of the skull, which he reported in 1900. In animal experiments he demonstrated the Cushing reflex - that raised intracranial pressure was accompanied by slowing of the pulse and a rise in blood pressure - essential features of today's monitoring of patients with head injuries.

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Cushing began the practice of careful documentation of the clinical features and of the pathological material of his patients - obtained at surgery or autopsy. Eventually he had the specimens of some 2000 verified brain tumours. Among many contributions was his description, with his pathologist, Percival Bailley, of the medulloblastoma, a highly malignant tumour of the brain stem, usually in children, which he published in 1924.

A particular interest was the pituitary gland, leading to the publication, in 1911, of a 350 page monograph which detailed 50 patients with endocrine disturbances of the gland, (another 20 years were to pass before he described the basophil tumour which bears his name). Cushing also solved many of the technical aspects of pituitary surgery. He devised the transnasal, trans-sphenoidal approach to the gland but used a large frontal flap with elevation of the frontal lobe of the brain when there was a large intracranial extension of the tumour. It is interesting that today, with modern fibre-optic technology, the trans-nasal approach has returned to popularity. In 1912, Cushing moved to the newly built Peter Bent Brigham Hospital in Boston, and here he spent the rest of his career.

With the outbreak of the First World War in 1914, Cushing was eager to be of service. In March 1915, he took his surgical team for a three month stint to a French military hospital outside Paris. Here he gained an extensive experience of high velocity missile wounds of the head and spine. While in France, he devised the use of an electromagnet attached to a nail to extract metallic missile fragments buried deeply in the brain.

With America's entry into the war, he returned in 1917 with an American neurosurgical team attached to the British Royal Army Medical Corps. A series of important publications arose from this experience. One study of the management of missile injuries of the brain took up a whole issue of the British Journal of Surgery. A technique introduced by Cushing, and still used today, was the use of the sucker to debride the missile track; pulped devascularised cerebral tissue disappears up the sucker, while healthy brain is unaffected.

One of the important technical problems in neurosurgery that Cushing had to overcome was haemorrhage. His innovations are in daily use today. Bleeding from the highly vascular scalp was dealt with by preliminary adrenaline infiltration and a row of haemostats to the fascial edges of the skin incision. He devised the silver 'Cushing clip' to control the cerebral and meningeal vessels, which is still used today. In 1926, working with the physicist William Bovie, he used a high frequency electric current to remove a highly vascular meningioma - a previous attempt at removal had failed because of severe bleeding - and the electric diathermy machine, still often called 'The Bovie' in the USA, came into general use. The following year, Cushing was able to recall many patients with supposedly inoperable vascular tumours and to tackle them with success.

Cushing trained a remarkable series of men, who went on to pioneer neurosurgery in the USA and Europe. Among them was an Australian from the London Hospital, Hugh Gairns. He later became Professor of Surgery in Oxford, opened the neurosurgical unit there and, in World War II, carried on the Cushing tradition by training the British Army neurosurgical teams. Incidentally, he was my professor of surgery and my chief when I worked in a post-war army neurosurgical hospital.

Cushing was a hard man - tough on himself and ruthless to his team. Hugh Gairns, who had served in the Australian Army in the First World War, used to say to us; 'A day working with Cushing in the theatre was worse than a year in the army in the Dardanelles'!

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by Professor Harold Ellis

Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.

About the author

Professor Harold Ellis

CBE, FRCS

Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London

No competing interests declared

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication June 2012.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.