Bovie,Cushing,and The Era of Electrosurgery

Electrosurgery plays an essential role in every head and neck operation. While electrical devices to cauterize, fulgurize, and electrodesiccate superficial tissues were developed starting in the late 19th century, ¹ it was the intense 2-year collaboration of an early biophysicist, William T. Bovie, PhD, and Harvey Cushing, MD, father of neurosurgery, which has led to modern electrosurgery. It all started with a chance meeting.

Bovie was born in 1882, the son of a Michigan family doctor. He was considered a gifted if slightly eccentric child who enjoyed tinkering with electrical gadgets. ² His path to education collapsed following his father’s premature death. Suddenly impoverished, Bovie attended a local business school. After working off his school debt as a teacher, he earned a doctorate in plant physiology at Harvard University. At graduation, Bovie found work as a research fellow at the Huntington Hospital for Cancer Research on the Harvard Medical School campus. Tasked with developing electrical devices for bloodless cancer biopsies, his first prototype used high-frequency alternating current delivered by a “cutting loop” to cut tissue by cellular dehydration.^2,3

Just a few blocks away at the Peter Bent Brigham Hospital, Harvey Cushing was struggling with the problem of hemostasis. ⁴ Cushing’s focus on preventing infection and controlling intracranial pressure reduced the frightening death toll from intracranial surgery. Still, despite the inventions of bone wax and silver surgical clips, uncontrollable bleeding made most brain tumors inaccessible to the neurosurgeon. In the fall of 1926, Cushing happened to witness a demonstration of Bovie’s new electrosurgical device.

“When I first had the good fortune to see this loop. . . I foresaw that a new tool had been put into our hands to facilitate the piecemeal removal of at least some of the heretofore inaccessible intracranial tumors.” ³

Following a failed first attempt at resecting an extracranial tumor due to profuse bleeding, Cushing invited Bovie (and his electrosurgical device) to attend the next operation. The hospital’s superintendent arranged for the necessary alternating current, brought in from a streetlight, and Bovie rolled his desk-sized electrical unit 4 blocks to Cushing’s OR ⁴ (Figure 1). Bovie, who knew little of surgery, worked the knobs, adjusting amperage and waveforms, as Cushing successfully resected the extracranial tumor. In the subsequent 2 years, their work advanced as Cushing attempted even more difficult excisions of superficial and finally deep-seat lesions (Figure 2).

Figure 1.

Early Bovie electrosurgical unit.

Figure 2.

Left—Original schematic of the electrosurgical pistol-grip and terminal electrodes (from US Patent 1813902 by WT Bovie, 1931). ⁵ Right—Acoustic neuroma accessed after cerebellar resection with electrosurgery (Cushing and Bovie, 1928). ³

Despite its tantalizing potential, surgeons were slow to adopt the electrosurgical device for fear of unintended complications. The risk of electrical fire with volatile anesthetic agents was a constant concern. Most procedures were therefore performed under local anesthesia or with rectal ether-oil. ⁴ Moreover, Bovie’s original unit did not include an effective dispersive electrode. ⁶ This meant current could accumulate and then flow through the patient to the table, surgical instruments, or the surgeon. As Cushing noted, “Once the operator (Cushing) received a shock which passed through a metal retractor to his arm and out by the wire from his headlight, which was unpleasant to say the least.” ²

Throughout his adult life, Bovie was known to be quick-tempered and egotistical. ⁷ Despite his revolutionary invention, Bovie was unable to gain tenure at Harvard, and Cushing could not secure a research position for him at the nearby General Electric Company. ² When his grant funding ran dry, Bovie left Harvard and electrical engineering. He sold the patent for his electrosurgical unit to the Liebel–Flarsheim Company for $1. ⁴ The instrument company continued to make electrosurgical units with Bovie’s name on them for another half-century.