The Path to the Soul: Harvey Cushing and Surgery on the Pituitary and Its Environs in 1916

Abstract

THE PATH TO THE SOUL: HARVEY CUSHING AND SURGERY ON THE PITUITARY AND ITS ENVIRONS IN 1916 DAVID C. ARON* . . . If it were notfor this protective misdirection of mother nature, I could predict that the researchfor Dr. Harvey Cushing in the region of the pituitary gland would eventually prove that body to be the seat of the soul.—Letter from Karl Germain to Harvey Cushing, Jan. 4, 1937 . . . As for the pituitary body being the seat of the soul, I suppose we are as likely to get into Heaven without one as we are with one. Certainly as a physiological structure, it is more important than the pineal gland where Descartes, I believe, located the soul.—Letter from Harvey Cushing to Karl Germain, Jan, 7, 1937 /. Introduction In 1916 Harvey Cushing first saw Karl Germain, a magician and attorney who like Cushing was from Cleveland, Ohio, and who was referred because of failing vision. After operating on his parasellar tumor, Harvey Cushing maintained a correspondence with Karl Germain until Cushing's death in 1939 [I]. In the above exchange, Karl Germain celebrated Harvey Cushing as the master of the pituitary gland. By 1937, this organ had come to be recognized as the master gland because of the discrete control it exerted over the other endocrine glands. Both Germain's letter and Cushing's response refer to the thesis proposed by Descartes in his Treatise on Man and Passions of the Soul that the pineal The author expresses gratitude to Dr. James Buchanan and Mrs. Glen Jenkins for sharing the Cushing-Germain correspondence and for their critical review of the manuscript , and to Ms. Sandra Evens for preparing the manuscript. *Division of Clinical and Molecular Endocrinology, Department of Medicine, Case Western Reserve University, and Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, Ohio 44106 (correspondence).© 1994 by The University of Chicago. AU rights reserved. 0031-5982/94/3704-0880$01.00 Perspectives in Biology and Medicine, 37, 4 · Summer 1994 551 was the seat of the soul. In a footnote to a 1910 paper, Cushing wrote: "The suggestive papers of Marburg and of Pappenheim (Virchow's Archiv , 1910) indicate that the pineal is deserving of special experimental investigation and may prove to have an importance to the economy other than as a vestigial seat of the soul" [2]. By 1916, the importance of the pituitary gland had been established, although many details remained to be worked out, a process that continues to this day [3-4]. Harvey Cushing played a key role in the development and refinement of techniques for surgery in the region of the pituitary gland [5-9]. The operation performed on Germain—although nearly forgotten by Cushing during his service in World War I—ultimately influenced Cushing's entire career. The pituitary gland is located at the base of the skull in a saddleshaped hollow of the sphenoid bone—the sella turcica or "Turkish Saddle "—and is surrounded by the meninges. Cushing wrote: "Indeed, its extraordinarily well protected position, its presence in all vertebrates and persistence throughout life, its remarkably disposed and abundant blood supply, would of themselves be enough to stamp the hypophysis as an organ of vital importance" [10]. The most direct surgical approach to the pituitary takes a route from below through the sphenoid sinus (transsphenoidal). Unlike an approach from above, this transsphenoidal route threatens few delicate neurological structures. Tumors, usually benign in nature, may arise from any of the tissue types in this region. Although tumors of the pituitary are most common, Karl Germain's tumor was a meningioma. The tumor arose above the sella and impinged upon the optic chiasm, resulting in impaired vision (decreased visual acuity and incomplete bitemporal hemianopsia, or decreased peripheral vision). Fortunately, there was no apparent dysfunction of the pituitary gland itself. Although treatment of thyroid hormone deficiency was introduced in 1891 by George Murray (a former student of Horsley, another neurosurgical pioneer), hormone replacement therapy for adrenal steroid deficiency did not become available until the 1940s. II. Historical Background of the Pituitary Gland The pituitary gland has been recognized since antiquity, but the elucidation of its role in health and disease had to await the modern era [3...