Historical Vignette

The Evolution of Pituitary Gland Surgery from the Ancients to the Millennials
Andrei Ionut Cucu1,2, Claudia Florida Costea3, Antonio Perciaccante4,5, Simon T. Donell6, Raffaella Bianucci7,8

Key words Located at the base of the skull, the pituitary gland has a long and controversial
- Pituitary gland history, not only in terms of its anatomy, but especially in the functions it per-
- History of hypophysis
- Pituitary surgery
forms and in the attempt to approach it surgically. Considered by Galen of
- Transsphenoidal surgery Pergamon to have a role in releasing waste products of the brain, a theory
- Endoscopic surgery accepted until the 17th century, the pituitary gland became a separate entity
Abbreviations and Acronyms
once with the anatomical descriptions of the famous Andreas Vesalius. At the
CT: Computed tomography beginning of the 18th century, researches of the time began to be more and more
MRI: Magnetic resonance imaging interested in this gland, trying to identify its functions, and at the same time
correcting the traditional theories that were wrong or incomplete. Later, they
From the 1Faculty of Medicine and Biological Sciences,
Stefan cel Mare University of Suceava, Suceava, Romania; turned their attention to experimental animal studies that represented the
2
Department of Neurosurgery, Prof. Dr. N. Oblu Emergency germinal nucleus for the transcranial and endoscopic pituitary surgery. In this
Clinical Hospital, Iasi, Romania; 3Department of review, an attempt has been made to record the entire history of anatomy,
Ophthalmology, Prof. Dr. N. Oblu Emergency Clinical Hospital,
Iasi, Romania; 4Laboratoire Anthropologie, Archéologie, physiology and surgery of the pituitary gland, from antiquity to the current day’s
Biologie (LAAB), UFR des Sciences de la Santé, Université surgical techniques.
Paris-Saclay (UVSQ) & musée du quai Branly - Jacques
Chirac, Montigny-le-Bretonneux, France; 5Department of
Medicine “San Giovanni di Dio” Hospital, Azienda Sanitaria
Universitaria Giuliano Isontina, Gorizia, Italy; 6Norwich he believed that waste products flowed anatomist Andreas Vesalius (1517e1564)
Medical School, University of East Anglia, Norwich, UK; down the pituitary stalk and reached the revised the views of Galen by performing
7
Department of Cultures and Societies, University of
pituitary gland. Furthermore, these waste dissection of human cadavers. He started
Palermo, Italy; and 8The Ronin Institute, Montclair, New
Jersey, USA products were thought to pass, through a School of Anatomy to educate the
To whom correspondence should be addressed:
ducts, throughout the sphenoid and students.9 He criticized the ancient
Claudia Florida Costea, M.D., Ph.D. ethmoid bones reaching the method of defining human anatomy by
[E-mail: [email protected]] nasopharynx, and were, then, evacuated dissecting animals (human dissection
Citation: World Neurosurg. (2023) 180:52-65. as pituita or nasal mucus.2-5 Moreover, was proscribed by the Church). He was
https://doi.org/10.1016/j.wneu.2023.09.004 Galen believed that this mucus (pituita) able to point out inaccuracies made by
Journal homepage: www.journals.elsevier.com/world- was filtered through the cribriform plate Galen. He was the first person to
neurosurgery of the ethmoid bone.3,5,6 This theory was describe the pituitary gland as a separate
Available online: www.sciencedirect.com spread and passed on, for more than entity.3,10 He called it the glandula pituitam
1878-8750/ª 2023 The Author(s). Published by Elsevier Inc. 2000 years. Toni (2000) gave an cerebri excipiens. In 1538, he was the first to
This is an open access article under the CC BY-NC-ND historical and epistemological perspective illustrate it, as the rete mirabile, in quo
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
of the hypothalamic-pituitary-thyroid axis vitalis spiritus ad animalem preparatur (Figure
with details on the Ancients’ views and an 1B) being the first to do so.3,11,12
INTRODUCTION overview up to the 1980s.7 Although Vesalius accepted the theory
The Latin word pituita means mucus or The purpose of this paper is to focus that this gland had a role in excretion of
phlegm. The pituitary gland (Figure 1A) is on the pituitary gland and update its pituita via the nose,3,4,13 he did not agree
so called because Hippocrates of Cos the history up to the turn of the with Galen’s theory that mucous was
(460e370 BC) in the 4th century BC millennium. filtered through the cribriform plate of
thought that nasal mucus was fluid from the ethmoid. He suggested that the
the brain.1 The Greek physician Galen of The 16th Century: The Pituitary Gland excretory pathway would be through the
Pergamon (130ec.200 AD,) in his book Described as a Separate Entity palatine canal and superior orbital fissure
De usu Partium, wrote “underneath the With the Renaissance, Western people into the sphenopalatine fossa and then
basin there is a spongy gland that is the wished to revive the Golden Age of An- out through the nose.3,14 Moreover, in
head of ox. its size is proportional to tiquity, so public human dissections his work De Humani Corporis Fabrica,
the size of the animal.”. Galen believed began to be more or less allowed. This fact Vesalius drew the pituitary distillation
that the sella turcica of the sphenoid led to a better understanding and a deeper process and illustrated the pituitary
bone was perforated and that, through exploration of knowledge regarding the stalk15,16 (Figure 1B).
several foramina, the blood vessels structures and functioning of the human Despite these advances and in anatom-
carried residues of pituitary.1 Basically, body.8 In this context, the fanous ical and other fields of science, it was not

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until the 17th century, when the anatomists Vieussens of Montpellier (1635e1715) (1758e1828) considered the pituitary gland
Konrad Viktor Schneider of Wittenberg hypothesized that the pituitary gland to be a large ganglion.4,12,13
(1610/1614e1680)17,18 and Richard Lower would play a role in the formation and Later, in 1778, Samuel Thomas von
of Oxford (1631e1691)19 definitively secretion of cerebrospinal fluid, Soemmering (1755e1830) called it hypoph-
showed that Galen’s teaching was especially due to its position at the base ysis cerebri, considering it, like Vesalius, a
incorrect. Both Schneider and Lower of the third ventricle.23,24 gland.12,26 In 1810, the German professor
disproved this concept and disagreed In 1724, the Italian anatomist Giovanni Joseph Wenzel from the University of
with the view of a communication Domenico Santorini (1681e1737) recog- Mainz (1768e1808) proposed that the
between the cerebral ventricles, the nized that the anterior pituitary is a pituitary gland would play an important
pituitary stalk, the pituitary gland and discrete entity, not a continuation of the role in the occurrence of epilepsy12,26 and
the nasopharynx.3,17,18,20 Using infundibulum, and called it the glandula published his conclusions in the
anatomical studies, in his book De pituitaria potior.3,25 The pars anterior, which monograph Beobachtungen über den
Catarrhis,19 Richard Lower described a expressed some milky fluid, was described Hirnanhang fallsüchtiger Personen
series of experiments in which he as a separate portion of the pituitary [Observations on the hypophysis cerebri
injected “milk or some black substance” gland.4,25 A few years later, in 1766, the of epileptic persons, Mainz 1810].
into the openings of the base of the Swiss anatomist and physiologist Wenzel came to this conclusion after
brain, noticing that nothing appeared Albrecht von Haller (1708e1777) came up following the anatomical changes of the
“around the palate, nostrils, mouth, with new findings, differentiating the pituitary gland in 20 patients with
throat or larynx”.10 pars anterior and the pars posterior. epilepsy, thus identifying atrophy or
Later, together with Thomas Willis Later, in 1779, Professor William Cullen hypertrophy of one of the lobes of the
(1621e1675), Lower proposed an hypoth- (1712e1790) of Edinburgh Medical School pituitary gland, and the appearance of
esis in which substances from the brain reported the extra-axial location of the exudate or inflammation.27,28
passed through the infundibulum to the pituitary gland, considering it an appendix A few years later, Pierre-Francois-Olive
pituitary gland, and from there they were to the brain”. Rayer (1793e1867) called it l’appendice sus-
distilled into the blood.3,19,21 Basically, Thus, at the beginning of the 18th cen- sphenoidal12,26,29 in his work Observations sur
Willis and Lower anticipated the theory tury, it had become clear that Galen’s les maladies de l’appendice sus-sphénoidal
of neurosecretory substances, described theory on the role of the pituitary gland (1832).29 In this monograph, Rayer
300 years later by Geoffrey Harris (1913e was incorrect. Scientists of the time began analyzed pituitary gland tumors,
1972), as the hypothalamic-hypophyseal to be more and more interested in this distinguishing between pituitary gland
portal circulation.22 At the same time, gland, trying to define and identify its hypertrophies and scirrhous tumors.29,30
Thomas Gibson (1674e1722) from functions. Among them the French anat- German physiologist Carl Gustav Carus
Cambridge, Franciscus Sylvius (1614e omist and physician Franz Joseph Gall (1789e1869) followed Gall’s lines,
1672) from Leyden, and Raymond considering the pituitary gland as the
rostral projection of the nervous sys-
tem.3,12,23 Later, the German physiologist
Ernst Burdach (1801e1876) proposed that
the spinal cord started from this gland,
and that the anterior and posterior lobes
of the pituitary gland were replicas of the
anterior and posterior tracts of the spinal
cord.12,23,26 The German anatomist
Johann Friedrich Meckel (1781e1833)
believed that the pituitary gland was used
to nourish the brain.3 At the beginning
of the 17th century, through the
contributions of each scientist, farther or
closer to the truth, the correct physiology
of the pituitary gland began to emerge.10

The 17th-18th Centuries: The Role of the

Pituitary Gland in Disease
Although the pituitary gland apparently
Figure 1. Drawings of the anatomical relations of pituitary gland in sagittal section. (A) 1, 10 anterior attracted little interest until the end of the
and posterior lobe of pituitary; 2, pituitary stalk; 3, optic chiasm; 4, lamina terminalis; 5, recessus
opticus; 6, anterior white commissure; 7, 7 0 coronary sinus; 8, anterior cerebral artery; 9, basilar 18th century, the invention of the micro-
artery; 10, posterior cerebral artery; 11, mammillary bodies; 12, cerebral peduncle; 13, pons. (Traité scope by Anton van Leeuwenhoek (1632e
d’Anatomie Humaine, Testut L, Paris (1900). (B) Versalius’ representation of the hypophysis cerebri 1723) accelerated the understanding of its
showing the portal (E) for receiving pituita from the brain (De Humani Corporis Fabrica Libri Septem,
Basel 1955 [public domain]).
anatomy and physiology, debunking many
ancient concepts.3 In 1742, the French

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anatomist and physician Joseph Lieutaud cells.39,40 Several years later, in 1892, examination and identified a walnut-
(1703e1780) observed that the pituitary Schoenemann further differentiated the sized sellar tumor that had eroded the
stalk was not a canal, as his predecessors chromophilic cells which were stained sella turcica and displaced the optic nerves
believed, but a solid rod, made of gray either with acidic dyes or with basic (Figure 2). Verga erroneously considered
substance, surrounded by pia mater.31 He dyes.41,42 Even with this glimpse of that the early loss of menstruation
also noted the hypothalamo-hypophyseal understanding of pituitary histology, the caused the appearance of the tumor and
portal system, describing many longitudi- role of the pituitary gland in humans was the clinical syndrome.45-47
nal blood vessels that communicated with not fully comprehended, and A few years later, in 1881, the Italian
the pituitary gland.31,32 It was also furthermore, it continued to be pathologist Vincenzo Brigidi (1838e1908)
Lieutaud who named the pituitary stalk, considered a vestigial organ until the reported a similar case in the Italian actor
proposing the term tige pituitare: “I have year 1908.43 Ghirlenzoni, who had a clinical descrip-
given the name pituitary stalk to this part However, it was not until the 18th cen- tion resembling acromegaly.48 He
because I believe that the term funnel tury that interest in the pituitary gland misinterpreted the finding of the tumor
would not be suitable for it”.3,4,31,32 began to grow in earnest with the emer- found at autopsy as hypertrophy of the
In 1797, Mathew Baillie (1761e1823), the gence and development of pituitary gland secondary to primary
royal physician to King George III, neuroendocrinology. disease of bone.
mentioned in his work Morbid Anatomy: Later, the French neurologist Pierre
“this gland is very little liable to be The 19th Century: The Anatomical-Clinical Marie (1853e1940) (Figure 3A) introduced
affected by disease”.3,33 He reported only Correlations of the Pituitary the term acromegaly, derived from the
one case in which the gland was In the 19th century, the traditional theories Greek terms akron (extremity) and megas
enlarged, “twice the normal size of (wrong or incomplete) about the functions (great) after reporting two such cases to
fibrous tissue”.23,33 At the same time of the pituitary gland began to be cor- his patients treated at Salpêtrière
anatomists began to speculate on the rected by defining the role of this gland Hospital of Paris49 (Figure 3B). Marie
role of the pituitary gland in the onset of and its involvement in the development of believed that the pituitary gland
disease. Through studies on cadavers, various clinical syndromes, especially the increased its volume secondary to bone
they recognized that the pituitary gland neuroendocrine ones. In 1839, the Vien- changes. Once with Pierre Marie, the
could grow in size, and consequently nese physician Joseph Engel (1816e1899), true interest in pituitary endocrinology
cause vision loss. The first to describe in his doctoral dissertation on tumors of began.50 Marie’s seminal work, in which
this pathology was the French surgeon the pituitary gland and infundibulum, Über he described his theories, was published
Jean Louis Petit (1674e1750), the first den Hirnanhang und den Trichter,44 rejected in the Révue Médicale Française and marked
director of the Academie de Chirurgie in the theory that the pituitary gland was the beginnings of pituitary
Paris. He was also the one who noticed involved in epilepsy.30 His work was neuroendocrinology.51
that in most cases of hydrocephalus the among the earliest that tried to establish A year later, in 1887, the Lithuanian
pituitary gland was squirrheuse the true role of the pituitary gland.30,44 physician Oskar Minkowski (1858e1931)
(scirrhous).23,34 In 1681, the Swiss Moreover, through describing the suggested that acromegaly actually
pathologist and pharmacologist Johann anatomical connections of the pituitary occurred secondary to the increase in pi-
Jakob Wepfer (1620e1695), who is gland within the brain, Engel also tuitary volume. However, Marie was un-
considered to have produced one of the speculated on neuroendocrine aware of the associated pituitary pathology
most famous monographs on stroke of communication, and is considered the until 1891, when he himself along with the
all times,35 reported a case of earliest theory.30 Romanian neurologist Gheorghe Marine-
enlargement of the pituitary where it was Many years prior to identifying a syn- scu (1863e1938) reported autopsy findings
twice the normal size.36 drome linked to pituitary disease, anato- in an acromegalic patient.52 The two
In 1705, the French anatomist Raymond mists were aware of the gland’s ability to reported that the pituitary gland was
Vieussens (1635e1715) also described the grow larger. Consequently, in the 17th and replaced by an adenoma, concluding that
case of a patient with a pituitary tumor the 18th centuries, anatomists observed during the normal function of the gland was to
size of a hen’s egg, associated with atro- post-mortem examinations that the pitui- inhibit somatic growth, and, therefore,
phy of the optic and olfactory nerves.37 tary gland could enlarge and lead to gigantism occurs due to lack of these
During the same period, Anton de Haen blindness by putting pressure on the optic inhibitions.52 Also during this period,
(1704e1776), professor of Medicine at the chiasm and nerves.42 In this context, in cases of acromegaly in patients with
University of Vienna, reported a pituitary 1867, the Italian neurologist and pituitary gland tumors were described in
tumor in a 20-year-old woman who had psychiatrist Andrea Verga (1811e1895) the literature,53,54 as observed in the
severe headaches, nausea, vomiting, visual (Figure 2) reported one of the earliest famous Irish Giant.55 Subsequently,
failure and amenorrhea; the case was clinical descriptions of acromegaly, pituitary disease began to be associated
published in Pars Quinta Rationis caused by a large-sized sellar tumor. He with other neuroendocrinological
Medendi.23,38 called the term prosopectasia, derived from syndromes.
In 1886, Lothringer and Dostoiewsky the Greek term prosopon (face) and ektasis In 1900, the French neurologist Joseph
independently divided the pituitary gland (enlargement).45 After the patient died of Babinski (1857e1932) reported on a young,
into chromophobe cells and chromophile typhus, Verga performed the post mortem obese woman with genital hypoplasia with

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Figure 2. (A) Drawing of a cranium and skull base of a 59-year-old A, Caso singolare de prosopectasia. Reale Istituto Lombardo di
female who suffered from acromegaly (prosopectasia), Scienze e Lettere Rendiconti Classe di Scienze Matematiche e
described by the Italian neurologist Andrea Verga in 1864. Note Naturali 1864; 1: 111e117). (B) Andrea Verga (1811e1895).
the destruction and enlargement of the sella turcica (from Verga

an associated pituitary tumor.56 A year During the same time, the Romanian dissecting adult human corpses, human
later, Alfred Froelich (1871e1953) anatomist Grigore T. Popa (1892e1948) fetuses and different animals.
described a case of a pituitary tumor in a (Figure 4A) and the Australian anatomist After 3-dimensional reconstruction of
patient without acromegaly, but who, Una Lucy Fielding (1888e1969) the vessels, the 2 anatomists first
clinically, had adipose-genital dystro- (Figure 4B) also brought important described portal circulation from the pi-
phy.57 None of them considered that their research on the pituitary gland. Together, tuitary to the hypothalamic region58
patient characteristics were the result of they performed a vascular study of the (Figure 4C). In 1930 the results of their
pituitary gland hypofunction. blood vessels in the pituitary region by studies were communicated to the
Anatomical Society of Great Britain and
Ireland and subsequently published.59,60
A central person in the study of the
relationship between the hypothalamus
and the pituitary gland was the British
neuroendocrinologist Geoffrey W. Harris
(1913e1971). He showed that the
secretion of the pituitary gland is
controlled via the hypothalamus by
releasing factors that are transported
from the hypothalamus to the pituitary
gland through the pituitary stalk.61,62

The Beginnings of Experimental Pituitary

Surgery in Animals
Also with the end of the 19th century, re-
searchers turned their attention to exper-
imental animal studies that represented
the germinal nucleus of later pituitary
surgery. In 1892, the Romanian neurolo-
gist Gheorghe Marinescu (1863e1938), an
Figure 3. (A) Pierre Marie (1853e1940). (B) A man affected by acromegaly (Wellcome collection,
dated to the end of the 19th century, public domain).
associate of Pierre Marie,63 reported the
survival of the experimental animal after

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ablation of the pituitary, but only for a same conclusion, namely that total (hyperpituitarism), the other to a
limited period. He used a transbuccal hypophysectomy was not compatible with diminished activity of the same epithelial
route where, after dividing the soft life. However, even into the 20th century, structure (hypopituitarism) seem capable
palate, he opened the sella turcica and the function of the pituitary was not yet of clinical differentiation”.3,71 Cushing
destroyed the pituitary gland using heat. fully understood.43 also described most of the functions of
In Marinescu’s operations, 3 Harvey Cushing (1869e1939) the pituitary gland,73 publishing, in 1912,
experimental animals survived 3, 5, and (Figure 6A) solved the mystery, noting the the book “The Pituitary Body and its
18 days.3,64,65 After this, in 1892, the similarity between these patients and Disorders”.74 He also performed
Italian pathologists Giulio Vassale (1862e hypophysectomized puppies in the hypophysectomies in dogs, proving that
1913) and Ercole Sacchi (1896e?) and laboratory. In 1909, Cushing published the pituitary gland is essential for life,
1894, respectively tried Marinescu’s The Hypophysis Cerebri, in which he and, thus introducing the principle of
approaches, observing the resulting compared the results of experiments on adrenal substitution.10
hypothermia, apathy, anorexia, dogs with the clinical features observed In 1912, Bernard Aschner improved the
polydipsia, weight loss, and coma. The in humans.71 In the same year, Cushing technique of hypophysectomies,
conclusion of the 2 was that this gland reported 20 experimental cases of describing in puppies immediate post-
produced an essential substance for hypophysectomy in the Hunterian operative arrest of growth, infantilism,
life.66,67 Laboratory, concluding that without this and failure of the epiphyseal cleft to
Before the start of the First World War, gland, life could not exist.72 close.68 A few years later, in 1917, William
the Romanian physiologist Nicolae C. In 1912, he was among the first to Blair Bell (1871e1936) reported that
Paulescu (1869e1931) (Figure 5A), the postulate the existence of a hormone of pituitary stem clamping had the same
Austrian physiologist Bernhard Aschner growth in the pituitary (Figure 6B). He was effects as hypophysectomy, with atrophy
(1883e1960),68 the American also the one who introduced the term of the uterus and ovaries.75 This was
neurosurgeon Harvey Cushing, and hyper- and hypopituitarism, mentioning followed by other experiments by
others, performed superb experiments on that the “two conditions, one due to a Cushing, who successfully prolonged the
dogs, trying to see the effect of pituitary pathological increased activity of the pars life of hypophysectomized animals by
gland removal.69,70 They came to the anterior of the hypophysis injecting extracts of animal pituitaries,
and by auto- or homo-transplantations of
glandular tissue.64 All these animal
experiments were undertaken to
understand the function of the pituitary
gland. They also helped develop the
surgical approaches needed in the
development of transcranial pituitary
surgery.

The Beginnings of Transcranial Pituitary

Surgery
In the late 19th century, after having
investigated the effect of canine hypophy-
sectomy,76 surgeons turned their attention
to transcranial surgical approaches in
humans.
The surgical indications for pituitary
tumors were initially related to vision loss
and headaches. Despite some publications
reporting clinical improvements in acro-
megalic patients after hypophysectomies,
Cushing initially indicated that surgical
intervention should be performed solely
for its mass effect, meaning for headaches
Figure 4. (A) Photograph of Grigore T. Popa (1892e1948) (public domain). (B) Photograph of Una
Lucy Fielding (1888e1969) (public domain). (C) A drawing of the portal circulation from the pituitary to and visual disturbances. However, surgical
the hypothalamus after Popa and Fielding, with original description: 1, hypophyseo-portal vessel; 2, resections had high mortality and
carotid artery; 3, hypophyseal artery; 4, small artery for pars tuberalis; 5, small artery for tuber morbidity rates until the early 1950s when
cinereum; 6, posterior communicating artery; 7, posterior cerebral artery; 8, small arteries for
infundibulum; 9, cavernous sinus; 10, hypophyseal vein; 11, small hypophyseal veins; 12, basal hydrocortisone and antibiotics became
vein; 13, sinusoids; 14, heavy glial sheaths of the hypophyseo-portal veins; 15, secondary distribution available.42
net; A, pars anterior of pituitary; P, pars posterior of pituitary; I, pars intermedia of pituitary; S, stalk The British surgeon Sir Victor Horsley
(from Popa G. A portal circulation from the pituitary to the hypothalamic region. J Anat. 1930;65 (Pt
1):88e89).
(1857e1916) (Figure 5B) attempted the
first surgical approach to the pituitary

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Figure 5. (A) Nicolae C. Paulescu (1869e1931) (public domain). Krause (1857e1937). (Images courtesy Ingeborg Emge, Fedor
(B) Victor Horsley (1857e1916) (public domain). (C) Fedor Victor Krause’s grandchild, from her personal collection.)

gland.76,77 He is considered the first because it involved the lifting of the frontal tumor pressing on the front of the optic
surgeon to have operated on a pituitary lobes. Intraoperatively, he noticed a cystic chiasma, and for this purpose I raised the
tumor.3 In 1889, he unsuccessfully tried adenosarcoma, which he described as frontal lobe, but found that the tumor was
to access a pituitary tumor that was inoperable, and the patient died a few really a cystic adeno-sarcoma of the pitu-
compressing the optic chiasm. He used a years later. Horsley testified “my first itary gland, and was inoperable.”.10,77
bi-frontal craniotomy approach; a tech- attention to this subject was drawn by Post mortem examination revealed
nique he called “cerebral dislocation” being requested in 1889 to operate on a significant softening of the frontal lobes.
Horsley considered that this occurred as
a result of the sacrifice of polar veins
draining into the superior sagittal sinus;
a sacrifice that was necessary to gain
access to the tumor. Horsely later
abandoned the transfrontal route for
pituitary tumors in favor of the
transtemporal approach.78 Despite
presenting his work at numerous medical
meetings, Horsley waited 17 years to
publish his case, later considering his
approach to be “prehistoric”.76 He
operated between 1904 and 1906 on at
least 10 patients with pituitary tumors in
which he used both subfrontal and
lateral middle fossa approaches, with a
mortality below 20% much lower than
compared to that of his colleagues at
50% to 80%.77,79 He also advocated for
surgery for pituitary tumors, emphasizing
Figure 6. (A) A photogrpah of Harvey Williams Cushing (from 1900e1901) (public domain). (B) An the importance of releasing mechanical
electron micrograph of growth hormone producing cell from the pituitary gland, University of
Edinburgh (Wellcome collection, public domain).
pressure on the optic chiasm to prevent
blindness.80 Horsley’s operations were

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successful, and were part of the have visual symptoms.3 In 1910, M. Heinz Stammberger (1946e2018),104,105
pioneering period of pituitary surgery. Silbermark suggested the approach to and Wolfgang Draf (1940e2011).106
In 1893, a few years later after Horsley, the pituitary gland through the Sylvian In 1906, guided by the work of Davide
surgeon Frank Thomas Paul (1851e1941) fissure, after performing several Giordano, Austrian surgeon Hermann
of the Royal Infirmary in Liverpool, oper- experimental operations on dogs.78,92 Schloffer (1868e1937) was the first sur-
ated on a patient of his colleague Richard Four years later, George Heuer (1882e geon to attempt pituitary tumor removal
Caton.81 After consulting with Horsley and 1950) applied Silbermark’s approach and through an extensive approach involving
using the subtemporal approach he developed an intradural intracranial resection of the sphenoid and ethmoid
suggested, Paul tried to resect a pituitary approach to the optic chiasm.93,94 He sinuses through a lateral rhinotomy
tumor in a young woman with was soon followed by Alfred Adson approach.107 Postoperatively, the patient
acromegaly.3,81 The tumor was never (1887e1951) of the Mayo Clinic. Thus, had a short period of cerebrospinal fluid
exposed and the patient died 3 months the advantages of the pterional approach, rhinorrhea and died of intracranial
later.82 using the natural planes of brain tissue hypertension 2 months later. Post mortem
At the same time, in Berlin, the father along the wing of the sphenoid bone, examination revealed most of the
of German neurosurgery, Fedor Victor made it the most widely used remaining tumor occluding the foramen
Krause (1857e1937) (Figure 5C),83,84 transcranial approach to the sellar of Monro.108 This technique was
performed an extradural right frontal region.95 The pterional approach, which simplified and improved a few years later
approach to remove a bullet from the minimizes brain retraction by splitting by Kocher and Kanavel,109 Hirsch110 and
optic foramen region in a patient who the Sylvian fissure and opening the basal Halstead.111
survived a suicide attempt.85 The patient arachnoid cisterns, was described in The trans-sphenoidal approach under-
recovered well postoperatively. Krause detail and promoted by Gazi Yasargil (b. went a number of changes. An important
appreciated the importance of seeing the 1925).96 one was made by Halstead, who opened
sella turcica: “As I had succeeded in the oronasal rhinoseptal approach through
reaching the optic foramen from the a sublabial gingival incision. This surgical
front, in order to extract the bullet, it Transnasal Pituitary Surgery approach was also performed by Harvey
seemed feasible to approach the pituitary At the end of the 19th century, acromegaly Cushing (Figure 6A), who perfected the
in the same way.” A few years later, in was recognized as related to the increase sublabial trans-sphenoidal route in his
1905, Krause successfully performed the in volume of the pituitary gland,97 a large series of 1912,112 191499 and 1922.113
first transfrontal pituitary operation, condition that could eventually lead to Thus, from 1910 to 1925, Cushing per-
choosing an extradural approach to avoid the patient’s death. In this context, formed 231 operations, with a mortality
damaging the brain.86 This approach was despite the very high risks, between rate of 5.6%.87 In these interventions,
the basis for a number of variants of 1890e1896, the Italian doctor Davide Cushing used the submucosal dissection
later trans-cranial approaches.87 Giordano (1864e1954) (Figure 7A) from technique recommended by Eisenberg
In 1907, after performing several oper- the Municipal Hospital of Venice and Kocher.3 Although he recommended
ations on cadavers, the German surgeon concentrated his efforts in trying to the transsphenoidal approach for most of
Wilhelm Braun was convinced that the improve the condition of his patients; his career (1909e1927),82 later, Cushing
pituitary gland should be approached based on his observations at post mortem abandoned it. In 1927 he returned to the
through a transtemporal approach examinations. He was the first to transfrontal approach,107 considering that
through the cavernous sinus. However, propose the transglabellar-nasal approach this route allows for better
unacceptably high mortality and morbidity for the surgical removal of the pituitary decompression of the optical apparatus.3
through division of the trigeminal body98 (Figure 7B). In 1929, he completely abandoned the
branches and ligation of the internal ca- In 1901, the otolaryngologist surgeon trans-sphenoidal route.82 Due to
rotid artery, were reported. A year later, in W. Alfred Hirschmann performed the first Cushing’s great influence at that time,
an attempt to approach a pituitary ade- paranasal operation,100 100 years after the the trans-sphenoidal approach to the pi-
noma, Louis Linn McArthur (1858e1934) invention of the first endoscope by Philipp tuitary was largely neglected in favor of the
resected the supraorbital rim along with a Bozzini in 1806.101 Subsequently, over the transcranial approach until the
portion of the orbital roof, accessing years, many improvements were made to 1960s.3,50,114,115
extradurally up to 5 mm proximal to the the scope, the main one being the Subsequently, transnasal surgical tech-
chiasmatic sulcus.88,89 development of the rod lens system, niques of the pituitary further developed.
Initially, the American surgeon Charles described by Harold Hopkins.102 This The Viennese otolaryngologist surgeon
Harrison Frazier (1870e1936) adopted this system used a series of neutral glass Oskar Hirsch (1877e1965) reported on a 35-
approach, but later changed it to an lenses, which improved the clarity 9 year-old woman a clinical syndrome rep-
intradural frontobasal approach.90 Due to times compared to the direct lighting resented by amenorrhea and galactor-
the occurrence of hypotension during the system.10 If Hirschman was the first to rhoea.116 Hirsch decided to operate, using a
intervention, Frazier modified the use the endoscope in the nasal cavity, completely endonasal trans-septal trans-
procedure into two stages.91 He later the otolaryngologists who most sphenoidal approach.10,117 Intraoperatively,
recommended that trans-nasal surgery popularized paranasal endoscopic Hirsch did not find a pituitary adenoma
should not be performed in patients who procedures were David Kennedy,103 as he expected, but a cyst. After post

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 HISTORICAL VIGNETTE
ANDREI IONUT CUCU ET AL. THE EVOLUTION OF PITUITARY GLAND SURGERY

1965, the Canadian neurosurgeon, Jules

Hardy (1932epresent), after a 1-year
fellowship with Gerard Guiot in Paris,
introduced the operating microscope and
developed the use of fluoroscopy.131 He is
considered the initiator of surgery for
microadenomas.79
From the 1960s until today, Hardy’s
technique, with some modifications, has
been widely used.128,129 However, most
older American neurosurgeons have been
reluctant to use this technique, probably
due to Cushing’s influence.10 In 1987,
Griffith and Veerapen132 reintroduced the
endonasal route first described in 1909
by Hirsch, thereby opening the horizon
for endoscopic pituitary surgery.108
Following the increasing collaboration
between neurosurgeons and otorhinolar-
Figure 7. (A) Drawing by Davide Giordano, representing his transglabellar-nasal approach to the
yngologists, the fully endoscopic trans-
pituitary in a cadaveric dissection (from Artico et al.98). (B) Drawing of the sagittal view showing the sphenoidal approach was introduced in
substitution of the 2 lateral retractors for a self-retaining bivalve speculum through which further the early 1990s. Thus, in 1992, Roger
surgical instruments are introduced (from Cushing99).
Jankowski, from the Department of
Otorhinolaryngology-Head and Neck Sur-
gery in Nancy, was the first to report the
mortem examination, he discovered that the fluoroscopy and intraoperative radiog- use of trans-sphenoidal endoscopy for pi-
tumor was a true adenoma.118 Hirsch raphy plus the introduction of the oper- tuitary adenomas.133 He was followed by
practiced in Vienna until 1938. He left ating microscope by Gerard Guiot123 and Sethi and Pillay,134 Rodziewicz et al.,135
because of the Nazis and settled in Jules Hardy.124 Other equally important Jho and Carrau from the University of
Boston. There he operated via the trans- key moments were the development of Pittsburgh Medical Center,136-138 and
sphenoidal approach for another 20 intraoperative frameless stereotaxy125 and Cappabianca and De Devitiis from the
years.108,119 In 1939, following experience intraoperative 3-planar computed tomog- University of Napoli.139-141
gained, Hirsch differentiated and raphy (CT) or magnetic resonance imaging Also worth mentioning is Professor
mentioned 3 important clinical entities (MRI) scanning.126 Edward R. Laws, Professor of Neurosur-
associated with pituitary gland pathology; In 1957, Gerard Guiot, after learning the gery at Harvard Medical School and Di-
acromegaly, adiposogenital dystrophy, and trans-sphenoidal approach from one of rector of Pituitary and Neuroendocrine
isolated visual defects without other Cushing’s pupils, Norman Dott,119 Center at Brigham and Women’s Hospital.
general manifestations.78 With the introduced it to France. He combined it He performed more than 6000 trans-
publication of the sublabial approach by with the use of intraoperative image sphenoidal operations over 6 decades,
Harvey Cushing, and the endonasal fluoroscopy, a system that allowed for having as a mentor the neurosurgeon
approach by Oskar Hirsch, the trans- better visualisation127; currently George Udvarhelyi from Johns Hopkins
sphenoidal approach was popularised.82 considered the first line image guidance University, making valuable contributions
Regarding the use of endoscopy in trans- system for pituitary surgery.128 to the development of this surgical
sphenoidal surgery, the first to use the Guiot was the first to report the use of technique.129,142
endoscope was the French surgeon Gerard endoscopy for sublabial trans-sphenoidal A major role in the development of pi-
Guiot (1912e1996) in 1961.120 Due to the surgery.108 Moreover, Guiot was the first tuitary surgery was also played by image
difficult visualization of anatomical to use the endoscope for inspection of guidance systems. The first system was
structures, he abandoned this technique. the sellar cavity at the end of introduced in 1965 by Guiot and improved
Subsequently, in the late 1970s, endoscopy surgery.120,129 In the same year, the by Hardy.131 Jules Hardy from Montreal
in pituitary surgery was progressively American gastroenterologist Basil learned the trans-sphenoidal technique
improved in conjunction with trans- Hirschowitz (1925e2013) demonstrated from Ferard Guiot and implemented the
sphenoidal microsurgery, especially by the efficiency of the fibre optic routine use of microscopy.129,143
Apuzzo et al.121 and Bushe and Halves.122 endoscope, illuminated at its distal end Another important milestone occurred
by a light bulb.120 A few years later, in in the 1990s, when the frameless stereo-
The 20th and 21st Centuries: Maturation of 1965, the German Karl Storz (1911e1996) tactic system was developed126,144 allowing
Pituitary Surgery revolutionized endoscopy, introducing an the arrangement of preoperative images in
A key moment in the development of pi- external source of cold light, coupled several planes during the operation.
tuitary surgery was the introduction of with a rod lens optical system.130 In Subsequently, intraoperative CT and MRI

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Table 1. Historical Synopsis of the Pituitary Gland

Date Person Life Dates Place Contribution

1500e500 BC Tantric Yoga and Vedic medicine Locate an energy center at the level of the thalamic-pituitary area147
c200 Galen 130ec200 Pergamon Pituitary gland a draining receptacle for brain fluid1
1316 Mondino de’Liuzzi da Bologna 1275e1326 Bologna Infundibular-pituitary-thyroid circuitry7,148
1555 Andreas Vesalius 1517e1564 Basel Drew the pituitary distillation process and illustrated the pituitary stalk16
1664 Thomas Willis 1621e1675 Oxford Proposed an hypothesis in which substances from the brain passed through the
Richard Lower 1631e1691 Oxford infundibulum to the pituitary gland, and from there they were distilled into the
blood; they anticipated the theory of neurosecretory substances19,147
1638e1663 Franciscus Sylvius 1614e1672 Leyden Hypothesised that the pituitary gland would play a role in the formation and
secretion of cerebrospinal fluid, especially due to its position at the base of the
third ventricle4
1681 Johann Jakob Wepfer 1620e1695 Montpellier Reported a case of enlargement of the pituitary where it was twice the normal
size36
1705 Raymond Vieussens 1635e1715 Amsterdam Described a case of a patient with a pituitary tumor the size of a hen’s egg,
associated with atrophy of the optic and olfactory nerves23,149
1718 Jen Louis Petit 1674e1750 Paris He noticed that in most cases of hydrocephalus the pituitary gland was
squirrheuse (scirrhous)34
1724 Giovanni Domenico Santorini 1681e1737 Venice Recognised that the anterior pituitary as a different entity, not a continuation of
the infundibulum25
1742 Joseph Lieutaud 1703e1780 Paris Discovers vessels in the pituitary stalk connected to those of the pituitary
gland31
1766 Albrecht von Haller 1708e1777 Lausanne Differentiated the pars anterior and the pars posterior4,23
1778 Samuel Thomas von Soemmering 1755e1830 Goettingen Introduced the term hypophysis cerebri23
1804 Philipp Bozzini 1773e1809 Mainz The earlist description of an endoscope101
1832 Pierre-Francois-Olive Rayer 1793e1867 Paris Distinguishing between pituitary gland hypertrophies and scirrhous tumors29
1864 Andrea Verga 1811e1895 Milano Reported one of the earliest clinical descriptions of acromegaly (prosopectasy)45
1872e1877 Theodor Hermann Meynert 1833e1892 Vienna Define the anatomical borders of the “neural portion extending forward from
August Forel 1848e1931 Munich the region of the subthalamus” (the hypothalamus)7
1886 Pierre Marie 1853e1940 Paris Introduced the term acromegaly after reported two cases23
1887 Oskar Minkowski 1858e1931 Breslau Suggested that acromegaly occurred secondary to the increase in pituitary
volume23
1889 Victor Horsley 1857e1916 London Attempted the first surgical approach to the pituitary gland77
1892 Gheorghe Marinescu 1863e1938 Paris Reported the survival of the experimental animal after ablation of the pituitary,
but only for a limited period65
1892 Giulio Vassale 1862e1913 Modena Reported that gland produced an essential substance for life; they also showed
Ercole Sacchi 1896e? that hypophysectomy affected water and mineral metabolism23
1892 Roberto Massalongo 1856e1919 Padova Attributed acromegaly to the hyperfunction of the pituitary23
1893 Frank Thomas Paul 1851e1941 Liverpool Tried to resect a pituitary tumor in a young women with acromegaly23
1893 Fedor Victor Krause 1857e1937 Berlin Performed an extradural right frontal approach to remove a bullet from the optic
foramen region85
1893 Wilhelm His 1831e1904 Leipzig Introduced the term “hypothalamus”
provides the first anatomical subdivision7
1894 Santiago Ramón y Cajal 1852e1934 Madrid Describes the supraoptico-hypophysial tract in rats (through Golgi’s silver
impregnation method)7
1900 Joseph Babinski 1857e1932 Paris Reported a young obese women with genital hypoplasia and pituitary tumor23
1901 W. Alfred Hirschmann ? Berlin Performed the first paranasal operation100

Continues

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 HISTORICAL VIGNETTE
ANDREI IONUT CUCU ET AL. THE EVOLUTION OF PITUITARY GLAND SURGERY

Table 1. Continued
Date Person Life Dates Place Contribution

1906e1907 Hermann Schloffer 1868e1937 Innsbruck Approached for the first time a pituitary tumor through an extensive approach
involving the resection of the sphenoid and ethmoid sinuses through a lateral
rhinotomy107
1908 Nicolae C. Paulescu 1869e1931 Paris, Bucharest Removed experimentally the anterior lobe of the pituitary, but with fatal
results23
1909 Davide Giordano 1864e1854 Venice Propose the transglabellar-nasal approach98
1910e1912 Harvey Cushing 1869e1939 Baltimore Postulate the existence of a hormone of growth in the pituitary
Introduced the term hyper- and hypopituitarism
Proved through hypophysectomies in dogs that pituitary gland is essential for
life112,113
1910 M Silbermark ? Vienna Approached in experimental operations on dogs the pituitary gland through the
Sylvian fissure92
1910 Oskar Hirsch 1877e1965 Vienna Developed the endonasal surgical approach for the pituitary23
1910 Albert Edward Halstead 1868e1926 Chicago Opened the oronasal rhinoseptal approach through a sublabial gingival
incision111
1912 Louis Linn McArthur 1858e1934 Chicago Resected the supraorbital rim to acces extradurally the pituitary gland89
1913 Charles Harrison Frazier 1870e1936 Pennsylvania Intradural frontobasal approach90
1913 Leon Konrad Glinski 1870e1918 Cracow Described the post-partum necrosis of the anterior pituitary23
1914 Morris Simmonds 1855e1925 Hamburg Described pituitary cachexia (Simmond’s disease)150
1928 Ernst Scharrer 1905e1965 Frankfurt Describes glandular cells in the fish hypothalamus (concept of neurosecretion)7
1930 Grigore Tudor Popa 1892e1948 London Discover the pituitary portal system59,60
Una Lucy Fielding 1888e1969
1938 Friedrich Feyrter 1895e1973 Danzig Identified clear cells in the anterior pituitary using the tartaric acid-thionin
staining4
1940e1955 Geoffrey Harris 1913e1971 Cambridge Establish the basis for the neural control of the pituitary gland secretion
John Green Demonstrated the neurovascular link with hypothalamus7
1949 Wolfgang Bargmann 1906e1978 Kiel Describes the posterior pituitary using Gomori’s chrome alum hematoxylin-
phloxine stain7
1957 Gerard Guiot 1912e1996 Paris The first to use the endoscope in sphenoidal surgery120
1969 Jules Hardy Montreal Introduced the operating microscope and developed the use of fluoroscopy131
1969 Gazi Yasargil Zurich Pterional approach96
1977 Michael L J Apuzzo Los Angeles Improved the technique of endoscopy in pituitary surgery was in conjunction
with trans-sphenoidal microsurgery121,122
1978 Karl August Bushe 1921e1999 Würzburg
1978 E Halves Würzburg
1985 David W Kennedy Philadelphia Popularised paranasal endoscopic procedures for pituitary surgery103-105,132
1985 Heinz Stammberger 1946e2018 Graz
1987 Huw B Griffith 1931e1993 Bristol
1992 Roger Jankowski Nancy The first to report the use of trans-sphenoidal endoscopy for pituitary
adenomas133
1995 Dharmbir Singh Sethi Singapore Described the use of a pure endoscopic endonasal transsphenoidal approach for
Premkumar Pillay the treatment of sellar lessions134
1997 Eitan Yaniv Tel Aviv Described a combined approach in which endoscope was used for the initial
Harry Z Rappaport approach to the sphenoid sinus151

Continues

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 HISTORICAL VIGNETTE
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Table 1. Continued
Date Person Life Dates Place Contribution

1977 Hae-Dong Jho Pittsburgh Reported the largest series of patients50 who have undergone endoscopic
Ricardo L Carrau endonasal transphenoidal surgery152
1999 e present Paolo Cappabianca Naples Naples had become the centre of the development of endonasal endoscopy in
Enrico De Devitiis Europe153; they had developed a monostril endoscopic transphenoidal approach
without a speculum and designed specific instrumentation for this approach154
and proposed tehnical improvements155,156
2000 e present Amin Kassam Pittsburgh Made the greatest contribution to the development of the technique in the
2000s, with expanded approaches, specific anatomical studies and techniques
for skull base reconstructions156,157

Adapted from Toni,7 Medvei,23 and Tritos and Klibanski.147

appeared and became popular, thus it critically for important intellectual con- 3. Maartens NF. The history of the treatment of
pituitary adenomas. Endocrine. 2005;28:9-26.
improving the visualisation of tumor tent; 3) approved the version to be pub-
remnants and the subsequent degree of lished; and 4) agree to be accountable for 4. Medvei VC. The History of Clinical Endocrinology.
surgical resection.145,146 At the beginning all aspects of the work in ensuring that Lancaster: The Parthenon Publishing Company
of the 21st century, pituitary surgery questions related to the accuracy or Group, Lancs; 1993.
became an independent subspecialty of integrity of any part of the work are 5. Costea C, Turliuc S, Cucu A, et al. The “poly-
neurosurgery (Table 1).10 appropriately investigated and resolved. morphous” history of a polymorphous skull
Conceptualization: Andrei Ionut Cucu, bone: the sphenoid. Anat Sci Int. 2018;93:14-22.
Claudia Florida Costea, Antonio Perciac-
CONCLUSIONS 6. Galenus C. De Ossibus ad Tyrones Liber. Ferdinando
cante, Simon T. Donell and Raffaella Balamio interprete. Cum notis perpetuis Casp. Hof-
The pituitary gland was originally seen in Bianucci. Methodology: Andrei Ionut manni, Medicinae Doctoris et Professoris in Academia
antiquity as an evacuator of the brain’s Cucu, Claudia Florida Costea, Antonio Norica. Typis Wecheliqanis, Francoforti ad Moenum.
1630.
waste products (nasal mucus). It took Perciaccante, Simon T. Donell and Raf-
hundreds of years to understand that it is a faella Bianucci. Formal analysis and 7. Toni R. Ancient views on the hypothalamic-pi-
functional organ. Starting in the 19th cen- investigation: Andrei Ionut Cucu, Claudia tuitary-thyroid axis: an historical and epistemo-
logical perspective. Pituitary. 2000;3:83-95.
tury, the correlation of the pathology of Florida Costea, Antonio Perciaccante,
the pituitary gland with clinical syn- Simon T. Donell and Raffaella Bianucci. 8. Turliuc D, Turliuc Ş, Cucu A, et al. A review of
dromes, especially the endocrinological Writing e original draft preparation: analogies between some neuroanatomical terms
ones, began to be understood. Later, Andrei Ionut Cucu, Claudia Florida and roman household objects. Ann Anat. 2016;
204:127-133.
experimental surgery on animals opened Costea, Antonio Perciaccante, Simon T.
the horizon for transcranial and endo- Donell and Raffaella Bianucci. Writing e 9. Goodrich JT. A millennium review of skull base
scopic pituitary surgery. In this review, an review and editing: Andrei Ionut Cucu, surgery. Child’s Nerv Syst. 2000;16:669-685.
attempt has been made to record the Claudia Florida Costea, Antonio Perciac- 10. Dubourg J, Jouanneau E, Messerer M. Pituitary
entire history of the pituitary gland and cante, Simon T. Donell and Raffaella surgery: legacies from the past. Acta Neurochir.
pituitary surgery, from antiquity to the Bianucci. Funding acquisition: Not appli- 2011;153:2397-2402.
current day’s surgical techniques. Howev- cable. Resources: Andrei Ionut Cucu,
11. Cushing H. The hypophysis cerebri: clinical as-
er, the evolution of new ideas and tech- Claudia Florida Costea, Antonio Perciac- pects of hyperpituitarism and of hypopituitarism.
niques continues with an expected cante, Simon T. Donell and Raffaella JAMA. 1909;53:249-255.
paradigm shift from using genome Bianucci. Supervision: Andrei Ionut Cucu,
12. Pait GT, Arnautovic KI. The pituitary: historical
sequencing and personalized medicine. Claudia Florida Costea, Antonio Perciac- notes. In: Tindall GT, Krisht AF, eds. Pituitary
cante, Simon T. Donell and Raffaella disorders: comprehensive management. Baltimore:
Bianucci. Lippincott, Williams & Wilkins; 1997.
CRediT AUTHORSHIP CONTRIBUTION
STATEMENT 13. Abderhalden R. Internal Secretion. Bombay: CIBA
REFERENCES Monographs; 1951.
All authors Andrei Ionut Cucu, Claudia 1. May M. Galen on the usefulness of the parts of
Florida Costea, Antonio Perciaccante, 14. Saunders JB. The Illustrations From the Works of
the body (de usu partium). In: Vol. The Ninth Book
Andreas Versalius of Brussels. Cleveland: World
Simon T. Donell and Raffaella Bianucci: 1) (the Encephalon, Cranial Nerves, and Cranium). Ithica:
Publishing; 1950.
made substantial contributions to the Cornell University Press; 1968.
conception or design of the work; or the 15. McHenry L. Garrison’s History of Neurology.
Springfield: Charles C. Thomas; 1969.
acquisition, analysis, or interpretation of
2. Galenus C. Galen on the usefulness of the parts
data; or the creation of new software used of the body. In: Peri Chreias Morion. Ithaca: De Usu 16. Vesalius A. De Humani Corporis Fabrica Libri Septem.
in the work; 2) drafted the work or revised Partium Cornell University Press; 1968. Basel: per Ioannem Oporinum; 1555.

62 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2023.09.004

 HISTORICAL VIGNETTE
ANDREI IONUT CUCU ET AL. THE EVOLUTION OF PITUITARY GLAND SURGERY

17. Schneider C. Dissertatio de osse cribriforme, et sensu ac 36. Wepfer JJ. Observations anatomicae, ex cadaveribus 55. Landolt AM, Zachmann M. The Irish giant: new
organo odoratus. Wittenbergae: Mevii; 1655. eorum, quos sustulit apoplexia. Amsterdam: Cum observations concerning the nature of his
exercitatione de ejus loco affecto. apud Henri- ailment. Lancet. 1980;1:1311-1312.
18. Schneider C. Liber primus de catarrhis. Wittenber- cum Wetstenium; 1681.
gae: T Mevii and E Schumacheri; 1660. 56. Babinski J. Tumeur du corps pituitaire sans
37. Randall RV, Scheithauer BW, Kovacs K. Pituitary acromégalie et avec arrêt de développement des
19. Lower R. De Catarrhis. London: Dawsons of Pall adenomas: historic considerations. In: Thapar K, organes génitaux. Rev Neurol. 1900;8:531-533.
Mall; 1963. Kovacs K, Scheithauer BW, Lloyd RV, eds.
Diagnosis and Management of Pituitary Tumors. New 57. Froelich A. Ein Fall von Tumor der Hypophysis
20. Marshall LH, Magoun HW. Discoveries in the Hu- Jersey: Humana Press; 2000. cerebri ohne Akromegalie. Wien Klin. Woche.
man Brain: Neuroscience Prehistory, Brain Structure, 1901;15:883-906.
and Function. Totowa, NJ: Humana Press; 1998. 38. de Haen A. Pars quinta rationis medendi. Wien:
Sumptibus Hermanni Josephi Krüchten; 1760. 58. Hökfelt T. The new neuroendocrinology-a
21. Tubbs RS, Loukas M, Hill M, Shoja MM, Cohen- perspective. J Intern Med. 2018;284:563-567.
Gadol AA. Richard Lower (1631-1691): acknowl-
39. Dostoiewsky A. Uerer den bau der vorderlappen
edging his notable contributions to the explora- 59. Popa G, Fielding U. A portal circulation from the
des hirnanhanges. Arch Mikrosk Anat Bonn. 1885/6;
tion of the nervous system: historical vignette. pituitary to the hypothalamic region. J Anat. 1930;
26:592-598.
J Neurosurg. 2009;111:1096-1101. 65:88-91.
40. Lothringer S. Untersuchungen ander Hypo-
22. Green JD, Harris GW. The neurovascular link 60. Popa GT, Fielding U. Hypophysio-portal vessels
physee Einiger Saugethiere Und des Menschen.
between the neurohypophysis and adenohy- and their colloid accompaniment. J Anat. 1933;
Arch Mikrosk Anat Bonn. 1886;28:257.
pophysis. J Endocrinol. 1947;5:136-144. 67:227-232.
23. Medvei V. A History of Endocrinology. Lancaster: 41. Schoenemann A. Virchows Arch. 1892;129:310.
61. Harris GW. Humors and hormones. J Endocrinol.
MTP Press; 1982. 1972;53:2-23.
42. Jane JA, Thapar K, Laws ER. A history of pitui-
24. Gibson T. The Anatomy of Humane Bodies Epitomized tary surgery. Operat Tech Neurosurg. 2002;5:
200-209. 62. Harris GW. The hypothalamus and endocrine
Wherein all the Parts of Man’s Body, with Their Actions
glands. Br Med Bull. 1950;6:345-350.
and Uses, are Succinctly Described According to the Most
Accurate and Learned Modern Anatomists. London: M. 43. Schaefer EA, Hering PT. The action of pituitary
extracts upon the kidney. Philos Trans R Soc Lon- 63. Turliuc MD, Cucu AI, Costea CF, Mohan A,
Fleisher; 1682. Ciurea AV. Gheorghe Marinescu (1863-1938) and
don, Series B. 1908;199:1-29.
La Cellule Nerveuse. 110 years since writting of
25. Santorini GD. Observationes Anatomicae. Venetis:
44. Engel J. Über den Hirnanhang und den Trichter. the major chapter of the old testament of
apud J. B. Recurti; 1724.
Inauguraldissertation. Gedruckt bei A. Pichler’s sel. neuropathology. Rev Med Chir Soc Med Nat Iasi.
26. Medvei V. The history of Cushing’s disease: a Wien: Witwe; 1839. 2019;123:676-681.
controversial tale. J R Soc Med. 1991;84:363-366.
64. Crowe SJ, Cushing H, Homans J. Experimental
45. Verga A. Caso singolare di prosopectasia. Rend R
27. Wenzel J. Observations sur le Cervelet, et sur les Di- hypophysectomy. Bull Johns Hopkins Hosp. 1910;21:
1st Lombardo Classe SC Mat Nat. 1864;1:111-117.
verses Parties du Cerveau dans les Épileptiques. Publiées, 127-169.
après sa mort, par son frère et son Collaborateur, C. 46. de Herder WW. The history of acromegaly.
Wenzel. Ouvrage Traduit de Làllemand, par M. Breton. 65. Marienesco M. C R Hebd Seances Mem Sc Biol. 1892;
Neuroendocrinology. 2016;103:7-17.
Paris: J.E.G. Dufour; 1811. 9:509-510.
47. Jane JA Jr, Laws ER. In: Wass J, ed. Handbook of
28. Romberg MH. A Manual of the Nervous Diseases of 66. Vassale G, Sacchi E. Sulla distruzione della
acromegaly. Bristol, United Kingdom: Bio-
Man. London: Sydenham Society; 1853. Ghiandola pituitaria. Riv Sper Freniat. 1892;18:
scientifica; 2001.
525-561.
29. Rayer P. Observations sur les maladies de l’ap- 48. Brigidi V. Archivo di Scuola Anatomie e Patologia di
pendice sussphénoidal (glande pituitaire) du 67. Vassale G. L’ipofisi nel mixedema e nell’acro-
Universita di Firenze. Firenze: Istituto di Studi megalia. Riv Sper di Freniat. 1902;28:25-39.
cerveau. Arch Gen Med. 1823;2:350-367. Superiori pratici e di perfezionamento in Firenze
- Sezione di Medicina e Chirurgia e Scuola di 68. Aschner B. Wein klin wochenschr demonstra-
30. Pascual JM, Prieto R, Rosdolsky M, et al. Joseph
Farmacia; 1811:65-92. tion von hunden nach ex- stirpation der hy-
Engel (1816e1899), author of a meaningful
dissertation on tumors of the pituitary infun- pophyse. Wein Klin Wochenschr. 1909;22:1730-1732.
49. Marie P. Sur deux cas d’acromégalie: hyper-
dibulum: his report on the oldest preserved
trophie singulière, non congénitale, des 69. Lindholm J. Cushing’s syndrome: historical as-
whole craniopharyngioma specimen. Virchows
extrémités supérieures, inférieures et cépha- pects. Pituitary. 2000;3:97-104.
Arch. 2000;476:773-782.
lique. Rev Med Liege. 1886;6:297-333.
31. Lietaud J. Essais Anatomiques, Contenant L’histoire 70. Paulesco N. L’hypophyse du cerveau. J Physiol
50. Grosvenor AE, Laws ER. The evolution of Pathol Genet. 1907;9:441-456.
Exact de Toutes les Parties qui Composent le Corps de
extracranial approaches to the pituitary and
L’homme, Avec la Maniere de Dissequer. Paris: Huart;
anterior skull base. Pituitary. 2008;11:337-345. 71. Cushing H. Papers relating to the pituitary body,
1742.
hypothalamus and parasympathetic nervous system.
32. Zuckerman S. The secretions of the brain; rela- 51. Pearce JM. Pituitary tumors and acromegaly Springfield: Charles C. Thomas; 1932.
tion of hypothalamus to pituitary gland. Lancet. (Pierre Marie’s disease). J Neurol Neurosurg Psy-
1954;266:789-795. chiatry. 2002;73:394. 72. Redford LL, Cushing H. Bull Johns Hopkins Hosp.
1909;20:105-107.
33. Baillie M, Johnson J, Nicol G. The Morbid Anatomy 52. Marie P, Marinesco G. Sur l’anatomie patholo-
of Some of the Most Important Parts of the Human gique de l’acromegalie. Arch Med Exp Anat Pathol. 73. Cushing H. Medical classic. The functions of the
Body. 2nd ed. London: J. Johnson & G. Nicol; 1891;3:539-565. pituitary body: Harvey cushing. Am J Med Sci.
1797:451. 1981;281:70-78.
53. Fritsche CF, Klebs E. Ein Beitrag zur Pathologie des
34. Petit JL. Mémoires de l’Académie royale des sciences. Riesenwuchses. Leipzig: Vogel; 1884. 74. Cushing H. The Pituitary Body and its Disorders.
Paris: Firmin Didot; 1718:99. Birmingham: Classics of Medicine; 1979.
54. Cunningham ED. A large sub-arachnoid cyst
35. Karenberg A. Historic review: select chapters of a involving the greater part of the parietal lobe of 75. Bell W. Experimental operations on the pituitary.
history of stroke. Neurol Res Pract. 2020;2:34. the brain. J Anat Physiol. 1879;13:508-517. Q J Exp Physiol. 1917;11:77-126.

WORLD NEUROSURGERY 180: 52-65, DECEMBER 2023 www.journals.elsevier.com/world-neurosurgery 63

 HISTORICAL VIGNETTE
ANDREI IONUT CUCU ET AL. THE EVOLUTION OF PITUITARY GLAND SURGERY

76. Horsely V. Functional nervous disorders due to 95. Fahlbusch R, Honegger J, Paulus W, Huk W, 115. Joshi SM, Cudlip S. Transsphenoidal surgery.
the loss of thyroid gland and pituitary body (The Buchfelder M. Surgical treatment of craniophar- Pituitary. 2008;11:353-360.
Brown Lectures, Lecture III). Lancet. 1886;2. yngiomas: experience with 168 patients.
J Neurosurg. 1999;90:237-250. 116. Hirsch O. Demonstration eines nach einer neuen
77. Horsley V. On the technique of operations on the methode operiten hypophysentumors. Verch Dtsch
central nervous system. BMJ. 1906;2:411-423. 96. Guidetti B, Fraioli B, Cantore GP. Results of Ges Chir. 1910;39:51-56.
surgical management of 319 pituitary adenomas.
78. Landolt AM. History of pituitary surgery. In: Acta Neurochir. 1987;85:117-124. 117. Liu JK, Cohen-Gadol AA, Laws ER Jr, Cole CD,
Greenblatt SH, Dagi TF, Epstein MH, eds. Kan P, Couldwell WT. Harvey Cushing and Oskar
A history of neurosurgery. Park Ridge: Thieme; 97. Bailey P. L’acromegalie et son histoire. Rev Neurol Hirsch: early forefathers of modern trans-
1997. (Paris). 1952;86:741-745. sphenoidal surgery. J Neurosurg. 2005;103:
1096-1104.
79. Thanabalasingham G, Karavitaki N, Cudlip S, 98. Artico M, Fraioli B. The Contribution of Davide
Wass JAH. Treatment of pituitary tumors: his- Giordano (1864-1954) to pituitary surgery: the
118. Hirsch O. Über Methoden der operativen
tory. Endocrine. 2005;28:3-8. transglabellar-nasal approach. Neurosurgery. 1998;
Behandung von Hypophysistumoren auf endo-
42:909-1011.
nasalem Weg. Arch Laryngol Rhinol. 1911;24:
80. Pollock JR, Akinwunmi J, Scaravilli F, Powell MP. 129-177.
Transcranial surgery for pituitary tumors per- 99. Cushing H. The Weir Mitchell lecture: surgical
formed by Sir Victor Horsley. Neurosurgery. 2003; experiences with pituitary disorders. JAMA. 1914;
63:1516-1525. 119. Hardy J. History of pituitary surgery. Neuro-
52:914-926.
chirurgie. 2010;56:358-362.
81. Caton R, Paul F. Notes of a case of acromegaly 100. Hirschmann A. Uber Endoskopie der Nase und
deren Nebenhohlen. Arch Laryngol Rhinol (Berl). 120. Guiot J, Rougerie J, Fourestier M, et al. Intra-
treated by operation. BMJ. 1893;2:1421-1423.
1903;14:194-202. cranial endoscopic explorations. Presse Med. 1963;
82. Cohen-Gadol AA, Laws ER, Spencer DD, De 71:1225-1228.
Salles AAF. The evolution of Harvey Cushing’s 101. Reuter M. The historical development of endo-
surgical approach to pituitary tumors from photography. World J Urol. 2000;18:299-302. 121. Apuzzo ML, Heifetz MD, Weiss MH, Kurze T.
transsphenoidal to transfrontal. J Neurosurg. 2005; Neurosurgical endoscopy using the side-viewing
103:372-377. 102. Cockett WS, Cockett AT. The Hopkins rod-lens telescope. J Neurosurg. 1977;46:398-400.
system and the Storz cold light illumination
83. Cucu AI, Turliuc S, Costea CF, et al. The brain- system. Urology. 1998;51:1-2. 122. Bushe KA, Halves E. Modified technique in
stem and its neurosurgical history. Neurosurg Rev. transsphenoidal operations of pituitary ade-
103. Kennedy DW. Functional endoscopic sinus sur- nomas. Technical note (author’s transl). Acta
2021;44:3001-3022.
gery. Technique. Arch Otolaryngol. 1985;111: Neurochir. 1978;41:163-175.
84. Costea CF, Turliuc DM, Sava A, et al. Fedor 643-649.
Krause (1857-1937): the father of German 123. Guiot G. In: Fahlbusch WK, ed. European workshop
104. Stammberger H. Personal endoscopic operative
neurosurgery. Romanian Neurosurgery. 2016;30: on the treatment of pituitary adenomas. Stuttgart:
technic for the lateral nasal wallean endoscopic
241-247. Thieme; 1978:202-218.
surgery concept in the treatment of inflammatory
diseases of the paranasal sinuses. Laryngol Rhinol
85. Krause F. Hirnchirurgie. Dtsch Klin. 1905;8: 124. Hardy J. Transphenoidal microsurgery of the
Otol. 1985;64:559-566.
953-1024. normal and pathological pituitary. Clin Neurosurg.
105. Stammberger H. Nasal and paranasal sinus 1969;16:185-217.
86. Krause F. Bemerkungen zur Operation der
endoscopy. A diagnostic and surgical approach
Hypophysengeschwülste. Dtsch Med Wochenschr. 125. Jane JA Jr, Thapar K, Alden TD, Laws ER Jr.
to recurrent sinusitis. Endoscopy. 1986;18:213-218.
1927;53:691-694. Fluoroscopic frameless stereotaxy for trans-
106. Draf W. Therapeutic endoscopy of the paranasal sphenoidal surgery. Neurosurgery. 2001;48:
87. Liu JK, Das K, Weiss MH, Laws ER, 1302-1307 [discussion: 1307-1308].
sinuses. Endoscopy. 1978;10:247-254.
Couldwell WT. The history and evolution of
transsphenoidal surgery. J Neurosurg. 2001;95: 107. Schloffer H. Zur frage der operationen an der 126. Elias WJ, Chadduck JB, Alden TD, Laws ER Jr.
1083-1096. hypophyse. Beitr Klin Chir. 1906;50:767-817. Frameless stereotaxy for transsphenoidal surgery.
Neurosurgery. 1999;45:271-275 [discussion: 275-
88. McArthur LL. Tumor of the pituitary gland; 108. Gandhi CD. Historical movements in trans- 277].
technic of operative approach. Surg Clin Chicago. sphenoidal surgery. Neurosurg Focus. 2001;11:E7.
1918;2:691-699. 127. Guiot G, Rougerie J, Brion S. L’uitilisation des
109. Kocher T. Ein fall von hypophysis tumor mit amplificateurs de brillance en neuro-radiologie et
89. McArthur LL. An aseptic surgical access to the operativer heilung. Dtsch Z Chirurgie. 1909;100: dans la chirurgie stéréotaxique. Ann Chir. 1958;23:
pituitary body and its neighborhood. JAMA. 1912; 13-37. 689.
58:2009-2011.
110. Hirsch O. Endonasal method of removal of hy- 128. Walker DG, Kaye AH. Image guidance and trans-
90. Frazier C. Lesions of the hypophysis from the pophyseal tumors. With report of two successful
viewpoint of the surgeon. Surg Gynecol Obstet. sphenoidal surgery: past, present and future.
cases. JAMA. 1910;55:772-774. J Clin Neurosci. 2003;10:289-292.
1913;17:724-736.
111. Halstead AE. Remarks on the operative treatment
91. Frazier C. Surgery of the pituitary lesion. Ann 129. Cappabianca P, de Divitiis E. Back to the Egyp-
of tumors of the hypophysis. Surg Gynecol Obstet.
Surg. 1928;88:1-5. tians: neurosurgery via the nose. A five-thou-
1910;10:494-502.
sand-year history and the recent contribution of
92. Silbermark M. Die intrakranielle extirpation der 112. Cushing H. The pituitary body and its disorders. the endoscope. Neurosurg Rev. 2007;30:1-7.
Hypophyse. Wien Klin Wochnschr. 1910;23:467-468. In: Clinical States Produced by Disorders of the Hy-
pophysis Cerebri. Philadelphia: JB Lippincott; 1912. 130. Linder TE, Simmen D, Stool SE. Revolutionary
93. Heuer G. Surgical experiences with an intracra- inventions in the 20th century. The history of
nial approach to chiasmal lesions. Arch Surg. 113. Cushing H. Les syndromes hypophysaires au endoscopy. Arch Otolaryngol Head Neck Surg. 1997;
1920;1:368-381. point de vue chirurgical. Rev Neurol. 1922;38: 123:1161-1163.
779-808.
94. Heuer G. The surgical approach and the treat- 131. Hardy J, Wigser SM. Transsphenoidal surgery of
ment of tumors and other lesions about the optic 114. Rosegay H. Cushing’s legacy to transsphenoidal pituitary fossa tumors with televised radio-
chiasm. Surg Gynecol Obstet. 1931;53:489-518. surgery. J Neurosurg. 1981;54:448-454. fluoroscopic control. J Neurosurg. 1965;23:612-619.

64 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2023.09.004

 HISTORICAL VIGNETTE
ANDREI IONUT CUCU ET AL. THE EVOLUTION OF PITUITARY GLAND SURGERY

132. Griffith HB, Veerapen R. A direct transnasal bwhclinicalandresearchnews.org/2018/07/12/ 153. Cappabianca P, Alfieri A, de Divitiis E. Endo-
approach to the sphenoid sinus. Technical note. edward-laws-the-prolific-pituitary-tumor- scopic endonasal transsphenoidal approach to
J Neurosurg. 1987;66:140-142. surgeon/. Accessed August 31, 2023. the sella: towards functional endoscopic pituitary
surgery (FEPS). Minim Invasive Neurosurg. 1998;41:
133. Jankowski R, Auque J, Simon C, Marchal JC, 143. Hardy J. Transsphenoidal hypophysectomy. 66-73.
Hepner H, Wayoff M. Endoscopic pituitary tumor J Neurosurg. 1971;34:582-594.
surgery. Laryngoscope. 1992;102:198-202.
154. Cappabianca P, Alfieri A, Thermes S,
144. Walker DG, Ohaegbulam C, Black PM. Frameless Buonamassa S, de Divitiis E. Instruments for
134. Sethi DS, Pillay PK. Endoscopic management of stereotaxy as an alternative to fluoroscopy for endoscopic endonasal transsphenoidal surgery.
lesions of the sella turcica. J Laryngol Otol. 1995; transsphenoidal surgery: use of the InstaTrak- Neurosurgery. 1999;45:392-395 [discussion: 395-
109:956-962. 3000 and a novel headset. J Clin Neurosci. 2002;9: 396].
294-297.
135. Rodziewicz GS, Chuang WC. Endoscopic
removal of organized chronic subdural hema- 145. Jane JA Jr, Han J, Prevedello DM, Jagannathan J, 155. Cappabianca P, Alfieri A, Colao A, et al. Endo-
toma. Surg Neurol. 1995;43:569-572 [discussion: Dumont AS, Laws ER Jr. Perspectives on endo- scopic endonasal transsphenoidal surgery in
572-563]. scopic transsphenoidal surgery. Neurosurg Focus. recurrent and residual pituitary adenomas: tech-
2005;19:E2. nical note. Minim Invasive Neurosurg. 2000;43:
136. Jho HD. Endoscopic pituitary surgery. Pituitary. 38-43.
1999;2:139-154. 146. Fahlbusch R, Ganslandt O, Buchfelder M,
SchottW, Nimsky C. Intraoperative magnetic 156. Cavallo LM, Somma T, Solari D, et al. Endo-
137. Jho HD. Endoscopic transsphenoidal surgery.
resonance imaging during transsphenoidal sur- scopic endonasal transsphenoidal surgery: his-
J Neuro Oncol. 2001;54:187-195.
gery. J Neurosurg. 2001;95:381-390. tory and evolution. World Neurosurg. 2019;127:
138. Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic 686-694.
pituitary surgery: an early experience. Surg Neurol. 147. Tritos NA, Klibanski A. Prolactin Disorders: From
1997;47:213-222 [discussion: 222-213]. Basic Science to Clinical Management. Boston: 157. Pérez-López C, Abenza-Abildúa MJ. History of
Springer; 2019. pituitary surgery. Neurosciences and History. 2020;8:
139. Cappabianca P, de Divitiis E. Endoscopy and 29-38.
transsphenoidal surgery. Neurosurgery. 2004;54: 148. Giorgi PP, Pasini GF. Anothomia di Mondino de’
1043-1050. Liuzzi da Bologna, XIV Secolo. Bologna: Istituto per
la Storia dell’Università di Bologna; 1992.
Conflict of interest statement: The authors declare that the
140. Cappabianca P, Cavallo LM, Esposito F, de article content was composed in the absence of any
Divitiis E. Endoscopic endonasal trans- 149. Vieussens R. Novum Vasorum Corporis Humani Sys-
tema. Amsterdam: Apud Paulum Marret; 1705. commercial or financial relationships that could be construed
sphenoidal surgery: procedure, endoscopic
as a potential conflict of interest.
equipment and instrumentation. Childs Nerv Syst.
2004;20:796-801. 150. Saeger W. Morris Simmonds and his importance Received 12 April 2023; accepted 1 September 2023
in hypophysis research from the current view-
Citation: World Neurosurg. (2023) 180:52-65.
141. Cappabianca P, Alfieri A, Colao A, Ferone D, point. Pathologe. 1993;14:117-119.
https://doi.org/10.1016/j.wneu.2023.09.004
Lombardi G, de Divitiis E. Endoscopic endonasal
transsphenoidal approach: an additional reason 151. Yaniv E, Rappaport ZH. Endoscopic transseptal Journal homepage: www.journals.elsevier.com/world-
in support of surgery in the management of pi- transsphenoidal surgery for pituitary tumors. neurosurgery
tuitary lesions. Skull Base Surg. 1999;9:109-117. Neurosurgery. 1997;40:944-946.
Available online: www.sciencedirect.com
142. Communication BO of S. Brigham clinical & 152. Jho HD, Carrau RL. Endoscopic endonasal 1878-8750/ª 2023 The Author(s). Published by Elsevier Inc.
research news. 2018. Edward Laws: The prolific transsphenoidal surgery: experience with 50 pa- This is an open access article under the CC BY-NC-ND
pituitary tumor surgeon. Available at: https:// tients. J Neurosurg. 1997;87:44-51. license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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