June 4: International Skull Base Surgery Day

On June 4, 1910, Harvey Cushing and Oskar Hirsch, separated by both surgical specialty and the Atlantic, independently performed their groundbreaking transsphenoidal operations that would shape the future of skull base surgery.[1] Together, their innovative approaches to the pituitary gland established the foundation of modern-day endoscopic skull base surgery. To recognize their legacy 115 years later, we propose that June 4 now become the annual International Skull Base Surgery Day.

Surgery of the pituitary gland began in the late 1890s with transcranial approaches by the neurosurgical pioneer Sir Victor Horsley and others. However, with mortality rates as high as 80% and substantial perioperative morbidity, surgeons continued to explore alternative techniques.[2] [3] Herman Schloffer, an Austrian surgeon, had studied the cadaveric dissections of Italian surgeon, Davide Giordano, and in 1907, Schloffer performed the first transsphenoidal pituitary surgery with a disfiguring lateral rhinotomy, total nasal translocation, and open sphenoethmoidectomy. In 1909, Harvey Cushing modified the nasal translocation to remove a pituitary tumor for an acromegalic patient referred to him by Charles Mayo.[1] [4]

Oskar Hirsch, a Czechoslovakian, who immigrated to Austria for medical school, became an otolaryngologist and studied endonasal sinus surgery with Markus Hajek in Vienna.[5] In March 1910, Hirsch successfully performed the first two-stage endonasal transsphenoidal resection of a pituitary tumor, after over a year of presenting and discussing the proposed technique.[6] Concerned that a two-staged procedure could result in an unacceptable delay of urgent optic nerve decompression, he refined his approach, and on June 4, 1910, Hirsch performed his first single-stage endonasal transsphenoidal pituitary tumor resection.[1] Hirsch would subsequently perform nearly 400 similar pituitary operations in Vienna, with significantly improved outcomes. As a Jewish surgeon, Hirsch was then forced to flee Austria by Nazi decree. He ultimately found refuge in Boston, which he chose in part due to earlier correspondence with Harvey Cushing who had once lived there as well.[7] In Boston, Hirsch would continue his innovative technique in collaboration with Massachusetts General Hospital neurosurgeon Hannibal Hamlin, the namesake and great-grandson of Abraham Lincoln's Vice President.[8] [9]

Meanwhile, in Baltimore, Harvey Cushing, a pioneer of immeasurable impact in neurosurgery, was likewise dissatisfied with the morbidity of even his modified nasal translocation approach. By combining the concepts of his influences and collaborators, Cushing incorporated sublabial, inferior nasal, and submucosal septal approaches. On June 4, 1910, Cushing performed his first sublabial submucosal transseptal transsphenoidal pituitary tumor resection.[1] Cushing would further refine this technique, still used by neurosurgeons around the world today, for sublabial pituitary surgery and vastly improve his surgical outcomes. However, with his increasing mastery of cranial surgery and lack of modern visualization tools, he ultimately abandoned the transsphenoidal approach by 1929 and performed transcranial pituitary surgery for the remainder of his career.[10]

Together, Harvey Cushing and Oskar Hirsch's work represented a pivotal departure from the more disfiguring, invasive, and dangerous approaches of the era. For patients with pituitary tumors, the rate of major complications dropped precipitously, and the contemporary understanding of cranial base surgery was born. The serendipitous timing of these operations, performed an ocean apart, underscores not only the convergence of neurosurgical and otolaryngological contributions to advancing skull base surgery since its inception but also the worldwide collaboration integral to the field's global development. Cushing and Hirsch, through their visionary and seminal work, have influenced generations of surgeons and impacted countless patients. Recognizing June 4 as International Skull Base Surgery Day would honor these luminaries and successive advancements, celebrate the multidisciplinary and international nature of our field, and inspire continued collaboration and innovation in skull base surgery.

Publication History

Article published online:
26 March 2025

• References

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