A Decade of Transformation for Neurosurgery That Spawned Its Next Generation of Leaders: The 1930s
After two decades of rapid evolution, the field of neurosurgery entered the 1930s with a critical mass of talent. While heavily influenced by the legacy of Dr. Harvey Cushing and Dr. Walter Dandy, young neurosurgeons entering practice were the first to be trained as members of a distinct scientific and technical discipline. The window had been opened for them to make their marks on the field. Two leaders of our field born during this decade of advancement and evolution, Stewart B. Dunsker, MD, FAANS(L), and David G. Kline, MD, FAANS(L), shared their thoughts on how the developments of the 1930s influenced the time in which they practiced.
A New Generation of Neurosurgeons
Though Dr. Cushing had trained many of this new generation of neurosurgeons, they were excluded from the foundational Society of Neurological Surgeons (SNS) – an elite group that limited its ranks to just 45 members. The need to organize and share individual experiences inspired William P. Van Wagenen, MD, and R. Glenn Spurling, MD, to found the Harvey Cushing Society in 1931 (1). This predecessor of the American Association of Neurological Surgeons (AANS) provided a forum for younger neurosurgeons. Dr. Kline reflected that this drive by young neurosurgeons to have “their own seat at the table and to be heard“ led to the formation of multiple neurosurgical organizations throughout the years.
The first meeting of the Harvey Cushing Society, held in Boston, in May 1932, opened with an operative clinic led by Dr. Cushing. What followed were talks that illustrated the broad field of neurosurgery, from brain tumors to sympathetic nervous system mediated pain (1). As expressed by Wilder Penfield, OM, CC, CMG, FRS, founder of the Montreal Neurological Institute and Hospital at McGill University, “The field of neurosurgery, both now and in the future, should not be confined to tumours of the nervous system… On the contrary, it should include the prevention and the cure of traumatic epilepsy, control of cardiovascular pain and of intractable pain of all types…” (2). Indeed, Dr. Penfield’s ground-breaking work mapping cortical function and surgical resection of scar for the treatment of epilepsy were instrumental in placing epilepsy under the purview of neurosurgeons (3). At that time, the medical treatment of seizures was limited to just one medication: phenobarbital.
The incorporation of spine surgery into neurosurgical practice was not as clear a path. As Dr. Dunsker highlighted, the joint work of William Jason Mixter, MD, a neurosurgeon, and Joseph Seaton Barr Jr., MD, an orthopaedic surgeon, placed spine surgery into both fields. In 1934, their landmark paper characterized herniated intervertebral discs as a cause of pain and weakness, debunking the belief that most such cases were caused by tumors (3). Despite such an early role of neurosurgeons in this work, establishment of the Section on Disorders of the Spine and Peripheral Nerves did not occur until 1978. Debate around neurosurgeons performing spinal instrumentation persisted well into the 1990s. Dr. Dunsker remembered the period when Cotrel, having developed the first “sophisticated instrumentation for the spine,” would not sell to neurosurgeons. The scientific work of Volker K. H. Sonntag, MD, FAANS(L), provided clear support for its use and brought the two disciplines together towards the advancement of spine surgery (4).
The Need for Education
As new departments of neurosurgery were being established across the country, particularly spreading west, a common theme developed through the 1930s. An emphasis was placed on the academic approach to neurosurgery. Exemplified by his 1935 lecture to the Second International Neurological Congress (and subsequent manuscript), Dr. Penfield stressed the importance of developing hypotheses and building upon previous observations (5). Both Drs. Kline and Dunsker noted that love of the field and the desire to continuously learn is fundamental to being a neurosurgeon, despite type and location of practice. In 1931, Cushing Society founding member Temple Fay, MD, wrote a letter to Spurling, discussing the organization of young neurosurgeons across the country, “There would arise from such a program a mutual addition to our knowledge, representing the possibilities of each member to carry on research under his particular opportunities (1).” As Dr. Dunsker stated, “Academics demand clinical work.” Despite the high degree of specialization that academic research can promote, Dr. Kline has eloquently argued for the importance of remaining well-rounded in neurosurgical knowledge and skill. “Do not forget that first and foremost… you are a neurosurgeon (6).”
Special thanks to Drs. Dunsker and Kline for sharing their time and observations.
Dr. Dunsker was born in 1934, earned his undergraduate degree from Harvard University and his medical degree from the University of Cincinnati before neurosurgical training at Washington University in St. Louis. He was a founding member of the AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves, serving as its president in 1987. He also served on the American Board of Neurological Surgery (ABNS) and was president of the American Association of Neurological Surgeons (AANS) in 2001. In 2002, he was recipient of the AANS Cushing Medal. His insight and personal mentorship has been invaluable to the author of this article.
Dr. Kline was born in 1934 and earned both his undergraduate and medical degrees from the University of Pennsylvania before completing neurosurgical training at the University of Michigan. He established the first subspecialty fellowship (peripheral nerve) in neurosurgery at Louisiana State University (LSU). He served as the president of the Society of Neurological Surgeons (SNS), secretary and chair of the ABNS, as well as on the Executive Committees of the AANS and the Congress of Neurological Surgeons (CNS). In 2005, he received the AANS Cushing Medal and, in 2008, the CNS Founder’s Laurel.
4. Masferrer, R., Gomez, C. H., Karahalios, D. G., & Sonntag, V. K. (1998) Efficacy of pedicle screw fixation in the treatment of spinal instability and failed back surgery: a 5-year review. Journal of neurosurgery, 89(3), 371-377.
2017 AANS/CNS Section on Pediatric Neurological Surgery
Nov. 28-Dec. 1, 2017; Houston
2nd Homburg ICP and Hydrocephalus Workshop
Nov. 28-30, 2017; Germany
22nd Instructional Course and 45th Annual Meeting of the Cervical Spine Research Society
Nov. 29, 2017 - Dec. 2, 2017; Hollywood, Fla.
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