Is it only neurosurgeons who can perform neurosurgical procedures? If there are places where patients suffer delayed treatment because of the need to transfer them to a medical facility with neurosurgical coverage, might not the answer be to train a new cadre of “generalist” or “acute care” surgeons?
It may be useful to consider these questions in light of the environment that gave rise to neurosurgery as a specialty. Gilbert Horrax described this period in his book Neurosurgery: An Historical Sketch. In the early years of the 20th century, general surgeons “unfamiliar as yet with any special knowledge of how to handle brain tissue, were attempting at infrequent intervals to do something to which they were entirely unaccustomed.” It became apparent that “to attain the desired end someone would have to devote his entire time to working out a new technic [sic] for operations upon the central nervous system.”
Horrax proceeded to document Harvey Cushing’s thoughts on the subject in 1905:
…many of [his colleagues in surgery] have expressed themselves emphatically against any form of operative specialization…I do not see how such particularization can be avoided if we wish more surely and progressively to advance our manipulative therapy. Are practice of hand and concentration of thought to go for nothing?
Wartime brought a new urgency to the question of who should perform neurological surgery. In his memoir Fifty Years of Neurosurgery, Ernest Sachs Sr. described the situation as the United States entered World War I. Cushing was already in Europe in 1917 when nearly every other American neurosurgeon was summoned to Washington. The U.S. Army planned to create 100 hospitals and wanted a neurosurgeon in each one. When informed that there were not 100 neurosurgeons in the world (remember, this was a specialty that was 12 years old at the time), Surgeon General William Gorgas replied, “That doesn’t interest me! It’s up to you to furnish the men!” In response, three centers were established, in New York, Chicago, and St. Louis, where experienced general surgeons learned the essentials of neurosurgery in six- to 12-week courses. The Army got its “neurosurgeons,” and as far as Sachs knew, “none of them went into neurological surgery as a specialty after the war.”
History more or less repeated itself a generation later. In 1941 the United States entered World War II, shortly after the American Board of Neurological Surgery came into being. There were only 30 or so Americans who were qualified in neurosurgery and ready for active military duty. Again, plans were made to turn “medical officers trained in general surgery” into combat-ready neurosurgeons. The training this time was slightly more elaborate, with a six-week introductory course taught by civilian neurosurgeons followed by two to three months at an Army neurosurgical center, as described by Eben Alexander Jr. in the AANS Journal of Neurosurgery. Some prominent neurosurgical careers arose out of this training, including those of Dr. Alexander himself, Donald Matson, Joseph Ransohoff, and Bertram Selverstone.
We would be foolish to pretend that appropriately intense training cannot teach other surgeons the necessary rudiments of neurosurgery. But we are not at war, at least not the kind mandating complete mobilization and massive deployments as in the world wars. Would we really be satisfied in turning the clock back so far that the rudiments of head trauma management would suffice as appropriate, quality care for our patients today? Shouldn’t we insist that neurosurgeons are those best equipped to manage diseases affecting the nervous system? Indeed, are practice of hand and concentration of thought to go for nothing?
Michael Schulder, MD, is professor and vice-chair in the Department of Neurological Surgery at New Jersey Medical School in Newark.