Ⅰ.

Introduction
2

The Making of a Great Neurosurgeon

MADJID SAMII, MD, PhD
President - International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625
Hannover, Germany

Key words: neurosurgery, training in neurosurgery, surgical skills

The career in neurosurgery is built on several cornerstones: the personality and

intellectual ability of the person, the level of the teacher, and the quality of the training
program.
For a successful career in neurosurgery, the basic education and training are of
fundamental importance. There are two main concepts related to the philosophy of
education in neurosurgery: in the first the focus is put on theory (study of textbooks,
guidelines, internet sources etc.), while in the second the focus is the practical training
(or “learning by doing”- concept). The ideal training should be based on a balance
between theory and practice. Factors that influence the neurosurgical education are the
ability of the educators and trainees on the one hand, and the organization of the
program and technical standards in the teaching center, on the other hand.
The influence of an educator or mentor is of paramount importance. His/her
knowledge and behavior should be live examples to follow for the trainees. It is almost
impossible to become a great neurosurgeon without having a teacher with a high level of
moral and ethic - a person that demonstrates honesty in his professional behavior,
both to his pupil and to his environment. In a good neurosurgical school, the patient's
welfare must be in the center of all considerations.
The knowledge in neurosurgery and neurosciences are growing permanently and the
management standards are improving. Therefore, the competent and excellent educator
must have the ability to remain flexible and capable to keep with the changing demands.
He/she has to have high ability for acquisition of new knowledge, for its critical appraisal,
and for its clinical application.
There are many parameters that could be considered as a prerequisite for a trainee to
become a great neurosurgeon: family background; outstanding results at school; sport
activity; ability to play a musical instrument, languages proficiency; social engagement;
motivation for neurosurgery; knowledge how to write a good scientific paper; ability to
present a project. But all these cannot substitute for the character of the person. Honesty
and dedication to the patients from the beginning of the education will determine the
success in the future.
What about the technical skills? Generally, it is believed that the skill of a neurosurgeon
is equal to his manual dexterity. According to my personal experience with hundreds of
pupils, I found that only those could make great careers who were dedicated and
competent in all aspects, related to the patent's management: starting with the thorough
history taking, complete examination and analytical evaluation of neurological,
neurophysiological, neuroradiological findings, and laboratory findings. Besides, it is
 The Making of a Great Neurosurgeon 3

essential that the trainee has a profound interest in the social life, mental condition and
expectations of the patient.
Last but not least, the endurance, mental power and health condition of the trainees
during surgeries influence the stability of their performance.
The manual skills reflect the intellectual ability for analysis of different situations during
surgery. I do not believe that a very skillful artist who is able to perform repeatedly a very
complicated piece would necessarily become a skillful neurosurgeon.
For the career of a great neurosurgeon, the research activity is of great value. Both basic
and clinical research is fundamental to achieve an academic position. I always give an
advice to my young residents to start as soon as possible to work on scientific projects and
write papers. After finishing such a paper they learn how to plan a study project, to
organize and perform it; how to decide on and carry out the varying statistical evaluation
of the data; and how to review the relevant literature. Moreover, they acquire the
expertise and knowledge on the state of the art of a certain topic.
A great neurosurgeon has to continue in all his professional life the scientific research
and keep the ambition to develop and further improve neurosurgery to the benefit of his
patients. Notably, the patient has to remain always in the center of his/her attention.
4

The Making of An Excellent

Neurosurgeon
JACQUES BROTCHI MD, PhD, FLORENCE LEFRANC MD, PhD and
MICHAEL BRUNEAU MD
Department of Neurosurgery, Erasme Hospital-Université libre de Bruxelles

Key words: neurosurgeon, excellgce, humility, multidisciplinary, experience

Humility, honesty, availability, team spirit and hard work are some of the conditions
to make an excellent neurosurgeon. Combination of brain excellence and hand skilful is
one of the characteristics of an outstanding neurosurgeon.

Training in allied specialties is also a key. To-day, with the development of imaging,
patients are coming with their CD-Rom when asking our opinion. We should never
forget we have to cure patients but not pictures. Therefore, good knowledge in medical
neurology, neuroradiology and pathology is really helpful in taking a good decision on
the indication for surgery. Taking time making a good anamnesis and precise neurological
examination contributes to an excellent diagnosis. Taking time to talk with the patient
and family before and after surgery is the base of confidence. Even if we are micro-neuro-
technicians, we should never forget human sense. We should teach our trainees to
avoid falling in computerized world and remind them that a patient is a human being
waiting for clear explanations on the treatment and post-operative course. In addition,
a patient has also an anxious family waiting for daily news. An excellent neurosurgeon
should combine technical and heart qualities.

Availability to the patient, the family, the nurses and younger colleagues is also a way
of life we should teach. That also means a team spirit. To-day, neurosurgery in no
more a one man show. Multidisciplinary approach is mandatory. Moreover, a leader must
share his knowledge with younger colleagues who should be associated in all events.

Excellence is also based on experience. Experience means success and pitfalls. Success
in 100% of our surgeries does not exist and we should learn from our mistakes or
pitfalls. Every complication should be analyzed and be a lesson for avoiding its repetition.
Therefore, humility and honesty make a neurosurgeon greater. A colleague who declares
he has no complications, no pitfalls, who has 100% success in his hands, is a danger for
our specialty and should never be trusted. It is our duty to train our fellows in a
tradition of auto-critics whenever something uneventful happens. Knowledge of his limits
is also a key, but it should not hidden self-confidence which is close-related with
experience.

About surgery itself, there are no small details. Every step is important. An example is
the position of the head which makes the procedure easy of difficult. Learning all
 The Making of An Excellent Neurosurgeon 5

approaches makes the difference between a neurosurgeon prisoner of one way to go and
the other who is able to propose the best approach to cure in a panel of different
approaches. Hand skilful is also based on hours of work and training in the lab and in the
operative theatre.

Neurosurgery of excellence needs a combination of a well trained brain with skilful

hands. It means hours of hard work during training time but also after. Learning from
colleagues all our life is a guarantee to stay aware of all new development and progress.
We should never stop learning. Our specialty is in constant progress and excellence also
means to be aware of all new publications on research and development. Facilitating and
encouraging research (basic and clinical) from our young trainees will stimulate new
vocations towards finding solutions in different problems we still have to face like
vasospasm or malignant brain and spinal cord tumors.

At the end, I want to say that a teacher should be proud when he is surpassed by his
fellows.
6

Ein Helden Leben:

A Life in Neurosurgery
MICHAEL L.J. APUZZO, M.D., Ph.D. (hon)
EDWIN M.TODD/TRENT H. WELLS, JR.
Professor of Neurological Surgery, Radiation Oncology, Biology and Physics
Keck School of Medicine, University of Southern California,
Los Angeles, CA USA

Key words: neurosurgery, autobiography

There are many exciting and noble professions but the gravity and concept of a life in
neurosurgery is clearly in its own category of elite status. It is a life of involvement with
the dramatic events of life and death and a terrible gray area in-between where lives are
disrupted and emotional pain is intense. It is by any measure an extraordinary calling.
This is a brief and somewhat fragmented story of a life in neurosurgery-–my life

I. Beginnings
New Haven, Connecticut is a smallish Connecticut town rooted deep in American
colonialism and uniquely blessed by the presence of Yale University within its limits. It
is a physically beautiful setting on Long Island sound, multicultural but predominantly
Italian in its inhabitants' cultural origins. I was born just before the second World
War. My father, Dominic, a machinist and fine craftsman, was a devoted husband and
exemplary father. Intelligent and diligent, he at times worked as many as three individual
jobs to maintain the upward mobility of his family. Our paternal ancestors were from
Amalfi, Italy. Sailors for generations, they left Italy for Argentina in the early twentieth
century with the advent of steam, an Atlantic storm and damaged ship brought them to
Ellis Island in New York. My mother, Ann Lawrence, was a nurse. Multifaceted in
talents, she was a mother who challenged her children to excel and left no stone
unturned to provide an intellectually fertile environment directed to music, art painting,
and sports. The Lorenz family, Austrian in origin, had originally migrated to Mahoney
City, Pennsylvania, where my grandfather worked in coal mines, later with my
grandmother, they migrated to New Haven.
My original home was a two family edifice with a chicken coop set in a "collision" area
for Italians, Blacks, and Hispanics in what might be termed a somewhat less than
desirable part of town. The atmosphere within the family was clearly upwardly mobile
with progress in both education and socioeconomic status expected and driven home
emphatically each day. Progress and change was expected on all fronts with hard work,
perseverance, and sustained goal orientation at the base of the behavioral pattern.
Honesty and a firm moral grounding in Catholicism was stressed. As the oldest of
three siblings I was expected to be a "pathfinder," setting the pace for my young brother
and sister. I was immersed in the piano, painting, the public library, films and sports at
 Ein Helden Leben: A Life in Neurosurgery 7

an early age–interests that would be life threads.

II. Education
At the age of four we moved to Westville, a largely middle class part of town, first in
an apartment and later in a three family house in a predominantly second generation Irish
culture. Our move was impaired by prejudice and bigotry that existed at the time
related to our Italian surname (after WWII). The Lorenz name was changed to Lawrence
and this was used to allow initial entry into the area. Due to the style of my parents and
a supportive group of Irish friends, I hardly felt a ripple.
After a brief period in public school, I transferred to Saint Aidans Elementary, a
parochial school established by our parish church where discipline and religion were
emphasized. The nuns, predominantly Boston Irish in origin, affected a peculiar brand
of education–effective with strong points of order and a fundamental sense of respect for
classes but with overtones of anger and prejudice. I was one of only two Italian in the class
and was constantly reminded of it–in less than flattering terms. Even at the age of ten I
found this curious and reveled in the multicultural attitude of my parents who stressed
the dramatic beauty of differences of racial and cultural groups. Problematically, the
Sisters of Notre Dame insisted that all should set their course to cut a path to Catholic
secondary education. At the age of twelve I decided that things would be different for me.
Hopkins Grammar was secondary school for boys, a preparatory school that offered an
enhanced opportunity for an elite college or university education. I had been introduced
to it through a summer camp where counselors were either faculty members or students
at Hopkins. I visited the campus–like an old English boarding school in the film "Tom
Brown's School Days." It was for me! Largely comprised of students who were children
of professionals and Yale faculty members, it offered a unique experience. Founded in
1660 it was steeped in the tradition of American Colonial times and insisted on honing
individuals in all respects–mind and body–art, culture, music, history, classics, language
etc etc. It was an elite and invigorating environment and my acceptance there was a major
turning point in my life, giving me the opportunity to develop and grow and to have a
chance to be accepted at Yale College. As a good but not exceptional student and much
better than average athlete, I was accepted by early action decision at the College. Their
decision was no doubt further influenced by my New Haven residence, Italian surname
and some strange endorsement of Hopkins Headmaster F. Allen Sherk, a former Yale
man, Mr. Sherk–a strict Puritan–presided over a no nonsense–zero tolerance
environment. Perhaps he was taken with my effort or application to tasks or my
emerging romanticism and idealism.
I entered Yale at 16 from a class of 40. I suddenly was consumed in a class of 1000–I
was overwhelmed!
As a freshman, I survived academically and even made the Dean's Honor list due to my
Hopkins grounding. I had initially entered with ideas of a career in architecture. (I was
a moderately gifted painter and sculptor and had won a number of local prizes).
However, the introductory course challenged my discipline in that chaotic Yale
environment. Coming from a family heavily engaged in the medical profession as
nurses, I felt some indirect pressure to consider that course but initially I resisted.
8 Introduction

Fig. 1 Cushing Historical Library, Yale School of

Medicine, New Haven, Connecticut

During my sophomore year my academics suffered and I was required to meet with
Henry Chauncey, Dean of students for the College–I thought it was over. After a long
discussion, Dean Chauncey arranged for me to work at the Medical School as part of my
scholarship requirement–out of all places–at the Harvey Cushing Historical Library!
(Figure 1)
There my supervisor was Madelyn Stanton–the deceased Cushing's former secretary
after he had returned to Yale after his time at Harvard. She was proper and stern! I would
descend into the "stacks" three afternoons a week, instructed to catalogue the Cushing
collection books on three by five inch cards. However, I spent time infatuated with the
"ancient" tomes on medical history and Cushing's neurosurgical collection in multiple
languages. Few cards were completed and I felt Miss Stanton's wrath! But I found a
direction–another turning point. In those stacks I decided that I would try to enter a
course in medicine.
Unfortunately, I was distracted by sports involvement and social interactions. My
grades, although satisfactory, were hardly of medical school candidate caliber. By March
of my senior year I had had been rejected by all but one of my applications and that was
the Boston University School of Medicine. I was called for an interview late in March and
was taken by its intimacy, warmth, and academic flavor–only 80 students per class
and associated with the then magnificent Boston City Hospital!–and Boston!! In spite of
welling enthusiasm and very congenial interviews I remained guarded, even pessimistic.
After finishing my time at the Cushing library, because of a secondary interest in
Oceanography, I was assigned as a work student to the Bingham Oceanographic
Laboratory–a fabulous place and opportunity. There I worked for Evelyn Hutchinson,
the first woman to earn a PhD from Cambridge, and came into contact with the niece of
John Fulton, the renowned neurophysiologist, who introduced me to many of the
elements of his character. Fulton was the Chairman of Physiology at the Medical School
and an exceptional neurophysiologist. He was probably one of the foremost individuals
in his field in the past 100 years and a founder of the American Association of
Neurological Surgeons as well as the Journal of Neurosurgery.
Under the direction of Fulton's niece, I learned to do hypophysectomies in 3 inch Keli
fish to determine seasonal change on gross weight. Many other interesting activities
consumed my interest there and I decided to work at the lab during the summer before
 Ein Helden Leben: A Life in Neurosurgery 9

my senior year. I was relatively well known as an earnest work student.

Two days after the interviews at Boston University Medical School, the laboratory's
director, Daniel Merriman, stopped me (I didn't even suspect that he knew who I
was). Dr. Merriman inquired about my medical school progress and said–"Oh Bunny
Soutter (the Dean at BU) was a classmate of mine at Harvard!"
Three days later I received a letter of acceptance.

Although New Haven had proximity to New York and I was familiar with that
immense city, I had never lived in a major city before. Boston was a revelation. My love
of music and art was indulged. I was finally out of the "nest" and I began to mature and
thrive in the supportive environment of the Boston Medical setting. The order and
direction of the medical program appealed to me and I naturally gravitated to subjects
of anatomy, pathology, and physiology. I became especially attracted to neuroanatomy,
where I excelled. In New Haven, I had ultimately majored in Psychology and Physiology
and had done a senior thesis studying lobotomized patients at the West Haven Veteran's
Administration Hospital. I was being drawn to a career related to diseases of the nervous
system. I was attracted to a number of colorful individuals in the neurological sphere,
particularly to the iconic Derek Denny-Brown, Harvard's noted neurologist-physiologist
who had weekly brain cutting conferences at the Boston City Hospital. Flavir Romanul,
his pathologist, was especially articulate and a unique cast of residents, students, and staff
contributed to the energy of the academic theater each week, cataloguing a variety of
common and esoteric neurological diseases.
I was totally taken by the intellectual and dramatic exercise. But I was certain that I
needed to move in a surgical direction–the combination of intellect and physicality was
attractive and the exotic and challenging nature of neurological diseases were, in my
opinion, unmatched. After all, my mother, an operating room nurse, had told me–"I'm
happy that you're planning a career in surgery–but whatever you do, don't do
neurosurgery! None of the patients do well or die!" I was moved to take up the challenge!
For a variety of reasons and with the help of Richard Egdahl, the renowned endocrine
surgeon, I decided to do a surgical internship at the Royal Victoria Hospital at McGill in
Montreal. Egdahl has been a resident with Lloyd MacLean, the chairman of surgery at "the
Vic" and had counseled me on various surgical opportunities along with John Mannick,
who later left BU to be chief of surgery at the Peter Bent Brigham. Part of the attraction
was the proximity of the Montreal Neurological Institute and the possible opportunity
to work there–epilepsy and the mystique of Wilder Penfield and the Institute's lore were
irresistible and I thought attainable.
Medical school had been successful in establishing both a firm grounding and
direction.

III. Surgical Transitions and Neurosurgery

Montreal was a fabulous, exotic, and international place. McGill and the Royal
Victoria Hospital reflected its character with the ultimate medical, surgical, and academic
standards. The hospital was outstanding across the board with modern pace setting
services in Cardiac, Transplant, and Orthopedic Surgery. All support services were
10 Introduction

high caliber with all medical specialties superb. Many of surgery's and medicine's great
luminaries seemed to be everywhere. As a "straight" surgical intern, I held special status,
moving into first year resident level duties and responsibilities after three months. My four
principle rotations involved general, cardiothoracic, and trauma surgeries, with every
other night and weekend call in house for one year with 4 days off at Christmas! The
intense experience was exhilarating.
We provided full surgical support for the adjacent Montreal Neurological Institute.
This gave me the opportunity to meet and observe many important people in the field,
including Bryce Weir (chief resident and later Chairman at University of Chicago), Henry
Garretson (junior staff member and later chair at Louisville as well as AANS president),
Phanor Perot (junior staff member and later Chair at South Carolina), and the Institute
Co-Directors, Theodore Rasmussen and William Feindel. As an aspiring neurosurgeon,
I was welcomed, embraced, and encouraged. I was both touched and energized.
However, although I had had aspirations of possibly training at the MNI, this proved
not to be feasible given the lack of available openings. I was given the opportunity to work
in the laboratories "in limbo" but I was anxious to move on with my training. Yale
provided a great opportunity and so after a valuable year in Montreal, I returned to Yale-
New Haven Hospital to begin a residency in neurosurgery. As embracing as the
experience as Montreal proved to be, Yale was harsh, insensitive, and chaotic. Once again,
I was struggling in transition. Entering the Tomkins 4 Ward full of hissing respirators and
patients left quadriplegic from motorcycle accidents, I was shocked at what seemed to be
the human carnage under my "care." At that time (July) the summer trauma was in high
gear and the evidence consumed the neurosurgical service day and night, seven days a
week. The house staff, all high caliber individuals, were driven by the pace and, although
low in their numbers, valiantly dealt often in disruptive fashion with mayhem. I
wondered, "What am I doing here?" Gradually and painfully, I adapted. Slowly the
more elegant aspects of our craft began to present themselves and I began to evolve as a
resident and an embryonic neurosurgeon.
William German, one of Cushing's late fellows, was chairman on my arrival; he was in
his seventies and in the later and closing months of his career; however, he provided
inspiration and the faculty was full of highly competent individuals, all of which
exhibited the strong persona required for success in the field.
Upon his retirement, German was replaced by William F. Colllins, Jr., a native New
Havener and Yalie who enforced high standards of practice both in the university and
private setting. He was a superb role model in his consummate professionalism and
devotion to the highest of intellectual standards. The bar was set exceptionally high.
Although Dr. Collins had inherited me, I never felt like a step-son. He gave me attention
and support, even working personally during an 18 month-laboratory experience in a
complex neurophysiological experiment. He always worked beyond what was expected,
passionately setting the proper example for his residents and staff. He was then and is
now, for me, extraordinary. Collins went on later to be editor of the Journal of
Neurosurgery and in the capacity helped me to gain experience that I would later bring
into play as editor of Neurosurgery.
As part of the Yale experience, we did important rotations at the Hartford Hospital,
then one of the nation's busiest clinical services, with a surgical volume of more than three
 Ein Helden Leben: A Life in Neurosurgery 11

thousand cases annually. This experience was, in theory, our exposure to high powered
technical neurosugery–with Yale New Haven providing principally the intellectual and
academic grounding. Hartford was a rich and memorable experience! There, William
Beecher Scoville and Benjamin Bradford Whitcome–two giants in the field, provided the
forces that drove the service. We were not only exposed to an exotic variety of problems
but had exposure to Scoville's creative personality and primal force. Periodically showing
evidence of technical genius, he constantly was impressive with his passion of invention
and reinvention, his lust for life and thirst for the extraordinary. An avid and practicing
internationalist, he was active in the World Federation of Neurosurgery and had a
steady stream of international luminaries and trainees as guests. The energy and sense of
vigor of the service was non-stop. There, my surgical confidence began to emerge and I
was inspired by the combination of surgical events and creative forces with an eye
toward progress. It lit my passion for the same and it continued to burn.

IV. Life as a Submariner

My residency was formally interrupted by the Cold War and VietNam. All medical
trainees were obliged to serve in some capacity. I had always been fascinated with
exotic science, Jules Verne, space travel etc etc. The Submarine base at Groton (New
London) was 50 miles from New Haven and the goings on at that installation were always
a source of intrigue for me. Nuclear power was in its infancy and the exploits of the
Nautilus, Seawolf, and Trident were a source of fascination. Given this and my "nautical
genes," I volunteered for extended service on Polaris missile submarines, (Figure 2,
page 1118) the most modern, complex device that man had ever devised up to that time.
The duty had the added perk of training and duty as a deep sea diver with scuba, hard hat,
and mixed gases qualifications.
My application was accepted and in January I traveled to Groton for induction and a
six-month period of training in areas of nuclear medicine, nuclear physics, radiation
medicine, submarine operations, submarine design, diving, and diving medicine. It
was another turning point in the honing of interests that would prevail during my
time as a neurosurgeon in academia.
The training was intense with 10 hours per day, six days a week of class, laboratory, and
practical exercises. I presume it was military education at its best–as a product of elite

Fig. 2 Nuclear-powered Polaris Fleet ballistic missile submarine,

Robert E. Lee, under way in the North Atlantic, circa 1967. The
Robert E. Lee was commissioned in 1960 at Newport News Virginia,
and was one of the five original 598 Class (George Washington) of
submarine missile platforms. The nuclear-powered submarine
changed international strategies of defense and deterrence.
12 Introduction

scholastic setting, I can now say that it was the most thorough and best organized
program for relating a body of knowledge and skills that I have ever experienced. At the
end of this taxing mental and physical period in which 40% "washed out," I was
confident and prepared to take on the challenge of hazardous duty service on a polaris
submarine. I was assigned to the SSB(N) (Submarine Ship Ballistic Nuclear) 601 Robert
E. Lee, a 400 ft., 7 story "monster" that was foot by foot the most expensive vehicle ever
created (Figure 2). In the middle of winter, my crewmates and I left New London for
Holy Loch Scotland to assume the service of the boat and undertake a sustained
submerged 100 day "patrol" to regions unknown, carrying more firepower than all
weapons detonated in all mankind's previous wars–but this time as a deterrent.
During a series of those three month patrols, I was able to observe and contemplate
regarding advanced submarine operations, complex navigation methods, nuclear events
and utilizations, radiation physics, robotics, communications and satellite operations. It
was a three month immersion into ultimate high technology, perhaps like none other at
the time. It was a remarkable experience, particularly when combined with the concept
of neurological surgery. It would be central in directing my intellectual research and ideas
during next decades in neurosurgery and played a primary role in the reinvention of our
field!

V. Los Angeles
The last year of my military service was spent in San Francisco as nuclear medical office
for San Francisco Bay. At the time, Charles Wilson, a friend of Bill Collins, was beginning
his period as chairman of UCSF. Charlie was very welcoming and an important
friendship was forged with that important service and Charlie himself.
I returned to New Haven to finish the remaining two years of training–a relatively
uneventful period except that people like Ted Kurze in Los Angeles were beginning to
introduce the operating microscope into neurosurgery and we were performing a
number of hyposecomies for metastatic pain and occasional clipping of cerebral
aneurysms using the instrument. Collins and Kurze had served in the Army together. I
met Kurze at an AANS meeting and we immediately established a bond but I wasn't
interested in working at the Los Angeles County General hospital. Ted was charismatic
but the service was not well grounded and its infancy was a full time academic enterprise.
I desperately tried to find a job at a University but, even with Collins's help, nothing
seemed to materialize. As the months passed by I was compelled to agree to taking a less
than attractive opportunity in private practice. Two weeks before my residency was to
end, I was contacted by my employers to be that the group had dissolved and there was
no job! Collins kindly gave me a temporary appointment as Instructor at Yale but
within 3 months I joined Ted Kurze at USC and I have never left (Figure 3).
People had warned me about USC and the lack of future in that environment but I saw
something different, a high volume of patients in a 3000 bed medical center, a futuristic
thinking, colorful and charismatic leader (Kurze), and a highly intelligent, energized "big"
brother in Martin Weiss, Kurze's established Vice Chairman. I quickly saw Marty as a
valued colleague with solid grounding in science, high ambition, and a remarkable
sparkling intelligence. In addition, I sensed a fabulous chemistry at USC with academic
 Ein Helden Leben: A Life in Neurosurgery 13

Fig. 3 Los Angeles County/University of Southern

California Medical Center, circa 1975.

freedom unencumbered. I sensed that anything–mostly good could happen!!

I soon discovered that all I had perceived was correct but there was more–fertile
resources in science, high technology, and futuristic perspective–all played into a
substrait of person that had been developing during the previous three decades–I was
comfortable in a second home!!
But not immediately!!
The most difficult times in a neurosurgeon's career are during points of transition and
the period between residency and immersion in practice (either private or academic) is
highly stressful. Events in the socioeconomic environment of Los Angeles impacted
severely on my adaptation in spite of support from Ted and Marty. I, in spite of being in
a sea of clinical opportunity, could not seem to get things started. I was very active in the
training program, surgery stream, and participated in hundreds of cases–in fact, my
application for the American Board of Neurosurgery Certification was thought to be
exaggerated in case numbers as they had never seen the variety and volume of pathology
presented in such short period. Otherwise, it seemed I had no ideas, no creative thought,
no inroad to a meaningful academic contribution. Bill Collins had told me "All I would
like to leave to neurosurgery is one meaningful contribution!" His words echo for me each
day. For whatever reason, there seemed no opportunity in sight and a malpractice
insurance crisis had me working weekends in the General Hospital Emergency Room to
make financial ends meet for my young family.
I began to investigate opportunities away from the university in Santa Barbara
particularly–nothing seemed to fit. My board examination approached. The exams
were held in Memphis, Tennessee. At that time Marty Weiss suggested that I see Harold
Young at the Medical College of Virginia who had begun some innovative work on the
immunology of gliomas. I had been fascinated with the immune response in our
transplantation patients at the Royal Victoria and brain tumors as now, were a real
challenge. I met with Harold Young after the board exam. The concept of a tumor
immunology lab was born. And that began a stream of repetitive exciting events,
discoveries opportunities, innovations, and major contributions that have helped to
reinvent neurosurgery-–each is a story in itself. It has been a deluge of exciting events and
involvement in the most exotic of settings imaginable traveling with meaningful purpose
14 Introduction

throughout my country and the world.

The areas have included tumor immunology, microsurgery, minimally invasive surgery,
endoscopy, imaging directed surgery, interstitial brachytherapy, stereotactic radiosurgery,
functional restoration, molecular and cellular neurosurgery, neuromodulation navigation,
vagal stimulation for epilepsy, and now nanotechnology!! All of these initiations and
developments studded with remarkable people, places, and events and a bibliography that
was 0 when I left Yale cites more than 600 contributions to the literature, including 45
individual published volumes.
These opportunities and contributions have been realized by effecting a vigilant,
innovative, and opportunistic spirit making the most of each seized chance and
maintaining a deep seeded, inveterate persistent modus operandi.

VI. Reinventing Neurosurgery

The thirty year period from 1976 to 1986 was a momentous "generation" for
neurosurgery and often it seemed that I was standing on "ground zero" for each
momentous and seminal event as the new neurosurgery was developed.
Work at USC had already focused on microsurgery before my arrival and I immediately
became engrossed in its possibilities and nuances with Kurze. We had one of the first
operating rooms "designed" for microneurosurgery with an overhead microscope and a
fertile relationship with Zeiss, (a leading manufacturer). We worked on new
instrumentation, scope sterilization, and application of the new craft. The new capability
seemed aptly suited for deep cerebral surgery and the service had a "tradition" of
transcallosal surgery with Phil Vogel who had worked at Sperry at Cal Tech in his
studies on callosal disconnection. Vogel showed me his transcallosal technique and I
decided to apply it to third ventricular midline access; the microscope made the process
fluid and the case volume of intreventricular lesions especially cystocercosis at the
general hospital gave more than ample opportunity to apply various maneuvers for third
ventricular access. We were able to quickly achieve a substantive experience that lent a
new dimension to deep cerebral surgery.
To augment this, Milton Heifetz, the creative surgical genius was a member of our
attending staff. He had acquired a very early set of the then new Hopkins angled
endoscope from Storz. Milt asked me if I had any use for them. We went to work
immediately. First in the laboratory and then in the clinical setting–applying endoscopy
to interventricular situations, aneurysm surgery, transsphenoidal procedures, and spinal
surgeries–it was 1977 and a new era in neurosurgery was born. Incidentally, one of my
greatest fascinations on submarine duty was the opportunity to use the periscope–the
parallel to endoscopy was obvious.
During the same period, I was intellectually compelled to make contact with the Jet
Propulsion Laboratory (JPL), NASA's center for robotic space exploration. At the time,
the Viking Project for a Mars Landing was underway. I used a few connections through
the Navy to get access and began to discuss neurosurgical issues with influential people
at the Lab. They were anxious to establish parallel relationships with potential "spin off"
applications of their technologies. I was welcomed and began to make transits between
Cape Canaveral, Florida, NASA's principal launch site, and Los Angeles, gaining an
 Ein Helden Leben: A Life in Neurosurgery 15

intimate view of the entire program and using Mars surface analysis technologies to create
and assess "finger-prints" of various brain tumors. The experience proved to be a
valuable catalyst for innovation related to concepts of miniaturization and surgical
minimalism as well as opening doors at the California Institute of Technology for
future research efforts. Most importantly, was a primer for creative thought and a
desire for large scale enterprise!
With the advent of CT scanning a new realm of opportunities opened for us in
neurosurgery. We now had maps of some accuracy to follow and I was determined to take
advantage of them.
The department of Radiation/Oncology at USC had an active radiobrachytherapy
program using Iridium 192 (Ir-192) for sarcomas, gynecological, rectal and various head
and neck tumors. Fred George, a former Navy Captain, was chairman and constantly
looking for new ideas and applications of technology. We had an immediate "meeting of
minds." As the first Hospital based CT scanner in Los Angeles was 25 feet from my office
in the General Hospital, it was natural that we would begin to make some efforts to
establish in primitive fashion operative application of the new technology. I began to
create a program of free hand placement of catheters in brain tumors that were later
afterloaded with Ir192. This was an initial step toward stereotactic radiosurgery and none
of us had any idea of what we were getting into. However, it was not an ideal first step.
I knew we had to create an instrument that would allow stereotactically refined placement
of sources–in an operating room. In 1977 at a ski meeting in Alta, Utah, I found it a
plastic prototype of what would eventually become the Brown/Roberst/Wells Steretotactic
System (Figure 4). I "stalked" Trent Wells, the brilliant engineer/designer/machinist who
helped to create the Todd/Wells frame more than a decade before had designed the
device. He did not initially receive me with open arms but he listened to my ideas and
spoke with Ed Todd later. Edwin Todd, a true Renaissance man with a doctorate in
Renaissance History, had spent time in John Fulton's Laboratory at Yale and had been
very paternal to me from the time of my arrival in Los Angeles. He endorsed me to Trent
and Trent in turn introduced me to Ted Roberts, then Chairman of Neurosurgery at the
University of Utah. Ted had financed the frame project. Ted and I had immediate
positive chemistry. He was a neurosurgeon and pediatric specialist, ever an intellect and
true gentleman. Highly collegial, he welcomed an amalgam with USC with me as a
principle investigator on his prototype instrument. The instrument was being fabricated
at Trent Wells's machine shop in Southgate, California-–only 10 miles from the General
Hospital. We were given prototype Number one, with two going to University of Utah and

Fig. 4 Original plastic conceptual prototype of the

BRW stereotactic instrument, 1978. Note the novel "N"
configuration of localization in Cartesian space through
secondary algorithms–the seminal concept in imaging-
directed stereotactic neurosurgery. 1978
16 Introduction

three to David Thomas at Queen's Square, London. We quickly went to work on

"watermelon phantoms" and did our first human case–one of the world's first–of
imaging directed stereotactic surgery in the fifth floor neurological operating room at the
Los Angeles County General Hospital in 1978 on a 60-year-old man with B-cell
lymphoma. This point biopsy was a seminal moment for all of imaging directed stereotactic
surgery including navigation and radiosurgery over the next thirty years. The base
algorithm, principles, and hardware were proven in humans with that case. I should add
that a number of other investigators, notably in France, Sweden, and Germany,
simultaneously were exploring similar concepts and devices.
However, this gave impetus to a new era in stereotactic neurosurgery and a cascade of
applications which are now in operation.
We immediately initiated a complex radiobrachitherapy program that reached its
highest sophistication in 1984 when it was replaced by radiosurgery. By 1981, I had begun
to be interested in Leksell's work in Stockholm and although a gamma knife was not
available, I thought that linear accelerators were an obvious choice for a number of
reasons to act as a delivery unit for energy. I spoke with the investigators in Italy and Spain
who had created primitive linear accelerator radiosurgery systems and related the
concepts to Zbignew Petrovich an intellectual activist who had assumed the chair in
Radiation Oncology at USC. He was supportive. Colleagues at Boston's Joint Center were
working on a similar project and Trent Wells was providing the hardware. Trent and I
went to work as did Gary Luxton, our radiation physicist. Quickly, the first radiosurgery
on a human was performed by us at the Norris Cancer Hospital in 1984–the rest is
history. We went on to acquire Gamma Knifes in 1994, 2001, and 2008. Also, we played
an important role in the development of the Cyberknife, installing one of the initial
prototype units at USC in 2002. We played an essential role in popularizing the concept
and refining its application over a 24 year period–a remarkable source of satisfaction as
the method has taken its place as one of the essential features of the neurosurgical
armamentarium.
Other than radiosurgery we were fortunate because of our industry ties to be central
on the development of "frameless" navigation systems, another methodology thhat has
revolutionized our discipline.
The concept of functional restoration with cellular substrates was introduced in the late
1980's with adrenal medullary autografts for Parkinson's disease; because of our
experience, reputation, and resources we were central in the exploration of the concept.
Although it was immediately successful, it served as a catalyst for an impending stage of
cellular therapies with stem cells and the employment of factors through our new ally
nanotechnology. We helped to establish and coined the terms neurorestoration, cellular,
and molecular neurosurgery!
These are only a few of the seminal involvements that we were privileged to experience
involvement with. Oh yes, the prototype ultrasonic aspirator (CUSA) was clinically
proven at USC and New York University in 1977!!!

VII. The Power of the Pen

There is no doubt that there is power in the pen!! Perhaps no greater contribution to
 Ein Helden Leben: A Life in Neurosurgery 17

our field can be accessible to each of us than a contribution to the literature of our time
and especially the peer reviewed literature of our fine journals. Through my residency,
I was nonproductive in this regard in spite of great support and the academic diligence
of William Collins and other faculty at Yale. I did develop a great respect for books,
writing, and scientific journals but the chance for a contribution seemed virtually
inaccessible to me at the time. However, during my period on nuclear submarines I was
required to write a meaningful medical thesis to be certified (qualified) as a bona fide
submarine and diving medical officer thus earning the right to wear the highly significant
"gold dolphin emblem" of a submariner who had truly "earned his spurs!" I decided to
address the topic of the "Management of Head Injuries on Nuclear Powered Submarines."
I poured myself into the task and over the course of a year produced a meaningful work
that drew considerable attention from the Bureau of Naval Medicine. Because of its
practical value it was ultimately published by the Navy and distributed to all submarines
in service and made a requirement of Submarine Medical training for several decades–a
source of great pride to me and a source of confidence and inspiration as well. Still, my
ideas and development in writing meaningful manuscripts was very slow in development.
I began a very modest case report on an incident of "Pineal Apoplexy" but left my
formal training time without a publication.
Upon my arrival in Los Angeles, Marty Weiss, some years my senior, took me under
his wing getting me involved in laboratory reports at first, later more complex clinical
studies, and little by little I began to blossom. Through, my general will and discipline and
the fertile environment of Los Angeles, I began to formulate ideas. Papers began to evolve
in rapid succession and, surprisingly, my name began to emerge from obscurity. This
required nearly a decade of hard work, commitment, and persistence in many difficult
circumstances. I was determined to be an academician and to make a contribution to the
field. As an associate professor in 1977 things became economically difficult. Because of
a malpractice insurance crisis I was unable to work in private practice to augment my
meager academic income and I was required to work "shifts" in the fabulously chaotic
emergency room of the General Hospital–this is a story in itself–very dramatic but
hardly the venue for a budding academic neurosurgeon!
However, persistence prevailed and as time passed circumstances improved and
opportunities presented themselves among which was a call from Carolyn Brown,
book editor for Williams and Wilkins in 1982. W + W was a highly respected medical
publishing house–family operated and keen in developing new young "editorial talents."
I was asked to prepare a small (250 page) monograph on the third ventricle as I had just
published on concept of the interformical third ventricular approach in
NEUROSURGERY. I seized this opportunity and with Carolyn's help went on to edit a
900 page classic work that went on to be the best selling monograph in the company's
history–a fact that put me "on the map" so to speak as a figure in operative neurosurgery.
This served as a catalyst for more literary opportunities and respect. There were a
multitude of invitations to speak at major national and international meetings. Ultimately,
I would go on to edit a total of 45 volumes to this point, thirteen of which were surgical
topical monograms. Thousands of new ideas welled up with travel, observations, and
acquaintances. It was a consummate "snow ball effect" with peer reviewed papers being
produced, oddly enough, with seeming ease as a barrier were broken. Now more than 600
18 Introduction

publications are evident in my bibliography.

Perhaps my greatest honor and task has been the stewardship of NEUROSURGERY.
Since 1991, it has been a challenging and formidable chore which I assumed with no
formal training–however I brought a broad knowledge of the field, energy, honesty, and
a passion for the advancement of Neurosurgery--–these are essential elements for the
stewardship and ultimate success in the task which grows relentlessly more complex each
day. The challenges are unending but the rewards and satisfaction that is attendant have
been unmatched in my experience.
Involvement with the "power of the pen" is always rewarding, satisfying, and edifying.
It is one of the consummate pleasures of neurosurgery and a catalyst for the development
of the mind, soul, and person. It is a ticket for the blossoming of the self.

VIII. Internationality and the Flattening of the Neurosurgical World

From my youngest days and educational period, I was fascinated by people, countries,
and differences. This was fueled by my interests in reading and motion pictures which
provided a catalogue of countries and characters. The fire was further stoked by my family
and the University setting in New Haven. Later Yale, Boston, and particularly Montreal
taught me the importance of understanding race, nationality, the joy of various
contributions to the experience of human existence. I have then always been a student
and advocate of internationalism and exchange at that level.
In 1988 an unusual opportunity came forward. I was scientific chair of the American
Association of Neurological Surgeons Annual Meeting. The large North American
meeting, although not overtly biased, were largely characterized by North American ideas
and individuals in podium sessions. International presence was minimal with the
exception of the occasional "glitterati" from abroad. We decided to augment and
showcase the New Orleans Meeting (1989) with an accentuated international flavor–a
radical step at the time. There was resistance but David Kelly, president, and James
Robertson, president-elect, endorsed the idea. It proved to be a unique success and be a
turning point. The 1990 Meeting San Francisco was enormous given the emphasis on
internationalism in 1989 and set new records in meeting attendance. The theme has been
replayed repeatedly in subsequent years.
Jet travel and the internet proved to be strong catalysts for the exchange of ideas and
I invested immense amounts of energy in those regards.
In 1991, I was asked to assume the Editorship of NEUROSURGERY. Immediately, I
established an expanded international advisory board which played and continues to play
a major role in the journal's function. Now more than 50% of all submissions and
published manuscripts are from outside of the United States, 45 countries and 150
international advisors are listed and play an active role on the board. I have advocated
increased involvement of the global community in all activities of the journal, Congress,
and any organization where I am active.
Over the past generation the world of neurosurgery has flattened and I have
passionately worked for this to be reality. The availability of high level practice is more
widespread and evident than at any time before. Each congress and specialty meeting is
more globally representative and through the internet information is readily available,
 Ein Helden Leben: A Life in Neurosurgery 19

conveyed by our website Neurosurgery-Online, raising local standards worldwide.

NEUROSURGERY, OPERATIVE NEUROSURGERY, and our special supplements
have a penetration of 13 MILLION readers worldwide and our podcasts will soon be
available in spanish, portugese, mandarin, korean, italian, and german.
More work needs to be done but inventive minds and unique personalities have
greater access to each other than ever before–and the catalysts for the information and
knowledge escalation is internationalism.
My particular journey has been highlighted by a myriad of high level professional and
personal international relationships that have created great depth and satisfaction in the
quest for self development. I suggest a similar effort for all–the rewards are immense!

IX. Lessons Learned

The neurosurgeon's life and the process of truly becoming a neurosurgeon is hardly
simple. Each individual cuts their own path. This is the reality and beauty of it. However,
for me to approach the issue in more concrete and direct terms, I would make the
following suggestions after four decades of struggling within this unique area:

1) Set distinct, long-term, lofty goals - one can't aim too high
2) Set your standards high
3) Have courage. There is no real loss in occasional failure
4) There is no need to conform
5) Be patient and satisfied with small rewards and steps all will add up
6) Aggressively explore every opportunity
7) Enjoy the process - most of all it a fabulous experience!

Enjoy the journey of a "hero's life" as a neurosurgeon–few have the opportunity!

Works Cited:
1. Apuzzo ML: A fantastic voyage: A personal perspective on involvement in the
development of modern stereotactic and functional neurosurgery (1974-2004).
Neurosurgery 56:1115-1133, 2005
2. http://www.uscneurosurgery.com/faculty_folder/apuzzo.html, Accessed 7-16-08
20

Towards a better future in profession

and life for women neurosurgeons-and
their patients
YOKO KATO
Dept. of Neurosurgery, Fujita Health University, Japan

Key words: neurosurgery, neurosurgeon, women, professional

Almost 30 years ago, women rarely chose surgery as a profession. Even in 1978 when
I graduated, 7 or 8 women out of a 100 student group, kept away from surgery, which was
considered to be too intense and heavy. They tended to choose ophthalmology,
otolaryngology, or pediatrics. At that time, without a doubt, there were many female
doctors who were especially interested in surgery, as they were efficient and skillfull.
However, they didn’t know anyone who had managed family, children and housework
all together, being primarily a doctor, not even thinking of becoming a neurosurgeon.
There was not enough social environment and confidence built to undertake such a career
at that time. However, time passes rapidly, and now the percentage of female students and
female doctors in Europe approaches 70-80%. There are more women-neurosurgeons
nowadays, but still female interns tend to avoid tough specialties, and surgery is given a
cold shoulder.
A national survey of women surgeons in Canada1) was undertaken to evaluate their
ability to combine career with personal and family care. A 93 item questionnaire was
mailed in July 1990 to 459 female surgeons. Most surgeons were married. Only 6.5% were
separated or divorced. 70% of them had at least one child. The most common surgical
specialty was obstetrics and gynecology. Women surgeons practicing in Canada were able
to combine productive careers with rewarding family lives and were satisfied with their
decision to do so despite the compromises involved.
Medical science has been dominated by men 2). There are still very few women
researchers in medical science. This science should be developed by both male and
female researchers if it is to be equally fair and offer good medical service to female and
male patients. Thus, gender neutrality in medical research is most desirable.
Sandrick3) has given her comments of the residency experience: the woman’s
perspectives in the journal Bull Am Coll Surg. She comments that every surgeons has to
go through residency with its long hours, the heavy case loads, the three-in-the-morning
emergencies, the probing questions on rounds, the snatches of sleep in the on-call
room, and the physical and emotional rigors of the OR. Many surgeons characterize
residency training as brutal, uncompromising, even harassing; it is no different for
men or women.
Female neurosurgeons in Japan comprise only 3% of total number of neurosurgeons
in Japan, while the total number of female doctors will hopefully reach 30% of the total
Japanese doctors by the end of 2015. However, the present work environment of female
 Towards a better future in profession and life for women neurosurgeons-and their patients 21

neurosurgeons is not so good. The recent tendency amongst the younger generation is
to enjoy life and thus to avoid selecting such professions where there is lot of dedication
and hard work demanded, besides a long residency program. The present generation of
female doctors does not want to take up surgical fields, especially the cardiac and
neurosurgical fields of surgery where maximum work load and tension exist in the
profession. It is the previous generation who still have to struggle to maintain their
positions and to progress ahead of their male counterparts. The social scenario for
and aspiring young female doctor to become a professional neurosurgeon in any
institution is not favorable. Hence, a basic solution lies in making social romance has
prevented female neurosurgeons from progressing and proceeding a step ahead of
male neurosurgeons in both the research field and clinical practice. The male chauvinistic
thinking of females being a weaker sex, whose only role in society is to bear and rear a
baby is an absolute misconception. We see achiever women in all walks of life, topping
their fields of interest, but the situation is not the same for female neurosurgeons as hardly
ever do we see a lady neurosurgeon being the president of any neurosurgical institution
or a neurosurgical conference.

Recently there were a series of medical reforms that drastically changed the medical
system of education and practice. Increased monitoring and control of responsibility in
medical practice and higher interest toward the QOL (Quality of life)among the patients
and general public, has shifted the frontline forward. Achievement in the treatment of
certain illnesses is considered a significant QOL improvement. In this new environment,
in which female doctors, account for nearly 40% of all doctors in Japan, have to work.
Neurosurgery has aspects that will keep young aspiring physicians away from it: long
working hours and many emergencies, and thus increasing numbers of female doctors
may therefore stay away from neurosurgery.
There is no maternity leave in Europe and this states that environment has been
arranged for female doctors. I hope that Japan will be the same way like Europe
someday. There are currently 369 female neurosurgeons in Japan. As the numbers of
female doctors is growing, we are facing lots of problems in neurosurgery. We have just
established a “Women doctors’ bank” and I hope this will give us some kind of solutions.
Regardless of the mixed responses, pregnancy, delivery and child raising, family
problems, inconvenient working time and discriminatioin have been clearly found.
That is the main concern at choosing residency too. The need for social, financial and
educational support has been outlined as a recommendation to the institutions regulating
the health care labor force. The implementation of a reform is very important and
may help the currently practicing women neurosurgeons, however, increasing their
number is a process that will be the result of the active intervention of our organizations
and supporters to all levels of social interaction-at national, governmental, academic,
NGO, informal groups, through media, family support and education, educational
institutions. We are certain that the evolution of the Japanese society we are witnessing
now will provide the highly qualified professionals-women the place they derserve.
I am having a hard time trying to envisage how neurosurgery will look in the future
and how can I, personally, contribute. Let me talk a little bit about myself- I received
enthusiastic congratulations from the media when in April 2006 I became the first
22 Introduction

female Japanese Professor in 60 years of neurosurgery, considered as a very male

dominated field of surgery. Neurosurgery has numerous charms and thrills. This is the
only branch where you can get actively in contact with living brain, and I am quite sure
this is one of the medical specialties where you are constantly able to refine your skills,
as if there is a mistake it can lead to disastrous results. Therefore, it was considered a
“scared” area in medicine. However, it also means it is stressful, with long hours of
surgery, with dedicated care for the patient for prolonged periods, making it a difficult
specialty to choose for a woman. As in the proverb “We tend to be good at those
things we like,” the first priority in choosing your specialty is that you must love it to
make it a life-long work. As for myself, I love neurosurgery and this is why I have
chosen it. I can not remember regretting my passion toward it because of the hard work.
My desire to complete it as my life-long treasure was always bigger than my worries. On
the other hand, you may think it would be physically easier in the specialties, such as
dermatology or internal medicine. That, however, totally depends on how you live
and how much you are dedicated to your medical professional role and what are you
trying to accomplish in medicine. If you think that way, there is no easy choice. At any
department of surgery, operations are the daily routine, but in medicine the personal
psychological contact with the patients and the beginning I found some families stating
they did not like female doctors, but as I built up my confidence after each case, these
minute issues became less and less important to me. I felt very strongly that once I built
up relations of trust and personal contact with patients, everything should be fine.
Now in the age of less invasive treatment, neurosurgery will see significant changes in
treatment methods. But the important thing is to have the spirit of a surgeons and
improve your skills, and this is something that should not ever change as time goes by.
As said in the old days, “Once in doubt, go for it,” if you are hesitating, take the
challenge, and if any young female doctors have this spirit, step in and go for
neurosurgery. If you can pursue that endeavor for the rest of your life or not, depends on
your own determination and spirit, and if you are brave enough, people around you will
accept you, approve you, and help you improve. When you have those hours of fatigue
and desperation, stop for a while and rest, and then start again, to make your dream come
true with each step forward you make. If you like neurosurgery, take it seriously, do not
hesitate, and take the challenge, and think of it as your future.

REFERENCES
1. Mizgala C, Mackinnon S, Walters B, Ferris LE. Women Surgeons. The results of the
Canadian population Study. Ann Surg 1993; 218: 37-46
2. Enker IC, Schwarz K, Enker J. The disproportion of female and male surgeons in
cardiothoracic surgery. Thorac Cardiovasc Surg 1999; 47: 131-135
3. Sandrick K. The residency experience: the woman’s perspective. Bull Am Coll Surg 1992;
77: 10-17