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Availability of neurosurgical care in Canada and the United States
Editorials
lems this is creating, and stimulate clinicians and radiologists to re-establish the original, and still existing, convention o f presenting cranial scans as viewed from above the patient, not as from below (Figure 1). Manufacturers of computerized scanning equipment should give serious thought to offering the conversion of cranial scans to displays acceptable to clinicians and to facilitate such conversion by direct negotiation with the owners
Surg Neurol 1983;19:554-9
555
of the equipment. T h e editorial boards of leading journals of neurology, neurosurgery, and neuroradiology are in an excellent position to help restore sanity and to protect the patients by ending this left-right confusion. J O H N SHILLITO, Jr., M.D. President of the Society of Neurological Surgeons Associate Chief in Neurosurgery. Children'., Hospital. Medical Center. Boston.
How Many Operations? N o t infrequently, one hears the statement that practicing neurological surgeons are not performing many operations. What is the evidence upon which such statements are based? Is it necessary that a neurosurgeon operate upon many brain tumors, spinal cord tumors, or aneurysms to be regarded as an adequate neurological surgeon? Is the man who treats seriously injured patients with severe head injuries or injuries to the spinal cord any less of a neurological surgeon than one who treats many patients with brain tumors? Is the neurosurgeon who relieves patients o f their back pain and sciatica and restores them to work a lesser surgeon? Certainly not! T h e neurological surgeon who is fulfilling his obligation is one who is serving his patients with his own type o f surgical skill. It could even be argued that one who saves a life by removing an intracranial hematoma is doing even m o r e for mankind than one who operates upon brain tumors. Let us stop classifying our fellow neurological sur-
geons as being greater or lesser because of the type of neurosurgical service which they supply. Let us also stop mouthing the unjustified statement that neurosurgeons are not doing enough operations. Before making such statements, we should actually know exactly what each neurosurgeon is doing and how well he is serving his community. At the m o m e n t , no one knows that, nor could he know it without making a massive survey of all the neurological surgeons in the United States. Such a survey may actually be impossible to make but nothing less will answer this question. It appears that very few neurological surgeons are spending their time twiddling their thumbs. Most of them seem to be busy. T h e y are not busy with work which they have made for themselves. They are busy because of the demands which their communities are making upon them. PAUL C. BUCY, M.D., Editor
Availability of Neurosurgical Care in Canada and the United States A man's reach will always exceed his grasp, to paraphrase R o b e r t Browning. It is all well and good to recognize that the ideal is m o r e than we can achieve, but it is never m o r e than we should seek. It was not long ago that the patients who developed an acute extradural intracranial h e m a t o m a was c o n d e m n e d to die because of the lack of adequate surgical care. Fortunately, that situation has in large measure been remedied, but still, not everywhere
or for everyone. T h e r e remain large areas of N o r t h America where adequate neurosurgical care is not available, particularly for neurosurgical emergencies. Recently, SURGICALNEUROLOGY published an analysis of the distribution of neurological surgeons throughout the world except in Canada and the United States. At this time, we propose to analyze, in detail, the situation in those two countries.
T a b l e 1. Neurosurgeons in the United States and Canada Number
of Area
Population
neurosurgeons
Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan
24,088,700 2,135,900 2,687,000 1,027,000 709,100 583,600 856,100 8,600,500 124,100 6,325,200 975,700
175 13 25 4 5 2 5 59 1 54 7
U n i t e d States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
226,504,825 3,890,061 400,481 2,717,866 2,285,513 23,668,562 2,888,834 3,107,576 595,225 637,651 9,739,992 5,464,265 965,000 943,935 11,418,461 5,490,179 2,913,387 2,363,208 3,661,433 4,203,972 1,124,660 4,216,446 5,737,037 9,258,344 4,077,148 2,250,638 4,917,444 786,690 1,570,006 799,184 920,610 7,364,158 1,299,968 17,557,288 5,874,429 652,695 10,797,419 3,025,266 2,632,663 11,866,728 3,196,520 947,154 3,119,208 690,178 4,590,750 14,228,383 1,461,037 511,456 5,346,279 4,130,163 1,949,644 4,705,335 470,816
2,997 44 3 35 23 454 36 56 9 38 134 64 18 7 129 50 30 14 40 59 14 90 91 88 44 30 61 11 14 16 8 65 15 221 64 12 132 26 50 132 22 13 28 6 75 186 16 6 79 61 18 57 3
Canada
Ratio 1 per 1 per 1 per 1 per 1 per 1 per 1 per 1 per 1 per I per 1 per
137,650 164,300 107,480 256,750 141,820 291,800 171,220 145,771 124,100 117,133 139,386
1 per v5,577 1 per 88,410 1 per 133,494 1 per 77,653 1 per 99,370 1 per 52,133 1 per 80,245 1 per 55,492 1 per 66,136 1 per 16,780 1 per 72,687 1 per 85,379 1 per 53,611 1 per 142,857 1 per 88,515 1 per 11)9,803 1per 97,113 1 per 168,101 1 per 91,536 1 per 71,254 1 per 80,333 1 per 46,849 1 per 63,044 1 per 105,208 1 per 92,622 1 per 75,021 1 per 80,614 1 per 71,517 1 per 112,143 1 per 49,949 1 per 115,(}76 1 per 113,294 1 per 86,565 1 per 79,445 1 per 91,788 1 per 57,726 1 per 107,974 1 per 116,357 1 per 52,653 1 per 89,899 1 per 145,296 1 per 72,858 1 per 111,400 1 per 115,030 1 per 61,210 i per 76,497 1 per 91,315 1 per 85,243 1 per 67,674 1 per 67,708 1 per 108,314 1 per 82,550 1 per 156,939
Editorials
In the March 1982 issue of SURGICALNEUROLOGY (1982;17:223-6), Watts and Adelstein published an important analysis of "Access to Neurosurgical Care" in the United States. They pointed out that there are areas in the United States in which people do not have adequate access to neurosurgical care based largely upon the distance separating the patient and the neurosurgeon. These areas include parts of Arizona, Kansas, Montana, Nebraska, Nevada, N e w Mexico, Oregon, South Dakota, Texas, Utah, and Wyoming. A glance at the map which they have provide confirms their conclusions. We propose here to approach this problem somewhat differently and to include Canada. As Watts and Adelstein pointed out, the considerations of the total number of neurological surgeons to the total population of these two countries is largely meaningless in determining the availability of neurosurgical care. Those figures are approximately one neurosurgeon to every 75,500 people in the United States and one neurosurgeon for every 137,650 people in Canada. The figures which will be used in the analysis published here have been taken from the World Directory o f Neurological Surgeons--Part I: United States of America and Canada (published in April 1980 by the Congress of Neurological Surgeons) as to the number and distribution of neurological surgeons; and from the World Almanac and Book of Facts for 1982 (published by Newspaper Enterprise Association, Inc. of New York) as to the figures o f population. Admittedly, these figures may vary somewhat in 1983, but they are the best figures readily available at this time. Furthermore, it is unlikely that retirements or deaths of neurological surgeons or changes in population since these figures were compiled would greatly alter the results of our analysis or our conclusions. In Canada, in spite of the obvious differences from the United States in the system of the delivery of medical care for the country as a whole, it is obvious that some striking discrepancies exist. Both Newfoundland and Manitoba have undesirably high ratios in the relation o f the number of neurological surgeons to the populat i o n - o n e neurosurgeon for 291,800 people in Newfoundland, and for 256,750 people in Manitoba. Even in the provinces where there are proportionately more neurological surgeons for the number of people, there is still a lack of availability of neurosurgical care for some o f the people. In British Columbia, which has the largest number of neurological surgeons in proportion to the total population, the majority of the neurosurgeons are located in Victoria, at the southern tip of Vancouver Island which is approximately 290 miles long, and around Vancouver in the southwestern part of mainland British Columbia, which is approximately 1,000 miles long and
Surg Neurol 1983;19:554-9
557
400 miles wide. Obviously many people in this province do not have neurosurgical care readily available. A Similar situation exists in Newfoundland. In Quebec where most of the neurological surgeons are in Montreal and Quebec City, there are many people who are either denied emergency neurosurgical care or must travel many miles to obtain neurosurgical care under any circumstances. Admittedly, in Quebec and Ontario much of the area in the northern part of these provinces is sparsely settled. In the more western provinces, the situation is considerably different. In Manitoba, all of the neurological surgeons are in Winnipeg; in Saskatchewan, they are in Regina and Saskatoon; and in Alberta, in Calgary and Edmonton. In each of these provinces, these cities are often a hundred miles or even much farther from many people. It would appear that Canada should have a larger number of neurological surgeons. To be sure, an increase in the numbers will not o f and by itself insure the availability o f neurosurgical care, but an increased number will go some ways in improving the situation. In the United States, in spite of a much greater number of neurological surgeons, the problem of providing adequate neurosurgical care is similarly deficient in a number of areas. A look again at the map provided by Watts and Adelstein will show that the deficient areas are most obviously in eastern Oregon, Nevada, southwestern Utah, northern Arizona, southern New Mexico, much of Montana and South Dakota, western N o r t h Dakota, central Nebraska, western Kansas and Oklahoma and southwestern Texas. SURGICALNEUROLOGY would be the last to accept that these deficiencies should be repaired by governmental fiat, but it would be among the first to insist that reducing the number of neurosurgical training programs will go far to maintaining the obvious lack of ability to obtain proper neurosurgical care. Let us look, for the moment, at the distribution of neurological surgeons in the different states as revealed by this survey. Those states where the number of neurological surgeons is large for the population--District of Columbia, California, Connecticut, Hawaii, Maryland and O r e g o n - - a l l with under 60,000 people being served by each neurosurgeon, are extremely varied. N o single explanation seems to fit all of them. The number of neurosurgeons in the District of Columbia appears to be high for at least two very different reasons: (a) the number of neurosurgeons associated with the governmen or the military; and (b) the fact that this city of limited area also serves the people of northern Virginia and neighboring Maryland. California and Hawaii might be regarded as areas having a more ideal climate. Maryland, Nevada, and Oregon, which have one neurosurgeon for 47,000, 50,000, and 53,000 people respectively, are also states in which there appears to be a very
558
Surg Neurol 1983;19:554-9
uneven distribution o f neurosurgical care, part of each state being inadequately served. Those states in which there is only one neurosurgeon for more than 100,000 people are also varied. They are Alaska, Idaho, Kansas, Michigan, Nebraska, N e w Hampshire, N e w Jersey, Ohio, Oklahoma, Puerto Rico, South Carolina, South Dakota, West Virginia, and Wyoming. SURGICALNEUROLOGYdoes not purport to know why these states are less well served nor would we be willing to try to tell the profession or the states what to do about this. We intend only to draw attention to the situation. It may be argued that modern transportation goes far to remedying these deficiencies So far as elective and non-emergency matters are concerned, this is true; but for the real neurosurgical emergencies, this is not true. The patient with a severe craniocerebral injury or an injury to the spine and spinal cord cannot wait to be transported long distances. Even 100 miles may often measure the difference between success and failure in such cases. It is becoming increasingly apparent that ruptured intracranial aneurysms often require very early
Editorials
treatment if good results are to be obtained. The farmer who falls from a horse or tractor o f is injured by a piece o f farm machinery, or the workman on an oil rig is just as deserving of good, prompt neurosurgical care as a man in the heart o f N e w York City or Los Angeles. Where neurological surgeons elect to practice cannot be dictated and is dependent upon many different factors. Does he like the activity of the busy city or the quiet o f the wide open spaces? Does his wife yearn for the cultural and entertainment facilities of an urban setting? Is he looking for exceptional educational opportunities for his children, for excellent hospital facilities, for the association o f other neurological surgeons, or for a nearby golf course? These and many other factors will enter into his choice. But if he is denied training in neurological surgery, he will have no choice to make. People, whether they reside in Canada or the United States, are entitled to the best possible neurosurgical care. The ultimate may not always be obtainable, but we can always strive to attain that goal. PAUL C. BUCY, M.D., Editor
Don't Delay Repeatedly, SURGICALNEUROLOGY has urged that patients with signs or symptoms suggesting the possibility that they have a brain tumor should be investigated earlier than they usually are. N o one would doubt that cerebral neoplasms continue to grow as long as they remain in the brain. N o one would doubt that it is more difficult to remove a cerebral neoplasm completely when it has been present for a long time and is larger and has done more damage to the brain. What has not been adequately recognized is that gliomas are not malignant tumors. If they are removed completely, the patients will be cured. Recently, Blume and his associates (Ann Neurol 1982; 12:538-41) have reported on a series of 35 patients under 21 years o f age who had focal epileptic seizures and who were found during surgery to have brain tumors in 16 instances. The mean duration o f symptoms prior to operation was 6 years in this group. Twelve of these 16 patients who had a brain tumor had a normal neurological examination. There can be no doubt that patients with focal seizures commonly have a brain tumor,
regardless of the age of the patient. All such patients should have a neurological examination, even though in this series, such examinations were not very productive. All patients with focal epileptic seizures should have an x-ray examination of their skulls. Most important of all. all patients with focal epileptic seizures should have an enhanced computed tomography (CT) scan. Most o f the tumors in the young patients reported in this article had slowly growing tumors--astrocytomas and oligodendrogliomas--for the most part, and only one glioblastoma multiforme. These are the tumors with the best outlook. These are the patients deserving of early diagnosis and intense efforts to remove their tumors completely. We neurological surgeons are still not doing well in curing cerebral gliomas. Almost all patients with such tumors still eventually die o f their tumors. We can do better; but, if we are to do so, we must operate and remove these tumors completely as early as possible. PAUL C. BUCY, M.D., Editor
lems this is creating, and stimulate clinicians and radiologists to re-establish the original, and still existing, convention o f presenting cranial scans as viewed from above the patient, not as from below (Figure 1). Manufacturers of computerized scanning equipment should give serious thought to offering the conversion of cranial scans to displays acceptable to clinicians and to facilitate such conversion by direct negotiation with the owners
Surg Neurol 1983;19:554-9
555
of the equipment. T h e editorial boards of leading journals of neurology, neurosurgery, and neuroradiology are in an excellent position to help restore sanity and to protect the patients by ending this left-right confusion. J O H N SHILLITO, Jr., M.D. President of the Society of Neurological Surgeons Associate Chief in Neurosurgery. Children'., Hospital. Medical Center. Boston.
How Many Operations? N o t infrequently, one hears the statement that practicing neurological surgeons are not performing many operations. What is the evidence upon which such statements are based? Is it necessary that a neurosurgeon operate upon many brain tumors, spinal cord tumors, or aneurysms to be regarded as an adequate neurological surgeon? Is the man who treats seriously injured patients with severe head injuries or injuries to the spinal cord any less of a neurological surgeon than one who treats many patients with brain tumors? Is the neurosurgeon who relieves patients o f their back pain and sciatica and restores them to work a lesser surgeon? Certainly not! T h e neurological surgeon who is fulfilling his obligation is one who is serving his patients with his own type o f surgical skill. It could even be argued that one who saves a life by removing an intracranial hematoma is doing even m o r e for mankind than one who operates upon brain tumors. Let us stop classifying our fellow neurological sur-
geons as being greater or lesser because of the type of neurosurgical service which they supply. Let us also stop mouthing the unjustified statement that neurosurgeons are not doing enough operations. Before making such statements, we should actually know exactly what each neurosurgeon is doing and how well he is serving his community. At the m o m e n t , no one knows that, nor could he know it without making a massive survey of all the neurological surgeons in the United States. Such a survey may actually be impossible to make but nothing less will answer this question. It appears that very few neurological surgeons are spending their time twiddling their thumbs. Most of them seem to be busy. T h e y are not busy with work which they have made for themselves. They are busy because of the demands which their communities are making upon them. PAUL C. BUCY, M.D., Editor
Availability of Neurosurgical Care in Canada and the United States A man's reach will always exceed his grasp, to paraphrase R o b e r t Browning. It is all well and good to recognize that the ideal is m o r e than we can achieve, but it is never m o r e than we should seek. It was not long ago that the patients who developed an acute extradural intracranial h e m a t o m a was c o n d e m n e d to die because of the lack of adequate surgical care. Fortunately, that situation has in large measure been remedied, but still, not everywhere
or for everyone. T h e r e remain large areas of N o r t h America where adequate neurosurgical care is not available, particularly for neurosurgical emergencies. Recently, SURGICALNEUROLOGY published an analysis of the distribution of neurological surgeons throughout the world except in Canada and the United States. At this time, we propose to analyze, in detail, the situation in those two countries.
T a b l e 1. Neurosurgeons in the United States and Canada Number
of Area
Population
neurosurgeons
Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan
24,088,700 2,135,900 2,687,000 1,027,000 709,100 583,600 856,100 8,600,500 124,100 6,325,200 975,700
175 13 25 4 5 2 5 59 1 54 7
U n i t e d States Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
226,504,825 3,890,061 400,481 2,717,866 2,285,513 23,668,562 2,888,834 3,107,576 595,225 637,651 9,739,992 5,464,265 965,000 943,935 11,418,461 5,490,179 2,913,387 2,363,208 3,661,433 4,203,972 1,124,660 4,216,446 5,737,037 9,258,344 4,077,148 2,250,638 4,917,444 786,690 1,570,006 799,184 920,610 7,364,158 1,299,968 17,557,288 5,874,429 652,695 10,797,419 3,025,266 2,632,663 11,866,728 3,196,520 947,154 3,119,208 690,178 4,590,750 14,228,383 1,461,037 511,456 5,346,279 4,130,163 1,949,644 4,705,335 470,816
2,997 44 3 35 23 454 36 56 9 38 134 64 18 7 129 50 30 14 40 59 14 90 91 88 44 30 61 11 14 16 8 65 15 221 64 12 132 26 50 132 22 13 28 6 75 186 16 6 79 61 18 57 3
Canada
Ratio 1 per 1 per 1 per 1 per 1 per 1 per 1 per 1 per 1 per I per 1 per
137,650 164,300 107,480 256,750 141,820 291,800 171,220 145,771 124,100 117,133 139,386
1 per v5,577 1 per 88,410 1 per 133,494 1 per 77,653 1 per 99,370 1 per 52,133 1 per 80,245 1 per 55,492 1 per 66,136 1 per 16,780 1 per 72,687 1 per 85,379 1 per 53,611 1 per 142,857 1 per 88,515 1 per 11)9,803 1per 97,113 1 per 168,101 1 per 91,536 1 per 71,254 1 per 80,333 1 per 46,849 1 per 63,044 1 per 105,208 1 per 92,622 1 per 75,021 1 per 80,614 1 per 71,517 1 per 112,143 1 per 49,949 1 per 115,(}76 1 per 113,294 1 per 86,565 1 per 79,445 1 per 91,788 1 per 57,726 1 per 107,974 1 per 116,357 1 per 52,653 1 per 89,899 1 per 145,296 1 per 72,858 1 per 111,400 1 per 115,030 1 per 61,210 i per 76,497 1 per 91,315 1 per 85,243 1 per 67,674 1 per 67,708 1 per 108,314 1 per 82,550 1 per 156,939
Editorials
In the March 1982 issue of SURGICALNEUROLOGY (1982;17:223-6), Watts and Adelstein published an important analysis of "Access to Neurosurgical Care" in the United States. They pointed out that there are areas in the United States in which people do not have adequate access to neurosurgical care based largely upon the distance separating the patient and the neurosurgeon. These areas include parts of Arizona, Kansas, Montana, Nebraska, Nevada, N e w Mexico, Oregon, South Dakota, Texas, Utah, and Wyoming. A glance at the map which they have provide confirms their conclusions. We propose here to approach this problem somewhat differently and to include Canada. As Watts and Adelstein pointed out, the considerations of the total number of neurological surgeons to the total population of these two countries is largely meaningless in determining the availability of neurosurgical care. Those figures are approximately one neurosurgeon to every 75,500 people in the United States and one neurosurgeon for every 137,650 people in Canada. The figures which will be used in the analysis published here have been taken from the World Directory o f Neurological Surgeons--Part I: United States of America and Canada (published in April 1980 by the Congress of Neurological Surgeons) as to the number and distribution of neurological surgeons; and from the World Almanac and Book of Facts for 1982 (published by Newspaper Enterprise Association, Inc. of New York) as to the figures o f population. Admittedly, these figures may vary somewhat in 1983, but they are the best figures readily available at this time. Furthermore, it is unlikely that retirements or deaths of neurological surgeons or changes in population since these figures were compiled would greatly alter the results of our analysis or our conclusions. In Canada, in spite of the obvious differences from the United States in the system of the delivery of medical care for the country as a whole, it is obvious that some striking discrepancies exist. Both Newfoundland and Manitoba have undesirably high ratios in the relation o f the number of neurological surgeons to the populat i o n - o n e neurosurgeon for 291,800 people in Newfoundland, and for 256,750 people in Manitoba. Even in the provinces where there are proportionately more neurological surgeons for the number of people, there is still a lack of availability of neurosurgical care for some o f the people. In British Columbia, which has the largest number of neurological surgeons in proportion to the total population, the majority of the neurosurgeons are located in Victoria, at the southern tip of Vancouver Island which is approximately 290 miles long, and around Vancouver in the southwestern part of mainland British Columbia, which is approximately 1,000 miles long and
Surg Neurol 1983;19:554-9
557
400 miles wide. Obviously many people in this province do not have neurosurgical care readily available. A Similar situation exists in Newfoundland. In Quebec where most of the neurological surgeons are in Montreal and Quebec City, there are many people who are either denied emergency neurosurgical care or must travel many miles to obtain neurosurgical care under any circumstances. Admittedly, in Quebec and Ontario much of the area in the northern part of these provinces is sparsely settled. In the more western provinces, the situation is considerably different. In Manitoba, all of the neurological surgeons are in Winnipeg; in Saskatchewan, they are in Regina and Saskatoon; and in Alberta, in Calgary and Edmonton. In each of these provinces, these cities are often a hundred miles or even much farther from many people. It would appear that Canada should have a larger number of neurological surgeons. To be sure, an increase in the numbers will not o f and by itself insure the availability o f neurosurgical care, but an increased number will go some ways in improving the situation. In the United States, in spite of a much greater number of neurological surgeons, the problem of providing adequate neurosurgical care is similarly deficient in a number of areas. A look again at the map provided by Watts and Adelstein will show that the deficient areas are most obviously in eastern Oregon, Nevada, southwestern Utah, northern Arizona, southern New Mexico, much of Montana and South Dakota, western N o r t h Dakota, central Nebraska, western Kansas and Oklahoma and southwestern Texas. SURGICALNEUROLOGY would be the last to accept that these deficiencies should be repaired by governmental fiat, but it would be among the first to insist that reducing the number of neurosurgical training programs will go far to maintaining the obvious lack of ability to obtain proper neurosurgical care. Let us look, for the moment, at the distribution of neurological surgeons in the different states as revealed by this survey. Those states where the number of neurological surgeons is large for the population--District of Columbia, California, Connecticut, Hawaii, Maryland and O r e g o n - - a l l with under 60,000 people being served by each neurosurgeon, are extremely varied. N o single explanation seems to fit all of them. The number of neurosurgeons in the District of Columbia appears to be high for at least two very different reasons: (a) the number of neurosurgeons associated with the governmen or the military; and (b) the fact that this city of limited area also serves the people of northern Virginia and neighboring Maryland. California and Hawaii might be regarded as areas having a more ideal climate. Maryland, Nevada, and Oregon, which have one neurosurgeon for 47,000, 50,000, and 53,000 people respectively, are also states in which there appears to be a very
558
Surg Neurol 1983;19:554-9
uneven distribution o f neurosurgical care, part of each state being inadequately served. Those states in which there is only one neurosurgeon for more than 100,000 people are also varied. They are Alaska, Idaho, Kansas, Michigan, Nebraska, N e w Hampshire, N e w Jersey, Ohio, Oklahoma, Puerto Rico, South Carolina, South Dakota, West Virginia, and Wyoming. SURGICALNEUROLOGYdoes not purport to know why these states are less well served nor would we be willing to try to tell the profession or the states what to do about this. We intend only to draw attention to the situation. It may be argued that modern transportation goes far to remedying these deficiencies So far as elective and non-emergency matters are concerned, this is true; but for the real neurosurgical emergencies, this is not true. The patient with a severe craniocerebral injury or an injury to the spine and spinal cord cannot wait to be transported long distances. Even 100 miles may often measure the difference between success and failure in such cases. It is becoming increasingly apparent that ruptured intracranial aneurysms often require very early
Editorials
treatment if good results are to be obtained. The farmer who falls from a horse or tractor o f is injured by a piece o f farm machinery, or the workman on an oil rig is just as deserving of good, prompt neurosurgical care as a man in the heart o f N e w York City or Los Angeles. Where neurological surgeons elect to practice cannot be dictated and is dependent upon many different factors. Does he like the activity of the busy city or the quiet o f the wide open spaces? Does his wife yearn for the cultural and entertainment facilities of an urban setting? Is he looking for exceptional educational opportunities for his children, for excellent hospital facilities, for the association o f other neurological surgeons, or for a nearby golf course? These and many other factors will enter into his choice. But if he is denied training in neurological surgery, he will have no choice to make. People, whether they reside in Canada or the United States, are entitled to the best possible neurosurgical care. The ultimate may not always be obtainable, but we can always strive to attain that goal. PAUL C. BUCY, M.D., Editor
Don't Delay Repeatedly, SURGICALNEUROLOGY has urged that patients with signs or symptoms suggesting the possibility that they have a brain tumor should be investigated earlier than they usually are. N o one would doubt that cerebral neoplasms continue to grow as long as they remain in the brain. N o one would doubt that it is more difficult to remove a cerebral neoplasm completely when it has been present for a long time and is larger and has done more damage to the brain. What has not been adequately recognized is that gliomas are not malignant tumors. If they are removed completely, the patients will be cured. Recently, Blume and his associates (Ann Neurol 1982; 12:538-41) have reported on a series of 35 patients under 21 years o f age who had focal epileptic seizures and who were found during surgery to have brain tumors in 16 instances. The mean duration o f symptoms prior to operation was 6 years in this group. Twelve of these 16 patients who had a brain tumor had a normal neurological examination. There can be no doubt that patients with focal seizures commonly have a brain tumor,
regardless of the age of the patient. All such patients should have a neurological examination, even though in this series, such examinations were not very productive. All patients with focal epileptic seizures should have an x-ray examination of their skulls. Most important of all. all patients with focal epileptic seizures should have an enhanced computed tomography (CT) scan. Most o f the tumors in the young patients reported in this article had slowly growing tumors--astrocytomas and oligodendrogliomas--for the most part, and only one glioblastoma multiforme. These are the tumors with the best outlook. These are the patients deserving of early diagnosis and intense efforts to remove their tumors completely. We neurological surgeons are still not doing well in curing cerebral gliomas. Almost all patients with such tumors still eventually die o f their tumors. We can do better; but, if we are to do so, we must operate and remove these tumors completely as early as possible. PAUL C. BUCY, M.D., Editor