The Evolution of
Carl H. Hauber, J.D., C.A.E., Chris A. Philips
Photograph of the Society of Neurological Surgeons, 1929 meeting attendees.
The integral role played by volunteer associations among the established
scientific disciplines was never more clearly demonstrated than
at the October 1919 meeting of the American College of Surgeons,
at which neurological surgery was declared to exist as a surgical
specialty. Those surgeons in attendance who were most interested
in this work decided that formal meetings for the exchange of
pertinent information should be arranged without delay (25). This
phenomenon, common to all legitimate scientific disciplines, provided
immediate reinforcement for the newest of surgical specialties.
It was a spontaneous and quite natural response for these surgeons
to join together and seek fulfillment of common needs, which could
be satisfied through group interaction. In the words of Harvey
Cushing, who first envisioned this organized effort, the initial
needs were to ". . . discuss our problems and compare results..
. ." Thus, a handful of surgeons committed themselves to
pursue Cushing's suggestion, without thought to the fact that
they were intuitively following a pattern, which, although not
uncommon throughout the western world, has had a profound impact
on sociopolitical development in the United States. With the decision
to join together, they took the first steps to form a voluntary
association in the country that has long been referred to as "the
nation of associations," a social phenomenon that has led
to the existence of a gigantic complex of volunteer institutions
that perform many of the functions that are strictly reserved
for the government elsewhere in the world (4, 7, 9, 10).
Years passed before neurological surgery showed all the essential elements of an established surgical specialty: 1) recognition by the American Medical Association in 1937 of a system of formal postdoctoral education unique to the specialty (11), 2) establishment of the American Board of Neurological Surgery in 1940 (2), and 3) proliferation of residency programs after World War II (27, 28). In contrast, the development of the association structure was rapid and, not unlike those individuals who made up its nucleus, forceful.
The Society of Neurological Surgeons (est. 1920)On March 19, 1920, only 5 months after the October 1919 meeting of the American College of Surgeons commonly accepted the formal genesis of the neurosurgical specialty in the United States, 11 interested surgeons (mostly educators) met at the Peter Bent Brigham Hospital in Boston, with Cushing as host. During the course of this clinical meeting, The Society of Neurological Surgeons was formed. Ernest Sachs recorded the founders as: Alfred Adson, Charles Bagley, Harvey Cushing, Charles Dowman, Charles Frazier, Samuel Harvey, Gilbert Horrax, Dean Lewis, Jason Mixter, Ernest Sachs, and Edward Towne (26). In his history of the first 50 years of The Society of Neurological Surgeons, A. Earl Walker notes that Cushing and Bagley invited Walter Dandy to join, but strained relationships between Dandy and both Frazier and Cushing caused him to decline (3).
The first formal meeting of The Society of Neurological Surgeons (November 26, 1920) was also convened in Boston. The first officers of the Society were Harvey Cushing, President, and Ernest Sachs, Secretary. Dean Lewis became the first Vice President the next year (3, 26). The original purposes of the Society, as set forth in its first adopted bylaws, were: 1) the development of the field of neurosurgery, and 2) the education of the medical profession, particularly the surgeons, in the idea that neurological surgery requires a special training in addition to that of the general surgeon (26).
The format of the meetings (semiannual until 1932 and annual thereafter) remained essentially unchanged until the early 1950s. This change to one meeting per year may have been influenced by the emergence of The Harvey Cushing Society in 1932, which is discussed in the next section. Prominent members took their turns hosting The Society of Neurological Surgeons meetings, which focused on morning operative clinics conducted by the host, then afternoon sessions at which scientific papers were delivered by members of the host institution. Those attending consisted of Society members and the guests whom they sponsored. From among these guests, new members were chosen. As the membership grew, the hosted operative clinic format became impractical and gave way to oral presentations of a growing selection of scientific papers. However, long before this time, the limited meeting format and the restricted access to membership (only open to prominent academicians in the neurosurgical community and limited to 45 members ) left a growing number of surgeons without access to these vital activities. In 1931, The Society of Neurological Surgeons consisted of only 29 members. History was to repeat itself.
The Harvey Cushing Society (est. 1931)Mounting concerns over the lack of a forum, much like that which the original founders of The Society of Neurological Surgeons sought in 1919, caused a group of 23 younger neurosurgeons to gather in Boston on May 6, 1932, to formally establish a second organization, which became known as The Harvey Cushing Society. Once again, legitimate common needs motivated a body of professionals to band together. However, unlike that of its precursor, the genesis of this organization was not spontaneous. Considerable discussion preceded its formal emergence, as those who were to be identified with this effort dealt with their concerns over the reaction that might be expected from their "seniors" who comprised The Society of Neurological Surgeons.
The fascinating dialogue and circumstances leading to the formation of this new society are well documented in a collection of original letters bound into two volumes, the first of which is entitled Notes of the History of the Founding of The Harvey Cushing Society, 1930-1931 (22). These volumes contain the letters between William P. Van Wagenen, R. Glen Spurling, R. Eustace Semmes, and Temple Fay that outline the philosophy and goals of their new society. For example, in his June 24, 1931, letter to Van Wagenen, Spurling describes the need for a new society:
The present society has only about two vacancies left, and that will bring their membership up to thirty-five [sic]. If they get beyond that number, the society will lose much of its charm and usefulness, because, as you undoubtedly realize, the small society is far more desirable from every point of view. Assuming that to be the case, there are, I figure, about 20 men who are doing neuro-surgery exclusively and are doing a good job of it, who will not be included in the membership of the old society for many years to come. In other words, it seems to me that there is a real need and place for another society, not with the idea of making it a stepping stone to the old society, but organized along the lines that would make it desirable to remain independent in its own right. (22)
The letters between the prospective organizers over the next several months often emphasized their beliefs that the new society was not to compete with The Society of Neurological Surgeons and was to allow the potential for neurosurgeons to be members of both societies. The July 17, 193 1, letter to Spurling from Fay captures the essence of the philosophy of the new society and reflects how it is organized to this day:
I am distinctly of the feeling that if this society is organized certain fundamental principles should be established, to avoid some of the difficulties encountered in the older society. I would far rather see a group of younger men organized to meet regularly, in a round table discussion of problems confronting the neurosurgeons, with a definite program assigned, similar to that carried on in the Association for Research in Nervous and Mental Diseases, than to gather each year at some clinic to see the host, 'strut his stuff/ to the envy or unfair criticism of those attending the meeting. I have felt that such a society would have its own place, irrespective of the older men, and would contribute more, in the end, if many of its members were assigned one year in advance, portions of the problem that required unbiased and fair analysis. Such a meeting could make a joint report, after it had heard the evidence from all sides, which could clarify many of the disputed points now under consideration, and advance in an orderly manner towards constructive additions to our neurological knowledge. (22)
Fay clearly recognized the historical need for the personal observation of surgical procedures, as these early neurosurgeons concentrated on the development and refinement of their surgical techniques. He also recognized that there was an emerging need to encourage independent research and developmental efforts by neurosurgeons and proposed that a new society could satisfy these needs by providing a forum for them to discuss their work and report on their results. Fay described this need as follows:
The most important phase of our problem rotates around investigation and advancement in the fields of neurosurgery, with the fundamental needs of establishing methods of early diagnosis and postoperative treatment, directed toward the protection of the patients, and a decrease in mortality. Such a program could be undertaken with a "clinic" as a minor factor. If such a society is organized, I believe it should stand on its own merits, the members feeling sufficient pride in its own maintenance, so that [Subsequent] membership in the older society would be unnecessary, or at least no added advantage. With the dedication of the younger society's activities toward the advancement of research problems, there would be no reason to confuse the two groups. (22)
Never were more visionary thoughts expressed during the period leading up to the formation of The Harvey Cushing Society.
A meeting was held on October 10, 1931, at the Hotel Raleigh in Washington, D.C., with Fay, Semmes, Spurling, and Van Wagenen in attendance. It was at this meeting that they decided that this new society was to encompass the disciplines of neurosurgery, medical neurology, neurophysiology, neuropathology, and roentgenology (29). They compiled a list of 36 physicians who would be encouraged to attend an organizational meeting for this new society.
Perhaps the most important decision the founders made was to consult Cushing about these plans. Less than a week after the organizational meeting, Van Wagenen visited "the Chief" and outlined plans for the new society. He discussed this visit in an October 15, 1931, letter to Spurling:
All told he was very much in favor of the idea as presented to him. He said that he had felt for a number of years that the old society had become too gastronomically inclined to be of much use. I believe that he also will allow us to use his name in connection with the society. (22)
Plans for the new society progressed, and, with Cushing's endorsement, most of those who were initially approached in connection with founding membership were quick to accept. In a great show of generosity and patriarchal pride in these plans that were made by so many of his past residents, Cushing offered to provide the facilities for the first meeting. This may have been the singular event that insured the acceptance of this new society, for no further notations fearing the displeasure of the "old society" are found in the letters. However, the format of this initial meeting resembled The Society of Neurological Surgeons meetings much more than it resembled the original concepts of its founders!
The first meeting of the new society was held on May 6, 1932, in Boston. Dr. Cushing welcomed 23 of the charter members, saying that he felt like an obstetrician bringing a new and protesting offspring into existence. He also cautioned them to remember that in 1 0 years' time, another group would be coming along that would look upon the present one as "senile and antiquated" (5).
The following officers were elected: William P. Van Wagenen, President; Glen Spurling, Vice-President; and Tracy Putnam, Secretary/Treasurer. After much discussion and many interesting suggestions, the name "The Harvey Cushing Society" was adopted. The single purpose of The Harvey Cushing Society, as stated in its first bylaws, was to promote the advancement of the various fields of organic neurology. Despite the lofty goals of The Harvey Cushing Society founders, and the genuine effort to broaden the scientific scope of the Society's meetings, membership was limited to just 35 at the outset (to include not only neurosurgeons but other neuroscientists, as aforementioned). The membership limit was increased to 50 in 1936, resulting in heated discussions the next year about "retiring" active members after 7 years to preserve the youth and integrity of the Society. Despite all of this, the number of members remained at fewer than 40 for several years. In fact, it took only 7 short years for The Harvey Cushing Society to find itself facing the very same challenge that brought it into existence, the disinclination to recognize and respond to the needs of the discipline to which it had devoted itself. In its initial form, The Harvey Cushing Society took its place alongside The Society of Neurological Surgeons as another inaccessible club.
The American Academy of Neurological Surgeons (est. 1938)In his history of the first 50 years of the Academy (23), Byron C. Pevehouse notes that the self-imposed limitation on total membership by both of the existing societies (as detailed in the previous sections) resulted in a growing number of neurological surgeons who were unable to participate in organized activities, except as invited guests. The specialty was simply growing faster than either organization desired to expand its membership.
The tendency of The Harvey Cushing Society not to respond to the needs of the younger element of the specialty clearly surfaced at the Society's Seventh Annual Meeting in Memphis, in 1938, where the leadership, including President Temple Fay, suggested that these young neurosurgeons might best solve their own problem by forming a third neurosurgical society. At the time, it was estimated that some 25 neurological surgeons in the United States were without organization affiliations. Several individuals (Spencer Braden, Dean Echols, Joseph Evans, William S. Keith, Frank Mayfield, Francis Murphey, and John Raaf) took the suggestion of a new society to heart and immediately convened an organizational meeting (April 22,1938, in Memphis), at which they agreed to establish the third neurosurgical society. Cincinnati was selected as the site of the First Annual Meeting, to be convened the next October.
At that first meeting (October 28, 1938), the new organization was named The Academy of Neurosurgery (somewhat a misnomer, as it was not intended to limit the membership to academicians), and the following officers were elected: Dean H. Echols, President, and Francis Murphey, Secretary/Treasurer. The name was later changed to The American Academy of Neurological Surgery.
Distinguishing this association somewhat from those preceding it, the organizers of the Academy decided that scientific attainment was not the only important factor to be considered in the selection of new members and that the interpersonal qualities of the candidates were to be assessed as well. This call for social compatibility among peers seems to reflect fundamental concerns among the "outsiders" of the time and suggests that the "private club" image of the established societies weighed heavily in the shaping of the Academy. The organizers even considered a plan similar to that which caused so much controversy among The Harvey Cushing Society leaders just 2 years before, suggesting that active membership be limited to 10 years to make room for younger members, insuring perpetuation of the Academy and avoiding the need for a fourth society. This suggestion was finally rejected by the Academy's leaders, just as it had been by the leaders of The Harvey Cushing Society.
Pevehouse reports that, at the Eighth Annual Meeting of the Academy (September 1946), as many as 20 invited guests were present. Only 4 new members were elected to membership, raising the total to 43. Serious discussions ensued regarding the many fine young neurosurgeons who wanted to become members. Lengthy discussions during this meeting, and again at the Ninth Annual Meeting in 1947, are said to have detracted from the usual positive tenor of Academy meetings. Interestingly, it was at the Tenth Annual Meeting of the Academy that Mayfield launched his first effort to resolve the multi-association conundrum, which had become a source of ongoing frustration to members and nonmembers alike. His concept envisioned combining the three associations into a single national body. After considerable discussion, the matter was referred to the Academy's Executive Committee for study.
With all the discussion and expressions of frustration, in the final analysis, a solution to finding a niche for the growing number of young neurosurgeons eluded the organized community. Simply stated, the members of the three existing societies placed a greater value on the professional and social intimacy that their limited numbers provided than they placed on any sort of obligation to assist their juniors along the path of professional growth. Thus, less than a decade after the Academy was established, a new generation of neurosurgeons who could not find a place in the existing societal structures was faced with forming its own group to satisfy these needs.
The Neurosurgical Society of America (est. 1948)It was Arthur Morris who, acting upon conversations with R. Eustace Semmes (one of the founders of The Harvey Cushing Society), decided to discover whether there was sufficient interest among other unaffiliated neurosurgeons to support the formation of yet another neurosurgical society. The response was encouraging and resulted in a meeting of the 17 founders who were listed in The Neurosurgical Society of America: 25th Anniversary Volume (Claude Bertrand, Joseph F. Dorsey, Carl J. Graf, C. Douglas Hawkes, Lew Helfer, Thomas J. Holbrook, Everett F. Hurteau, Harry P. Maxwell, William F. Meacham, Arthur Morris, William B. Patton, Frank J. Otenasek, George E. Roulhac, Edward B. Schlesinger, I. Joshua Spiegel, Charles E. Troland, and Jack I. Woolf). The first elected officers were: Arthur Morris, President; Frank Otenasek, Vice President; Jack Woolf, Recording Secretary; Edward Schlesinger, Corresponding Secretary; and I. Joshua Spiegel, Treasurer. Joseph F. Dorsey, C. Douglas Hawkes, and George Roulhac were elected Councilors (21). The new society was originally named The Neurosurgical Society of North America, in deference to Canadian founder Bertrand and an anticipated Canadian constituency.
This new society was the first to structurally commit to a youthful membership, originally limiting active membership to neurological surgeons under age 45 and requiring transfer to a senior category of membership when members reached that age. In later years, when the first members became subject to this restriction, the bylaws were changed to allow them to continue in active membership!
This Society did not distinguish between academicians and private practitioners. Instead, it placed strong emphasis upon members and their families, encouraging the attendance of wives and children at annual meetings and selecting meeting locations conducive to this sort of involvement. According to The Neurosurgical Society of America: 25th Anniversary Volume, it was equally clear that the approach to the Annual Scientific Program was to be less formal and unfettered by tradition:
The tradition of frank, searching but friendly discussion of the papers in depth was inaugurated and set a useful pattern for the future. The usefulness of a society geared to sharing mutual problems, unhampered by conventional constraints on candor and debate was immediately apparent. (21)
Although The Neurosurgical Society of America had established a permanent and useful niche in the organizational milieu of neurosurgery, it certainly was not seen by the neurosurgical community as a solution to the problem of providing universal access to significant organizational activities and relationships among colleagues. This Society was to be the fourth and the last of the series of "limited access societies" that, at their origin, seemingly offered the final solution to the "insiders versus outsiders" problem that had plagued neurosurgery since it was first recognized that The Society of Neurological Surgeons was not destined to be the ultimate forum for all neurosurgeons.
A NEW ERA FOR ORGANIZATIONThe post-World War II years witnessed unprecedented growth in the numbers of neurological surgeons and major repositioning in neurosurgery's organizational complex. The Harvey Cushing Society, which had limited membership to Board-certified neurological surgeons just 2 years after the American Board of Neurological Surgery was established in 1940 (29), gradually emerged as the principal forum for both discussion and publication of important developments in neurological surgery. However, Board certification would prove to be the next (and perhaps the final) arbitrary obstacle to accessing the organizational relationships that virtually every neurological surgeon has insisted on since the specialty emerged.
Congress of Neurological Surgeons (est. 1951)Only 2 years after The Neurosurgical Society of America was founded, an important chapter in the history of organized neurosurgery unfolded. An association was formed with no ostensible limitations to membership among neurosurgeons. All neurosurgeons were welcome, including those who were youthful or experienced, those who were Board certified or non-Board certified, and those from any country of origin. This new association envisioned, as the key to protecting its liberal membership philosophies, a firm policy to limit the age of its leadership to 45 years. Unlike the more drastic measure originally taken by The Neurosurgical Society of America (to limit the age of all active members to 45 years), this innovative concept stood the test of time and remains in effect today (8).
The origin of the Congress of Neurological Surgeons can be traced to the September 1950 meeting of a group of neurological surgeons at Sea Island, GA, then to a Chicago meeting on February 6, 1951, which resulted in the distribution of invitations to attend a formational meeting the next May in St. Louis. Twenty-two neurosurgeons attended. The following purposes were agreed upon: 1) to study and discuss the principles of neurological surgery, 2) to study developments in scientific fields allied to neurological surgery, and 3) to honor living leaders in the field of neurological surgery. The first officers were: Elmer C. Schultz, President; Carroll A. Brown, Vice President; and Bland W. Cannon, Secretary. The "Congress," as it was to become known, convened its First Annual Meeting in Memphis on November 15,1951. During its 1st year in existence, membership grew to nearly 70 active members, which was larger than the active membership of any other neurosurgical organization except The Harvey Cushing Society, a remarkable testimonial to the genuine need for such an organization.
THE ERA OF PARALLELISM: THE CUSHING AND THE CONGRESS
In the years that followed, The Cushing Society (with its annual meeting in the spring) and the Congress (convening its annual meeting each fall) both thrived. The Cushing Society concentrated on communicating significant scientific developments in both its annual meeting program and its principal publication, The Journal of Neurosurgery (6, 12, 28). The Congress maintained a decidedly didactic format, inviting selected leaders in the field to discuss their work and making every practical effort to encourage young neurosurgeons and neurosurgical residents to participate, thus exposing these young professionals to a broad range of practical philosophies and techniques. In 1977, the establishment of the official journal of the Congress, Neurosurgery (30), allowed for broader dissemination of information in this dimension.
Although The Cushing Society continued to wrestle with the fact that a significant element of the specialty was not qualified to join its ranks, its leaders would not compromise the Board certification prerequisite. Even concepts of provisional membership were consistently rejected. Despite the organizational complexities that can be traced to this restrictive philosophy, it must be observed that the insistence upon Board certification as the hallmark of neurosurgical practice has had a profound impact on the quality of neurosurgical care delivered in the United States. Moreover, this philosophy is supported, without reserve, by all established neurosurgical societies, including the Congress, which has contributed significantly to preparing young neurological surgeons for that "final step" in their career preparation, the Oral Board Examination.
As the years passed and these two organizations continued to develop in parallel, another significant factor emerged. When younger neurosurgeons became Board certified and joined The Cushing Society, they did not drop out of the Congress. Instead, most maintained membership in both organizations, attesting to the valuable role that each has played in the professional lives of contemporary neurological surgeons.
A NATIONAL SPOKESMAN FOR NEUROSURGERY
It was in 1962 that Hendrick J. Svein, then Secretary of The Cushing Society, raised the issue that was first touched upon by Frank H. Mayfield at The American Academy of Neurological Surgeons meeting in 1948, that of forming a single organizational voice for the neurosurgical community (29). Although Mayfield originally suggested combining the three existing associations, Svein threw the gauntlet down before The Harvey Cushing Society:
During the last several years I have occasionally had some misgivings and doubts as to whether or not The Harvey Cushing Society is fulfilling its obligations to its members. These misgivings and doubts can be pretty well summarized by asking the question, should neurosurgery in this country have an official spokesman: if so, who? Should The Harvey Cushing Society not be a bit more imaginative, a bit more aggressive, and provide a bit more in the way of leadership? There are many areas and problems which directly involve neurosurgery and neurosurgeons in this country in which I think The Harvey Cushing Society should interest itself and serve as an official spokesman. (29)
Mayfield was to become President-elect of The Cushing Society the next year. Later, he was to reflect upon his strategy:
The educational and social experiences derived from membership in The Harvey Cushing Society were consuming, but I continued to be concerned by its failure to deal with [this] important problem. The post of President-Elect, with the assurance that I would become President, appeared to me to provide the opportunity to address this issue. (29)
And so he did address the issue, gathering his political forces and diplomatically paving the way for this major step in the organizational listing of the neurosurgical specialty (29). Two years later, at the end of his term as The Cushing Society President, and with all of his plans carefully laid, he used his Presidential Address to issue what was to become known as the "Mayfield Proclamation:"
... by rather common agreement among neurosurgeons within the United States, and I think throughout the world, The Harvey Cushing Society has in fact become the representative organization for neurosurgeons within the United States. . . . with the approval of the Board of Directors of The Harvey Cushing Society, I, Frank H. Mayfield, President, do hereby proclaim The Harvey Cushing Society, Inc. to be in fact the official organization representing the neurological surgeons of the United States ... (13)
Mayfield went on to suggest that the name not be changed but that an appropriate subtitle be added. The Cushing Society's Articles of Incorporation were amended just I year later (May 1966) to add "The American Association of Neurological Surgeons," in parentheses after the official name. That same year, the bylaws of The Cushing Society were amended to realign the Board of Directors in such a way as to provide representation from the other four national neurosurgical societies (The American Academy of Neurological Surgeons, the Congress of Neurological Surgeons, The Neurosurgical Society of America, and The Society of Neurological Surgeons).
In 1967, the transition continued. The name, The Harvey Cushing Society, was changed to the name the society maintains today: "The American Association of Neurological Surgeons, founded in 1931 as The Harvey Cushing Society," soon to become known as "AANS."
The American Association of Neurological Surgeons
The bylaws were amended in 1967, this time in reaction to an appeal from the Canadian Neurosurgical Society, reminding AANS leadership that this society was designed to represent all neurological surgeons on the North American continent, that membership was not exclusively available to those certified by the American Board of Neurological Surgery, but was equally available to certificants of the Canadian Royal College of Physicians and Surgeons (Neurosurgery). Furthermore, the Canadian Society stressed that the Canadian constituency of the AANS was of sufficient size when compared with the memberships of any association in the United States except the Congress of Neurological Surgeons. A representative of the Canadian Neurosurgical Society was added to the AANS Board of Directors. That same year, the Chairman of the AANS Membership Committee was removed from the Board of Directors in favor of a Board member-at-large, once again underlining the effort of the AANS leadership to equitably represent the interests of all members of the specialty, whatever their chosen affiliation (or lack thereof).
In the years that ensued, the sociopolitical distinction between the AANS and the Congress, on the one hand, and the other more narrow-interest neurosurgical societies, on the other hand, became progressively more clear. At the same time, this "grass roots" element became more and more vocal, principally through the forum made available by a joint Socio-Economics Committee (JSEC), one of four operational committees maintained conjointly by the AANS and the Congress. These activities continued to intensify as the JSEC met twice each year (at the AANS and the Congress annual meetings). Through deliberations of state delegates, resolutions were framed and presented to the two parent organizations for consideration. Finally, these and related activities resulted in some profound changes in the AANS structure as state representatives sought a greater voice in the national affairs of neurosurgery. The following summary of this evolution, extracted from the official records of the AANS, was first cataloged by Byron C. Pevehouse (24).
In 1976, the AANS bylaws were amended to add two members-at-large to the Board of Directors, bringing the total to three. These three Board members were each assigned to represent a region of the United States (Eastern, Mid-country, and Western). Not satisfied with this solution, the JSEC suggested that the three Board members-at-large be replaced by four Board members, each representing one of four geographical quadrants, defined by the JSEC as Northeast, Southeast, Northwest, and Southwest. In 1977, the AANS bylaws were once again amended, reflecting this suggestion. The Board, now comprised of five officers, the two most recent past presidents, five neurosurgical society representatives, and four quadrant representatives, was the largest ever to manage the AANS. This Board configuration remained unchanged until 1980 when a strong backlash occurred, bringing into question the advisability of allowing the majority of the AANS Board of Directors (9 of 16) to be selected by either another neurosurgical society or a joint committee.
Again, the bylaws were amended, eliminating all nine of these special interest positions on the Board of Directors and adding an equal number of Board members-at-large, to be elected by the general membership. The most senior of the two past-presidents was also eliminated, reducing the size of the Board to 15 members. This "nationalized" concept was to last only 3 years, when members of the former JSEC, now the Joint Council of State Neurosurgical Societies, sponsored an amendment to the AANS bylaws reinstituting directorship for the four regional quadrants and stipulating that the nominees be selected by the state delegates from each quadrant.
Over the next decade, the bylaws were amended several times; each successive amendment provided a more equitable balance between the AANS Nominating Committee, other organized "power bases," and the grass roots membership. This delicate balance was further enhanced by a carefully constructed nominating protocol, later supplemented by nomination procedural requirements that were levied upon the quadrants to ensure that individual members were provided every opportunity to participate in the nominating process.
The final composition of the Board of Directors, as it exists today (five officers, one past-president, five members-at-large, and four quadrant members), was supplemented in 1992 by the addition of a non-voting liaison from the Young Neurosurgeons Committee, established that same year (14). Involvement of young neurosurgeons in the leadership of the AANS vaulted from desirable to essential when the AANS bylaws were amended to provide voting membership for a "provisional" class of membership designed to encompass those individuals who have completed their residencies and who are fulfilling practice requirements before taking their Oral Board examinations.
ORGANIZED NEUROSURGERY TODAY
The years that came after the Mayfield Proclamation were truly evolutionary in terms of taking organized neurosurgery out of the hands of a few dynamic individuals and projecting the decision-making process well out into the neurosurgical community. The AANS Board of Directors was undoubtedly cognizant of the axiom that association leaders who feel directly answerable to their constituencies will reflect that obligation in their decision-making processes. Those leaders who sense a freedom from this link tend to demonstrate a propensity to do as they see fit. Irrespective of their commitment and their sincerity, it is inevitable that association leaders who take this latter course may be remembered for their valor and their panache but not for their sensitivity and their responsiveness to the members who must rely upon elected leaders to ensure that they are not forgotten in the heat of battles that are fought in their names!
During the years of rapid evolution experienced by the AANS, the relationship between the two major neurosurgical associations (the AANS and the Congress) has cycled several times between harmony and uncomfortable truce, with the other neurosurgical societies remaining essentially uninvolved. Problems, for the most part, can be traced to strong individuals (and groups of strong individuals) among the respective leaderships who were inclined toward less-than positive interpretations of the actions of their counterparts.
Although precious time and resources have been wasted on these political skirmishes, the parallel relationship of the AANS and the Congress has fared quite well in terms of reflecting the fundamental needs of the neurosurgical community. In fact, the element of competition can be seen as a driving motivation to both organizations, with the AANS leaders feeling closely scrutinized in their judgments and evaluated on the results and the Congress leaders striving to attain a position of greater parity in key scientific, educational, and sociopolitical areas of interest.
The Joint Committees, another phenomenon of the parallel structure were designed to serve the specialty in four key operational areas. In addition to the socioeconomically oriented forum discussed previously, the AANS and the Congress have provided for Joint Committees in the areas of education, government-related activities, and the assessment of substances and devices. Although these joint efforts have minimized duplication of effort and costly parallel operations in some key areas, they have had a tendency to operate somewhat independently of their parent organizations. It would be unfair to blame this condition on the joint Committees. To the contrary, the examination of official records from both parent organizations demonstrates (with important exceptions) that the Joint Committees were left without defined charges and specific directions, designed to take maximum advantage of their substantial capabilities. The results of joint Committee activity, although often productive and of notable value to the specialty, were not part of any "master plan" conceived by the AANS and the Congress to bring these substantial resources to bear on the highest priority challenges facing the specialty at any given point in time. In fact, until the strategic planning activities of the parent organizations are more closely coordinated, it will be difficult to realize the potential of these joint operational arms.
To further complicate matters, the activities generated by these joint Committees were reported separately to the parent organizations, resulting in independent deliberations and decisions. Inevitable inconsistencies required subsequent resolution, a cumbersome and time-consuming process, frequently taking months to accomplish, and even prompting a notable element of independent activity at the Committee level. This condition presented a formidable obstacle to AANS efforts to fulfill its "national spokesman" role and ultimately prompted a decisive reaction from throughout organized neurosurgery.
By mutual agreement among the established neurosurgical societies, the Liaison Committee was established, consisting of the presidents and presidents-elect of the AANS, the Congress, The Canadian Neurosurgical Society, the Academy, The Neurosurgical Society of America, and The Society of Neurological Surgeons. This Liaison Committee met in April 1976 at the AANS Annual Meeting (20). Only the Canadian Society was not in attendance. The AANS was represented by Richard DeSaussure (outgoing President), Lester Mount (incoming President), Charles Drake (President-elect), and Donald Dohn (Secretary); the Congress representatives were Robert Ojemann (President), Bruce Sorenson (President-elect), and David Kelly (Secretary); the Academy was represented by William Sweet (President-elect); The Neurosurgical Society of America representatives were George Ehni (President) and Shelley Chou (President-elect); and The Society of Neurological Surgeons was represented by William Collins (Secretary). The purpose of the meeting was to deal with a general concern over the need to ensure that the neurosurgical specialty would be heard as a single voice and not through random opinions being expressed without prior consensus among applicable leaders. Apparently, the greatest concern lay in unauthorized testimony and statements on the Washington scene. Other problems involved the overlap in committee work and the negative effect that could result from a lack of harmony in such activities. The difficulty in coordinating other Joint Committees (in addition to the Washington Committee) was voiced, and discomfort was expressed over the lack of budget controls. It was clear that the organized neurosurgical community was not at all comfortable with the manner in which the national spokesman role, delegated to the AANS in 1965, was being diluted. The Committee called upon the AANS and the Congress, along with their Joint Committees, to find a solution to this problem.
Soon thereafter, the presidents and secretaries of the AANS and the Congress met in New York City (18). After considerable discussion, it was agreed that regularly scheduled joint meetings of the AANS and the Congress officers should be convened for the purpose of ensuring that organized surgery would speak with a single voice that reflected previously agreed-upon policies.
The first meeting of the Joint Officers convened in October 1976 at the Congress annual meeting in New Orleans. Although the parent organizations vested no decision-making authority in this joint meeting process, understanding and coordination between the two broadly based associations improved markedly. However, as the years have passed, demands upon organized medicine (including neurosurgery) have increased exponentially, as has the flow of important information throughout the specialty and between the AANS and the Congress. By the mid-1980s, the Joint Officers had become as much a "bottleneck" in the communications flow as it was a solution to the problem of coordinating these important activities.
In 1991, AANS President James T. Robertson convinced the AANS Board of Directors that, if the Congress was to continue to share equally in the critical decision-making process that supported the national spokesman role, then it should share equally in the substantial costs related to all of these activities (16). Robertson envisioned the Congress as an equal "stakeholder" in all of neurosurgery's support facilities, most of which are owned by the AANS. He suggested that the AANS Board of Directors and the Congress Executive Committee could together direct the Joint Officers, who would, in turn, be empowered to manage and coordinate all operational activities in support of the neurosurgical specialty. The Congress leaders decided that they did not want to undertake this responsibility. Instead, their alternative solution was that the joint Officers be delegated the authority to manage the Joint Committees (including the Joint Council of State Neurosurgical Societies, formerly JSEC and such other joint activities that the two parent organizations deemed appropriate. They, in turn, agreed that the AANS President would chair all joint Officers meetings thereafter and that tie votes of the Joint Officers would be decided by the AANS President. These latter provisions were designed to preserve the national spokesman role of the AANS within the new structure, while at the same time providing the younger Congress leaders maximum participation in the deliberations on issues affecting the specialty. This concept was adopted by the joint Officers (19) and later by the AANS Board of Directors (15) and the Congress Executive Committee (17).
At this writing, the new joint Officers concept has been in effect for 4 years. In that short time, it has been demonstrated that the decision-making process could be streamlined without further complicating the national spokesman role.
THE FUTURE OF ORGANIZED NEUROSURGERY
Over the years, many well-meaning individuals (and groups) have brought forth "solutions" to the somewhat ungainly parallel structure within which organized neurosurgery has continued to function. There were those who would form an "umbrella organization." Others would merge the AANS and the Congress into a single organization. Some would be content to simply dissolve one of the organizations altogether. However , these are not three distinct suggestions at all. They encompass a single concept, variously described, to seek compatibility with as many interests as possible within the specialty. Why then, when a national survey (1) of neurosurgeons demonstrated that a substantial majority of the neurosurgical community would favor a single organization, has some formal amalgamation not occurred? Is it because the ultimate structure has not yet been conceived or that the perfect compromise has not yet been negotiated? The solution does not lie in structures and compromises. The Harvey Cushing Society was not formed by some structural genius. Nor was the Congress of Neurological Surgeons the product of diplomatic prowess. These key organizations each emerged in their own time, because the fundamental needs of neurosurgeons were not being met, which resulted in an element of unified action to seek a solution. Yet, as we have shown, The Harvey Cushing Society did not remain static after the Congress came into being. Instead, it entered an unprecedented period of development. After 15 years of parallel activity, it was The Cushing Society/AANS, a somewhat unwieldy organization, but nonetheless operational in all essential areas, that the neurosurgical community finally accepted as the overall organizational catalyst.
It is noteworthy that, with all its complexities, the current sociopolitical structure has survived nearly 30 years, much of this during the most difficult, frustrating, and demanding times ever faced by organized medicine in the United States. It has adapted to change and has gained steadily in its responsiveness and effectiveness. If this positive pattern ends, if the present association structure becomes unresponsive to the fundamental needs of its constituency as a whole, then it will be changed, just as surely as it changed in 1931, 1938, 1948, 1951, and 1965.
The true challenge that the leaders of neurosurgery face today is to concentrate all resources at their disposal upon the contemporary challenges facing the specialty (and its patient population). If they do so, then internal (structural) change will be ongoing, positive, and taken in stride, not drastic and regressive.
Above all, it must be remembered that these associations are social phenomena in the purest sense. They belong to their members, not to their leaders. They are manifestations of the neurosurgical community as a whole, not the products of a few visionary individuals' decisions. The genuine visionaries, history repeatedly confirms, are those who can recognize and articulate the true will of the community as a whole and thereby initiate an effective response. The day when these fundamental truisms are forgotten will be the day that history begins to repeat itself once again.
The contributions of neurosurgeons and others to the historical materials collected by the Archives of The American Association of Neurological Surgeons provided an excellent basis for the research performed in the development of this document, and, to them, we are indeed grateful.
References and Comments