As an online journal, Surgical Neurology focuses upon being “International” in its circulation and outreach. Since first launched just over 3 years ago, it has become the most circulated, widely read online neurosurgical journal in the world. It is unique not only through the manner in which it is available to physicians and surgeons worldwide, but also in being available to anyone who can access the internet, and at no cost.

Over the course of the past half-century it has been with excitement and appreciation that those of us practicing in hospitals and medical centers in developed countries have observed the ever increasing level of excellence in medical and surgical care available to patients. However, in less well developed countries this has generally not been the case. In developing countries, trained physicians and surgeons are few in number, availability of modern day medical equipment and supplies tends to be sorely lacking, and ongoing medical education programs are often nonexistent.

Several generations ago, the imagination and respect of the world became focused upon a German theologian, musician, and philosopher of great renown who at age 39 and at the very pinnacle of his great success and acclaim gave it all up in order to study medicine. After completing medical school, he left the life of comfort and great recognition he had known in Europe and went to the jungle in Africa. There he built a hospital on the banks of the Ogooue’ river at a place called Lambarene, located in French Equatorial Africa, now Gabon. His name was Dr. Albert Schweitzer.

With the exception of making periodic visits back to Europe to raise money through speaking and giving organ recitals, Dr. Schweitzer spent the rest of his life taking care of the medical needs of people who came to the hospital he had built in the jungle 200 miles upstream, and a 14 day journey by river raft from the nearest point of civilization. Dr. Schweitzer did his work as a committed, caring doctor of medicine, remaining there until his death at age 90.

People everywhere seemed captivated through reading or hearing the story of this famous German who “had it all” yet opted to “give it all away” through service to others in the remoteness of a West African jungle in order that they might have at least some degree of medical care. Though this once famous man who gave it all up to become a physician then dedicated his life to bringing care to those “whom others had passed by” died nearly 60-years ago, his name is still recognized, known, and highly respected all around the world.

As a result of the miraculous changes that have come to us in our time through high-tech telecommunications, computers, international jet travel, and coupled with all of the advances in medical treatment and technology that have occurred during the past half-century, another Dr. Albert Schweitzer appears unlikely. Still, an even more amazing story is unfolding in developing countries today and the words for that story are being written by the huge number of physicians, nurses, and other humanitarian assistance workers who are tirelessly at work in places around the world where there is great need. One of these modern day “Albert Schweitzer like physicians” who have committed their lives to responding to the medical needs of others less fortunate is Gretchen Birbeck, M.D.

Dr. Gretchen Birbeck is a Professor of Neurology at Michigan State University where she also serves as Director of International Neurologic and Psychiatric Epidemiology (IMPEP). Remarkably, in addition to these major professional responsibilities Dr. Birbeck has also for the past number of years spent 6 months out of each year doing hands-on medical programs in Zambia, East Africa. She even maintains homes in both Michigan and Zambia in order that she can carry out her academic responsibilities at Michigan State University while also doing the work of improving neurological healthcare for the people in that far away developing country.

In speaking with Professor Birbeck, and through reading her contributions to the medical literature, especially impressive is her mention in a May 2002 Lancet Journal article of her having successfully performed the surgical evacuation of an acute epidural hematoma. Under any circumstance this would have been an amazing operative report coming from a Neurologist with no neurosurgical operative training, but more amazing still was that she performed this emergency, life-saving operation with use of a dental drill! Dr. Birbeck wrote these words in her paper: “The satisfaction I gained as the patient woke up and began to move his previously paretic side gave me a brief glimpse of what motivates anyone to train in surgery, something that was previously a mystery to me.”

This account by Dr. Birbeck offers two important great truths for us as neurosurgeons and/or specialists in allied areas of the neurological sciences. First is that through utilizing knowledge learned within and without our sometimes fairly narrow fields of ultraspecialization, coupled with sterile techniques and good common sense, each one of us can venture far beyond our level of training expertise when someone's well-being and perhaps life depends upon our doing so.

As a personal perspective on doing all that can reasonably be done in treating patients in developing country situations my own volunteer medical mission work in developing countries, and in places where wars were being fought, began in 1985. During the early years of my own volunteer medical mission work, it was necessary for me to perform a wide variety of nonneurosurgical operations. This usually meant performing general surgical operations, C-Sections, trauma cases of all kinds, doing skin grafts and dealing with problems ranging from knife or arrow wounds to Hippo bites and Water Buffalo gorings. Having had one year of general surgical residency before beginning my neurosurgical residency program, and then spending 2 years on active duty in the USAF operating alongside fully trained general surgeons, made it possible for me to do this.

The second great truth as regard performing diagnostic procedures and neurosurgical operations under developing country circumstances is that through using whatever might be available in terms of equipment (i.e., Dr. Birbeck and the dental drill), coupled with some necessary innovation and common sense, neurosurgical problems can often be handled with at least some degree of success.

In 1986 my wife and I made the first of what became many short-term visits to Tenwek Mission Hospital in Kenya. This was a 230 bed mission hospital located 50 miles from the nearest town, and it served the medical needs of an estimated 350 thousand people of the Kipsigis and Maasai tribes. Tenwek had only four full-time doctors at that time, supplemented intermittently with short-term physician volunteers. I was there as a surgeon volunteer, the first neurosurgeon ever to serve at that remote hospital. The medical license issued by the Kenyan government identified me as the second neurosurgeon licensed in that country.

As had been explained when my wife and I made that first medical missionary visit to Tenwek Hospital, I was to function as one of the two surgeons there. This would mean doing primarily general surgery as well as whatever neurosurgical cases I might be able to do without use of an operating microscope or neurosurgical instruments routinely used at home. In preparation, I brought a large black bag of neurosurgical instruments, gel foam, thrombin, cottonoids, and also ventriculoperiteonal (VP) shunts with me. Since almost every operation I did in the U.S. entailed use of the operating microscope, I had also brought with me an ancient little ENT/Ophthalmic Microscope that we came to refer to as, “The Mickey Mouse Microscope.” Tenwek Hospital did have an old X-ray machine but no computed tomography (CT). Electrical power was limited, supplied by a diesel generator, and was prone to failure at very inopportune times leading to operating by flashlight.

One day a young girl suffering with extremely bad headaches, ataxia, and projectile vomiting was brought in. Having only an old X-ray machine to work with I had to rely upon the history and neurological examination, and through this diagnosed a probable posterior fossa midline tumor.

After placement of a right parietal burr hole, I inserted the ventricular end of a VP shunt and encountered very high pressure. Then after slowly draining some cerebrospinal fluid (CSF) to reduce pressure, injected several cc's of air through the ventricular tubing into the right lateral ventricle. With the ventricular catheter still in place and while maintaining the sterile field, several members of the operation room (OR) team picked the little girl up and moved her through a backward somersault to cause movement of the air bubble into her third ventricle. AP and lateral skull X-rays were done and showed an obstructed fourth ventricle. Having now demonstrated a mass in the 4^th ventricle causing obstructive hydrocephalus, we proceeded with additional prepping and draping then placement of a VP shunt.

When the little girl awakened from the anesthesia we found her to be neurologically intact and headache free. After waiting several days to allow things to settle down she was again anesthetized. Then she was placed in one of the four previously used and discarded halo braces we had brought with us, positioned with the head slightly flexed and prone on chest rolls in preparation for a suboccipital craniectomy [ Figure 1 ].

Figure 1

Patient positioned in Halo brace for suboccipital craniectomy for tumor removal

After completing the suboccipital craniectomy exposure, I used the little “Mickey Mouse” ENT/Ophthalmological microscope my surgeon friend back in the U.S. had given to me as somewhat of a substitute for the operating microscope I used in almost every operation back in the U.S. [ Figure 2 ].

Figure 2

Sub-occipital craniectomy for removal of 4th ventricular tumor

I opened the dura and found the 4^th ventricle obstructed by tumor then proceeded in removing as much of it as possible in order to achieve a good decompression. The little girl did very well postoperatively with no headache, neurological deficit, and with rapid progression to her normal status [ Figure 3 ].

Figure 3

Patient on second post-op day

CONCLUSIONS

While we obviously must keep our emphasis in training programs and in medical practice here in the U.S. and in other developed countries around the world upon achieving the very highest levels of excellence possible, medical and surgical care in the developing world lag far behind. This is of course totally unacceptable and the burden felt by increasing numbers of physicians, surgeons, nurses, and people from other walks of life is to reach out with a helping-hand to the less fortunate people in this world and do what we can to “make a difference” in their lives.

Deeply committed people like Dr. Gretchen Birbeck are following the course blazed those many years ago by Dr. Albert Schweitzer, and they are making that difference that in the course of time will bring better health and medical care to people everywhere. We can thank the Bill and Melinda Gates Foundation, the Conrad N Hilton Foundation, Samaritan's Purse, International Medical Corporation, Doctors without borders, and many others in the church, business, and professional communities for all they have done and are doing.

The mission of Surgical Neurology International is facilitating the sharing of information and providing that, which is perhaps most urgently needed in lifting up medical care of those in the developing world, and that is medical education. Each of us can “make a difference” in the lives of others, and a good way to do this is through becoming a volunteer willing to share with others in need.

Dr. Gretchen Birbeck spoke from her heart through that article in Lancet in May of 2002 as she wrote: “Of all the professional pleasures I enjoy as a specialist in Zambia, teaching is one of the best. Nurses, clinical officers, and physicians eagerly absorb any clinical instruction offered.”

Another great truth that seems a good way to end this article is that, “Life becomes full, when you begin to give it away through sharing what you have with others.”