Est Modus in Rebus

In the July 2013 issue of the American Journal of Neuroradiology an editorial appeared, authored by Dr H.J. Cloft, entitled “Capitalism and Commodities: My Two Cents.”¹

In the editorial, Dr Cloft explains that nowadays “more that 20 years after the invention of the Guglielmi Detachable Coil” neurointerventional devices are “mature,” and that, for a skilled operator, an endovascular aneurysm case is routine and analogous to an appendectomy.

Dr Cloft also explains that currently our specialty has progressed to the point that “it no longer consists of a few pioneers trying to improvise new therapies by using nonapproved materials.”

After reading this editorial, I felt compelled and obliged to express my point of view and my criticism regarding these 2 questionable assertions, as well as the way in which these assertions were presented and the language used.

First, one has the right to assert that the devices we use nowadays are more “mature” than they were in the past (I doubt, however, that all the modern “approved” devices and techniques are “mature”), but one cannot assert that the endovascular treatment of brain vascular diseases (like an aneurysm) is analogous to an appendectomy! This inopportune analogy has all the potential of acting as a diminutio capitis² of the doctors who perform neuroendovascular procedures. Notwithstanding the progress of the devices we use, this proposed analogy seems an inadequate and heretical way of evaluating things. The analogy constitutes an unnecessary and self-harming way of downplaying our difficult discipline. The reality is that there is no comparison between the often very complex, treacherous, and potentially life-threatening treatment of a brain aneurysm and the relatively simple appendectomy, which is often performed by unsupervised residents. To reinforce this concept, I shall say that I never accepted the unfortunate labeling of our techniques as “minimally invasive”: our procedures are less invasive than open neurosurgery, but they are not minimally invasive!

Second, one should pay more respect to the fathers of our discipline, the pioneers who created the discipline starting from zero. No one should say “[our specialty] no longer consists of few pioneers trying to improvise new therapies while using non-FDA-approved materials.” The expression “trying to improvise” has a negative connotation that I find unacceptable. It is a derogatory way of depicting the enormous effort of the pioneers of our discipline. Most pioneers did not “improvise.” On the contrary, they “invented.” Moreover, they did it in a rational way. The distinction between “improvising” and “inventing” is crucial. Most pioneers did not use only standard, available materials simply because they were creative scientists and game changers. Therefore, in the process that eventually led to the creation of the discipline, they used materials that were the fruit of their “pioneeristic” work. Unavoidably, there were some excesses by a few. Nevertheless, I would have shown more deference and humility (and less pride) in referring to those who paved the way of the new discipline, often paying a high price for following their creativity. I would not have called them “improvisators.”

• © 2014 by American Journal of Neuroradiology