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Historical papers
@Springer-Verlag 1991 Child's Nerv Syst (1991) 7:53-55
History of pediatric neurosurgery in the United States and Canada * Larry K. Page Department of Neurological Surgery, University of Miami School of Medicine, 1501 N.W. 9th Avenue, Miami, FL 33136, USA Received February 7, 1990/Revised July 6, 1990 !
Abstract; Neurosurgery was sporadically practiced on children from prehistoric times until the Harvey Cushing era. The formal development and teaching of the specialty was begun by Franc Ingraham under Cushing's direction in 1929. The growth of pediatric neurosurgery at Boston Children's Hospitat under the direction of Franc Ingraham and Donald Matson until the late 1960s is described, as is its subsequent spread throughout the United States and Canada. More recently, a number of societies and journals have played important roles in shaping and advancing the specialty. Currently, a proposal to require additional training for certification in pediatric neurosurgery is being considered by several organizations in North America. Key words: Pediatric neurosurgery - History - Hydrocephalus - Ingraham - Matson
Remote past Early evidence of pediatric neurosurgery [6] comes from a trephined skull excavated in Iran: that of an 11-year-old dating back to between 1 100 and 800 B.C. The child survived long enough for partial regeneration of the skull defect to occur. Hippocrates [3], circa 400 B.C., recommended decompression and trephination as treatment for hydrocephalus. Once the era of aseptic operations had begun in the late nineteenth century A.D., Macewen, Godlee and Horsely showed that diseases of the central nervous system could be successfully treated surgically.
the early part of the twentieth century, the first neurosurgical clinic at Peter Bent Brigham Hospital in Boston. He trained a generation of neurosurgeons who spread the practice of the new speciality throughout North America and Europe. Although Cushing's contributions mainly concerned adults, he did describe a lumboperitoneal shunt [1] in 1905, whereby a silver cannula connected the subarachnoid space through a vertebral body with the peritoneal cavity. Cushing's most important pediatric contribution [2] appeared in Surgery, Gynecology and Obstetrics in 1931: "Experiences with the cerebellar astrocytomas: a critical review of 76 cases." Peter Bent Brigham Hospital had not only been built adjacent to Harvard Medical School, but was located just across the street from Boston Children's Hospital (Fig. 1). In 1929, Cushing sent one of his pupils, Franc Ingraham, to the Children's Hospital to take over his practice there. From that time onward, Ingraham (Fig. 2) devoted his professional life to the development of pediatric neurosurgery. He was instrumental in defining and developing methods of surgical treatment for craniosynostosis, diastematomyelia, hydrocephalus, infantile subdural hematoma and effusion, and the various forms of spina bifida. Although a shy and reserved gentleman, he was able like Cushing - to attract and develop a number of talented pupils who would further pediatric neurosurgery in London (UK), Toronto, Pittsburgh, Cincinnati and Winston-Salem. If Cushing was the father of neurosurgery, Ingraham was certainly the first to promote the growth and development of pediatric neurosurgery.
Early twentieth century
Recent past
Harvey Cushing was the first to direct his principle efforts toward surgery of the nervous system and to develop in
One prot6g6 who stayed on with him was Donald Matson, co-author with Ingraham of both the classic paper on infantile subdural hematoma [4] in 1944 and the first textbook of pediatric neurosurgery [5] in 1954. Matson (Fig. 3) made significant contributions to the manage-
* Presented at the XVII Annual Meetingof the InternationalSociety for Pediatric Neurosurgery, Bombay 1989
54
Fig. 1. Old Boston Children's Hospital with Harvard Medical School in the background (courtesy John Shillito)
Fig. 2. Franc Douglas Ingraham
(1898-1965) Fig. 3. Donald Darrow Matson
(1913-1969)
ment of cerebellar astrocytoma, craniopharyngioma, brain abscess and intraspinal tumor. Torkildsen's ventriculocisternal shunt [11], described in 1939, was the first reliable, long-term treatment for hydrocephalus. However, it was not effective for communicating hydrocephalus and worked only occasionally for obstructive hydrocephalus in the pediatric age group. Matson's lumboureteral [7] and ventriculoureteral [8] shunts, introduced in 1949 and 1951, respectively, provided the first effective, long-term treatment for communicating and obstructive hydrocephalus in children. The
first successful valve shunting device was designed and built by John Holter, an industrial technician whose child had died of hydrocephalus. Using Holter's valve, Nulsen and Spitz [10] reported shunting the ventricular fluid of hydrocephalic children to th e jugular vein in 1952. Many improvements in materials, in design of shunting devices, and in operative techniques have since been made. The safest and most reliable treatment for childhood hydrocephalus is currently the ventriculoperitoneal shunt. Matson became the driving force of the neurosurgical training program at Children's Hospital and Peter Bent
55 Brigham Hospital in the 1950s and 1960s. He was a great educator and a master surgeon. Just prior to his untimely death in 1969, M a t s o n updated and completely re-wrote Neurosurgery of infancy and childhood. R e m a r k a b l y little of this extraordinary text [9] has become outdated over the past 20 years. In the 1960s other centers were developed and/or expanded. Significant clinical, educational, and research contributions have been made because of talented and focused efforts in Toronto, Philadelphia, Pittsburgh, Chicago, Columbus, Los Angeles, Washington, New York and Cincinnati. In September 1969, Kenneth Shulman invited 37 neurosurgeons to a meeting in New York to form the first pediatric neurosurgical society 1. After much debate, it was decided to keep peace with the neurosurgical establishment of the time by organizing under its aegis. Thus was born the pediatric section of the AANS. During the 1970s and 1980s, pediatric neurosurgery came of age in m o s t of the major cities in the United States and Canada. A n t h o n y J. Raimondi was instrumental in founding the International Society for Pediatric Neurosurgery in Chicago in 1972. The American Society for Pediatric Neurosurgery was founded in 1978.
Present Scientific papers now appear not only in the traditional neurosurgical and pediatric literature, but in refereed publications that are primarily concerned with pediatric neurosurgical topics. Child's Nervous System (formerly Child's Brain) is the official journal of the International Society for Pediatric Neurosurgery. Concepts of Pediatric Neurosurgery publishes papers from the annual meetings of the American Society for Pediatric Neurosurgery. Pediatric Neuroscience and the Journal of Pediatric Neurosciences contain neurosurgical articles as well as those of related disctipines. Similarly, Zeitschriftfiir Kinderchirurgie publishes the proceedings of the Society for Research into Hydrocephalus and Spina Bifida, articles that formerly appeared in Developmental Medicine and Child
Neurology. Future Neurosurgical training programs in the United States and C a n a d a must now have a "designated pediatric neurosurgeon," There is a m o v e m e n t afoot to require an additional year as a fellow in an approved pediatric neurosurgical center before a trainee can qualify as a certified 1 The first pediatric neurosurgical society to be formed was the European Society for Paediatric Neurosurgery, in 1967 in Vienna, Austria, when the first scientific meeting was also held. The Editor
pediatric neurosurgeon. This raises certain questions. Which centers will be approved by whom, and what criteria will be required, for fellowship training? Will the residents in these centers then suffer from inadequate experience with pediatric cases? Must candidates be Board certified prior to receiving special certification in pediatric neurosurgery? Will periodic re-certification in either or both be required? Must certified pediatric neurosurgeons confine their practice to the pediatric age group? I f so, should children with vascular lesions, seizure foci, skull base and parasellar tumors and other conditions that occur much more frequently in adults be treated by pediatric neurosurgeons? Franc I n g r a h a m and Donald M a t s o n were superb neurosurgeons for adults as well as for children.
Comment The pediatric part of neurosurgery is a difficult niche in which to work. To be good at it, one needs to be well trained and well-read; one also needs to contribute toward its betterment and to have particular devotion to the care of babies and children. Beyond these considerations lie definitions and requirements - fences that are perhaps best not built. Someone has said that a pediatric neurosurgeon is difficult to define, but easy to identify. M a y b e we should leave it at that.
References 1. Cushing H (1908) Surgery of the head. In: Keen WW (ed) Surgery: its principles and practice, vol 3. Saunders, Philadelphia, pp 17-76 2. Cushing H (1931) Experiences with the cerebellar astrocytomas: a critical review of seventy-six cases. Surg Gynecol Obstet 52:129-204 3. Hippocrates (1853) Oeuvres completes d'Hippocrate, vol 8 (translated by Littre E). Bailli6re, Paris 4. Ingraham FD, Matson DD (1944) Subdural hematoma in infancy. J Pediatr 24:1-37 5. Ingraham FD, Matson DD (1954) Neurosurgery in infancy and childhood. Thomas, Springfield, Ill 6. Mallin R, Rathbum TA (1976) A trephined skull from Iran. Bull NY Acad Med 52:782-787 7. Matson DD (1949) A new operation for the treatment of communicating hydrocephalus: report of a case secondary to generalized meningitis. J Neurosurg 6:238-247 8. Matson DD (1951) Ventriculo-ureterostomy. J Neurosurg 8:398-404 9. Matson DD (1969) Neurosurgery of infancy and childhood, 2nd edn. Thomas, Springfield, Ill 10. Nulsen FI, Spitz EB (1952) Treatment of hydrocephalus by direct shunting from ventricle to jugular vein. Surg Forum 2:399 11. Torkildsen A (1939) A new palliative operation in cases of inoperable occlusion of the sylvian aqueduct. Acta Chit Scand 82:117
Historical papers
@Springer-Verlag 1991 Child's Nerv Syst (1991) 7:53-55
History of pediatric neurosurgery in the United States and Canada * Larry K. Page Department of Neurological Surgery, University of Miami School of Medicine, 1501 N.W. 9th Avenue, Miami, FL 33136, USA Received February 7, 1990/Revised July 6, 1990 !
Abstract; Neurosurgery was sporadically practiced on children from prehistoric times until the Harvey Cushing era. The formal development and teaching of the specialty was begun by Franc Ingraham under Cushing's direction in 1929. The growth of pediatric neurosurgery at Boston Children's Hospitat under the direction of Franc Ingraham and Donald Matson until the late 1960s is described, as is its subsequent spread throughout the United States and Canada. More recently, a number of societies and journals have played important roles in shaping and advancing the specialty. Currently, a proposal to require additional training for certification in pediatric neurosurgery is being considered by several organizations in North America. Key words: Pediatric neurosurgery - History - Hydrocephalus - Ingraham - Matson
Remote past Early evidence of pediatric neurosurgery [6] comes from a trephined skull excavated in Iran: that of an 11-year-old dating back to between 1 100 and 800 B.C. The child survived long enough for partial regeneration of the skull defect to occur. Hippocrates [3], circa 400 B.C., recommended decompression and trephination as treatment for hydrocephalus. Once the era of aseptic operations had begun in the late nineteenth century A.D., Macewen, Godlee and Horsely showed that diseases of the central nervous system could be successfully treated surgically.
the early part of the twentieth century, the first neurosurgical clinic at Peter Bent Brigham Hospital in Boston. He trained a generation of neurosurgeons who spread the practice of the new speciality throughout North America and Europe. Although Cushing's contributions mainly concerned adults, he did describe a lumboperitoneal shunt [1] in 1905, whereby a silver cannula connected the subarachnoid space through a vertebral body with the peritoneal cavity. Cushing's most important pediatric contribution [2] appeared in Surgery, Gynecology and Obstetrics in 1931: "Experiences with the cerebellar astrocytomas: a critical review of 76 cases." Peter Bent Brigham Hospital had not only been built adjacent to Harvard Medical School, but was located just across the street from Boston Children's Hospital (Fig. 1). In 1929, Cushing sent one of his pupils, Franc Ingraham, to the Children's Hospital to take over his practice there. From that time onward, Ingraham (Fig. 2) devoted his professional life to the development of pediatric neurosurgery. He was instrumental in defining and developing methods of surgical treatment for craniosynostosis, diastematomyelia, hydrocephalus, infantile subdural hematoma and effusion, and the various forms of spina bifida. Although a shy and reserved gentleman, he was able like Cushing - to attract and develop a number of talented pupils who would further pediatric neurosurgery in London (UK), Toronto, Pittsburgh, Cincinnati and Winston-Salem. If Cushing was the father of neurosurgery, Ingraham was certainly the first to promote the growth and development of pediatric neurosurgery.
Early twentieth century
Recent past
Harvey Cushing was the first to direct his principle efforts toward surgery of the nervous system and to develop in
One prot6g6 who stayed on with him was Donald Matson, co-author with Ingraham of both the classic paper on infantile subdural hematoma [4] in 1944 and the first textbook of pediatric neurosurgery [5] in 1954. Matson (Fig. 3) made significant contributions to the manage-
* Presented at the XVII Annual Meetingof the InternationalSociety for Pediatric Neurosurgery, Bombay 1989
54
Fig. 1. Old Boston Children's Hospital with Harvard Medical School in the background (courtesy John Shillito)
Fig. 2. Franc Douglas Ingraham
(1898-1965) Fig. 3. Donald Darrow Matson
(1913-1969)
ment of cerebellar astrocytoma, craniopharyngioma, brain abscess and intraspinal tumor. Torkildsen's ventriculocisternal shunt [11], described in 1939, was the first reliable, long-term treatment for hydrocephalus. However, it was not effective for communicating hydrocephalus and worked only occasionally for obstructive hydrocephalus in the pediatric age group. Matson's lumboureteral [7] and ventriculoureteral [8] shunts, introduced in 1949 and 1951, respectively, provided the first effective, long-term treatment for communicating and obstructive hydrocephalus in children. The
first successful valve shunting device was designed and built by John Holter, an industrial technician whose child had died of hydrocephalus. Using Holter's valve, Nulsen and Spitz [10] reported shunting the ventricular fluid of hydrocephalic children to th e jugular vein in 1952. Many improvements in materials, in design of shunting devices, and in operative techniques have since been made. The safest and most reliable treatment for childhood hydrocephalus is currently the ventriculoperitoneal shunt. Matson became the driving force of the neurosurgical training program at Children's Hospital and Peter Bent
55 Brigham Hospital in the 1950s and 1960s. He was a great educator and a master surgeon. Just prior to his untimely death in 1969, M a t s o n updated and completely re-wrote Neurosurgery of infancy and childhood. R e m a r k a b l y little of this extraordinary text [9] has become outdated over the past 20 years. In the 1960s other centers were developed and/or expanded. Significant clinical, educational, and research contributions have been made because of talented and focused efforts in Toronto, Philadelphia, Pittsburgh, Chicago, Columbus, Los Angeles, Washington, New York and Cincinnati. In September 1969, Kenneth Shulman invited 37 neurosurgeons to a meeting in New York to form the first pediatric neurosurgical society 1. After much debate, it was decided to keep peace with the neurosurgical establishment of the time by organizing under its aegis. Thus was born the pediatric section of the AANS. During the 1970s and 1980s, pediatric neurosurgery came of age in m o s t of the major cities in the United States and Canada. A n t h o n y J. Raimondi was instrumental in founding the International Society for Pediatric Neurosurgery in Chicago in 1972. The American Society for Pediatric Neurosurgery was founded in 1978.
Present Scientific papers now appear not only in the traditional neurosurgical and pediatric literature, but in refereed publications that are primarily concerned with pediatric neurosurgical topics. Child's Nervous System (formerly Child's Brain) is the official journal of the International Society for Pediatric Neurosurgery. Concepts of Pediatric Neurosurgery publishes papers from the annual meetings of the American Society for Pediatric Neurosurgery. Pediatric Neuroscience and the Journal of Pediatric Neurosciences contain neurosurgical articles as well as those of related disctipines. Similarly, Zeitschriftfiir Kinderchirurgie publishes the proceedings of the Society for Research into Hydrocephalus and Spina Bifida, articles that formerly appeared in Developmental Medicine and Child
Neurology. Future Neurosurgical training programs in the United States and C a n a d a must now have a "designated pediatric neurosurgeon," There is a m o v e m e n t afoot to require an additional year as a fellow in an approved pediatric neurosurgical center before a trainee can qualify as a certified 1 The first pediatric neurosurgical society to be formed was the European Society for Paediatric Neurosurgery, in 1967 in Vienna, Austria, when the first scientific meeting was also held. The Editor
pediatric neurosurgeon. This raises certain questions. Which centers will be approved by whom, and what criteria will be required, for fellowship training? Will the residents in these centers then suffer from inadequate experience with pediatric cases? Must candidates be Board certified prior to receiving special certification in pediatric neurosurgery? Will periodic re-certification in either or both be required? Must certified pediatric neurosurgeons confine their practice to the pediatric age group? I f so, should children with vascular lesions, seizure foci, skull base and parasellar tumors and other conditions that occur much more frequently in adults be treated by pediatric neurosurgeons? Franc I n g r a h a m and Donald M a t s o n were superb neurosurgeons for adults as well as for children.
Comment The pediatric part of neurosurgery is a difficult niche in which to work. To be good at it, one needs to be well trained and well-read; one also needs to contribute toward its betterment and to have particular devotion to the care of babies and children. Beyond these considerations lie definitions and requirements - fences that are perhaps best not built. Someone has said that a pediatric neurosurgeon is difficult to define, but easy to identify. M a y b e we should leave it at that.
References 1. Cushing H (1908) Surgery of the head. In: Keen WW (ed) Surgery: its principles and practice, vol 3. Saunders, Philadelphia, pp 17-76 2. Cushing H (1931) Experiences with the cerebellar astrocytomas: a critical review of seventy-six cases. Surg Gynecol Obstet 52:129-204 3. Hippocrates (1853) Oeuvres completes d'Hippocrate, vol 8 (translated by Littre E). Bailli6re, Paris 4. Ingraham FD, Matson DD (1944) Subdural hematoma in infancy. J Pediatr 24:1-37 5. Ingraham FD, Matson DD (1954) Neurosurgery in infancy and childhood. Thomas, Springfield, Ill 6. Mallin R, Rathbum TA (1976) A trephined skull from Iran. Bull NY Acad Med 52:782-787 7. Matson DD (1949) A new operation for the treatment of communicating hydrocephalus: report of a case secondary to generalized meningitis. J Neurosurg 6:238-247 8. Matson DD (1951) Ventriculo-ureterostomy. J Neurosurg 8:398-404 9. Matson DD (1969) Neurosurgery of infancy and childhood, 2nd edn. Thomas, Springfield, Ill 10. Nulsen FI, Spitz EB (1952) Treatment of hydrocephalus by direct shunting from ventricle to jugular vein. Surg Forum 2:399 11. Torkildsen A (1939) A new palliative operation in cases of inoperable occlusion of the sylvian aqueduct. Acta Chit Scand 82:117
