The History of Pediatric Neurosurgery

R. Michael Scott

1.1 Introduction

The beginning of the subspecialty of pediatric neurosurgery is perhaps best documented in a letter, currently in the possession of the Chief of Pediatric Neurosurgery at the Boston Children’s Hospital, written by Harvey Cushing in 1929 to a woman requesting care for her child with a probable brain tumor: “the right thing is to have you take him to see Dr. [Franc] Ingraham at the Children’s Hospital, and to abide unequivocally by what he says.” Over the next 30 years, neurosurgeons around the world began to devote major parts of their practice to the care of infants and children with neurosurgical disorders, and by the early 1950s, dedicated pediatric neurosurgical services were being established in the world’s major cities, including Boston, Buenos Aires, Chicago, London, Paris, Philadelphia, and Toronto, to name just a few. A major reason for the development of these services was the increasing prominence of prestigious children’s hospitals staffed by committed pediatric subspecialists in all areas of medicine and surgery, who were founding world-renowned services in their own specialties. It was only natural that pediatric neurosurgery would come into its own, driven by similarly committed neurosurgeons and institutions influenced by dedicated pediatricians, subspecialists, and hospital administrators, who wanted only the best-trained neurosurgical specialists to care for their patients. As Robin Humphreys pointed out in the earlier edition of this chapter, however, many neurosurgeons who specialized in the care of pediatric patients continued to have simultaneous adult practices through the 1960s and 1970s. At the time of this writing (2012), however, there are now several hundred neurosurgeons in the United States and Canada whose practices are limited to pediatric patients, and who practice exclusively in pediatric hospitals. How did this change come about?

One of the major influences on the development of our subspecialty was the publication of influential textbooks that outlined the presenting signs and symptoms of pediatric neurosurgical disorders, their diagnosis, and their surgical management. The anatomy and treatment of many congenital anomalies were difficult to understand, given the limitations of imaging before the development of computed tomography (in the 1970s) and magnetic resonance imaging (in the 1980s), and the rarity of many of these conditions; an experienced pediatric surgeon’s delineations of these conditions via a text was often the only way of advancing knowledge in the field of neurosurgery. The medical publisher Charles C Thomas published many short, themed monographs on conditions like medulloblastoma and spina bifida, and many pediatric case series were published in our journals, particularly the Journal of Neurosurgery, but it was not until the pivotal Neurosurgery of Infancy and Childhood,¹ by Franc D. Ingraham and Donald D. Matson, published in 1954, that any such compendium was available for the interested neurosurgeon or resident. The second edition, now authored solely by Matson, was published in 1969,² aand it became the authoritative pediatric neurosurgical text for many of us in training or in practice during that era; many of Matson’s diagnostic aphorisms remain relevant even today. The text remains a fascinating window into the treatment strategies of the pediatric neurosurgeon practicing in the middle of the 20th century. Other texts were published over the next two decades, but as pointed out by Robin Humphreys, quoting the comments of Kenneth Till, it was not until pediatric neurosurgeons “began to discover one another”^3,4 and to discuss mutual interests that this special area of neurosurgery began to flourish and subspecialty societies began to form to encourage the exchange of ideas and promote better care for the pediatric neurosurgical patient.

In the first edition of this chapter, Dr. Humphreys canvassed pediatric neurosurgeons at some of the oldest and most established pediatric neurosurgical centers in the world to record their histories for posterity, and I have quoted liberally from his initial chapter depictions in the sections that follow.

1.2 Program Development and Institutional Histories

1.2.1 Australia (E. A. Lewis, MD and D. Simpson, MD, Written Communications to Dr. Humphreys, October 2004)

The development of pediatric neurosurgery from its general neurosurgery roots is well illustrated by its evolution in Australia. General surgery arrived with the first fleet in 1788, but it was more than 100 years before the first successful adult neurosurgical cases were undertaken. The grandfathers of pediatric neurosurgery in Australia, like those in many other countries, had obtained their initial experience in other disciplines. T. Y. Nelson, a general pediatric surgeon, and his pupil, Marcel Sofer Schreiber, were perhaps the earliest practitioners of children’s neurosurgery in Sydney. Reginald Hooper, who in the late 1950s was appointed to the Royal Children’s Hospital, took the lead in Melbourne. Donald Simpson had been working in Adelaide since 1949; by 1956, he had established a relationship with the Adelaide Children’s Hospital.

The Australian neurosurgical community also felt Donald Matson’s influence when Matson visited that country in 1966, by which time freestanding children’s hospitals located in the country’s capital cities had been established. Then, as now, the challenge was the provision of “high-quality service over the tyranny of distance” (E. A. Lewis, MD, written communication to Dr. Humphreys, October 2004). Today, there are neurosurgeons specializing in pediatric neurosurgery throughout Australia and New Zealand.

1.2.2 Boston, Massachusetts—Boston Children’s Hospital

“If anyone can lay claim to be the father of pediatric neurosurgery, it would be Franc Ingraham.”⁵ Born in 1898, Ingraham entered Harvard Medical School in 1921 and received his medical degree 4 years later. He then spent 3 years with Harvey Cushing, 1 year in surgical research at Johns Hopkins, and an additional year working with Sir Charles Sherrington in the physiology laboratories at Oxford. Returning to Boston from England in 1929, Ingraham, with his extensive clinical and investigative background, focused on the rapidly expanding area of neurologic surgery for children at Cushing’s request.⁶ As noted earlier in this chapter, he started a pediatric neurosurgical service at Boston Children’s Hospital that to the author’s knowledge was the first of its kind. Generations of pediatric neurosurgeons in America and throughout the world were the benefactors of either his tutelage or that of his pupil, co-worker, and successor, Donald Matson. Over 40 neurosurgeons came to Boston Children’s Hospital to spend extended periods of time learning this new subspecialty, and many of them became chairpersons of their own departments or directors of their own pediatric neurosurgical services in academic institutions throughout North America and the world. Ingraham and his colleagues described the diagnosis and treatment of such clinical entities as subdural hematoma during the first 2 years of life,⁷ subdural effusions complicating bacterial meningitis in infancy,⁸ premature closure of cranial sutures,⁹ diastematomyelia,¹⁰ persistent dermal sinus tracts, and other variations of congenital spina bifida,¹¹ as well as the classification and treatment of hydrocephalus.¹¹ Ten years before his 1954 text with Matson, Ingraham had published Spina Bifida and Cranium Bifidum.¹² Matson and Ingraham’s collaboration sadly ended with Ingraham’s death in 1965 and Matson’s demise 4 years later of Jakob-Creutzfeldt disease.

1.2.3 Buenos Aires, Argentina (G. N. Zuccaro, MD, Written Communication, January 2005)

Raul Carrea was perhaps the first dedicated pediatric neurosurgeon in Argentina, beginning neurologic research when he was a student. In the mid 1940s, he worked with Pio del Rio Ortega. Shortly afterward, he continued his training as a Commonwealth Fund fellow in New York at Columbia University, where he worked both in neurophysiology research and in neurosurgery. Following his return to Buenos Aires, Carrea developed his neurosurgical career at the Cancer Institute Angel H. Roffo and at the Ricardo Gutierrez Children’s Hospital. Although this hospital had been founded in 1875, there was no designated neurosurgeon; general surgeons operated on the sporadic neurosurgical cases. At that institution, Carrea in 1956 created the first Department of Pediatric Neurosurgery, with its own special ward, an associated neuroradiology facility, and operating rooms. It was the first such department in Argentina. Subsequently, he created the first residency program in neurosurgery at the Children’s Hospital based on his belief in the need for specialized training.

Carrea’s interest in the treatment of hydrocephalus resulted in the imaginative strategy of deviating obstructed cerebrospinal fluid to the mastoid air cells, thereby saving the lives of many children at a time when shunt systems did not exist. Eventually, he designed his own shunting system, but the cost restricted its accessibility to families with means. The budget restrictions at the Children’s Hospital prompted Carrea to organize a group of parents and wealthy friends to create the Foundation for the Fight against Neurological Diseases in Childhood (FLENI). The foundation flourished under his leadership, and his department of neurosurgery became a state-of-the-art center that still has an international reputation in the field of neurologic diseases.

1.2.4 Cape Town, South Africa—Red Cross War Memorial Children’s Hospital

The Department of Neurosurgery in Cape Town was established in 1946 by Hermann de Villiers Hammann, a South African trained in Germany.^13,14 As a rule, children were operated on by general neurosurgeons until 1970, when Professor J. C. (Kay) de Villiers was appointed as the first full-time academic neurosurgical head in Cape Town. He quickly recognized that there was a need to establish pediatric neurosurgery as a subspecialty; this decision was facilitated by the fact that Cape Town had the only freestanding pediatric hospital in South Africa. The Red Cross War Memorial Children’s Hospital had been established after the Second World War with contributions from the citizens of Cape Town, given in memory of those fallen. De Villiers developed a combined spinal dysraphism clinic, which he ran assisted by personnel from the orthopedic and urology departments. In the years that followed, the first full-time academic pediatric neurosurgical post was created at the Children’s Hospital, and the hospital became the referral center for most of southern Africa.

1.2.5 Chicago, Illinois—Children’s Memorial Hospital (D. G. McLone, MD, Written Communication to Dr. Humphreys, June 2004)

Neurosurgery was established at Children’s Memorial Hospital in 1950 by Luis Amador, who must have been influenced by the presence of Paul Bucy and Percival Bailey at Northwestern University. Amador, described as a true academic and technically skilled surgeon, held only a part-time appointment at Children’s Memorial Hospital, which was typical for that era. During that decade, he accepted international trainees, such as Kenneth Till and Sanat Bhagwati, for additional experience in pediatric neurosurgery; this training opportunity for neurosurgeons from around the world was to become a consistent feature of the pediatric neurosurgical service at Children’s Memorial Hospital during the years that followed. Bhagwati, training with both Till and Raimondi, went on to spearhead the development of pediatric neurosurgery in India, where over 150 neurosurgeons now devote most of their practice to the care of pediatric patients.¹⁵

Meanwhile, Anthony Raimondi, born and raised in Chicago but schooled in medicine at the University of Rome, had completed his neurosurgical residency with Joe Evans at the University of Chicago.¹⁶ During this time, Raimondi had an opportunity to study pediatric neurology under Douglas Buchanan. This experience doubtlessly contributed to his decision to dedicate his life to pediatric neurosurgery. In what would now be considered a fellowship, Raimondi worked with Amador at Children’s Memorial Hospital. In 1963, when he was 34 years old, Raimondi went across town to the Cook County Hospital. Although his responsibility was primarily the care of adult patients, he was still absorbed by the surgical disorders that affect a child’s nervous system. He was intrigued by the potential of cerebrospinal fluid shunt systems as well as the utility of cerebral angiography as a diagnostic tool in children.

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