Pediatric Neurosurgery – New Kid on the Block

Harvey Cushing, the recognized father of neurosurgery, with a pediatric patient. When Cushing sent Franc Ingraham (inset) to take charge of his practice at the Boston Children’s Hospital, the first pediatric neurosurgeon was born. It would take another 40 years before a pediatric neurosurgical meeting was organized by Ken Shulman. The Cushing photo is from the forthcoming book “The Legacy of Harvey Cushing: Profiles of Patient Care,” edited by Aaron Cohen-Gadol, MD, MSc, and Dennis Spencer, MD, and published by the AANS and Thieme.

I was taught as a resident that “adults may be big kids, but kids ain’t little adults.” Medicine is an ancient art, but pediatrics, the art of caring for the young, is a young branch of medicine. From antiquity onward, physicians understood that children were subject to different diseases than adults, and treatises on children’s care were written by Roman, Arab, and Renaissance European physicians. However, premodern doctors usually were reluctant to care for sick children, who “give no other light into the knowledge of their diseases than what we are able to discover from their uneasy cries and the uncertain tokens of their crossness,” as Walter Harris noted in Acute Disease in Infancy, published in 1689.

The emergence of scientific medicine in the 19th century was accompanied by an interest in improving public health. Increasing urbanization worked to increase infant and childhood mortality, because of overcrowding, unsanitary living conditions, and the adulteration of food and cow milk. Children above all bore the brunt of these problems, and their distinct needs began to be addressed by the increasingly organized field of medicine. In 1858, the German-educated American physician Abraham Jacobi coined the term “pediatrics,” and this specialty was officially born.

Neurological surgery itself, barely 100 years old, is even younger as a discipline. The early brain surgeons operated on children as well as adults. This included Harvey Cushing, who recognized the preponderance of posterior fossa tumors in children, and who described the clinical syndromes associated with these lesions. Pediatric neurosurgery was born out of this experience in 1929 when Cushing sent Franc Ingraham to take charge of his practice at the Boston Children’s Hospital. It would take another 40 years before a pediatric neurosurgical meeting was organized by Ken Shulman.

The first fellowship in pediatric neurosurgery was at the Toronto Hospital for Sick Children, starting in 1972. At this time, not very long ago, there were few neurosurgeons dedicated to caring for children. Many department chairmen scoffed at the idea, but in 1978 the American Society for Pediatric Neurosurgery was founded. Much of the society’s attention in its early years was devoted to discussion of “enforcement”—who should do pediatric cases, and what exactly was the scope of practice of a pediatric neurosurgeon, a question that perhaps remains unresolved.

Should only pediatric neurosurgeons operate on children? Should pediatric
neurosurgeons operate only on children? As Larry Page wrote, “A pediatric neurosurgeon is difficult to define, but easy to identify.” They are neurosurgeons who understand that the kids for whom they care ain’t little adults.

Michael Schulder, MD, is professor and vice chair in the Department of Neurological Surgery at New Jersey Medical School in Newark.

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