From the Division of Neurology, Children’s Memorial Hospital, Northwestern University Medical School, Chicago, IL.
Address correspondence and reprint requests to Dr. John J. Millichap, Division of Neurology, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 51, Chicago, IL 60614 jmillichap{at}childrensmemorial.org
The founding period of child neurology occurred in 3 phases:1) early individual contributory phase, 2) organized trainingphase, and 3) expansion phase. In the late 19th and early 20thcenturies, individuals in pediatrics, neurology, and psychiatryestablished clinics and made important contributions to theliterature on childhood epilepsy, cerebral palsy, and pediatricneurology. The latter half of the 20th century saw the organizationof training programs in pediatric neurology, with fellowshipssupported by the NIH. This development was followed by a rapidexpansion in the number of trainees certified in child neurologyand their appointment to divisions of neurology in children’shospitals. In recent years, referrals of children with neurologicdisorders have increased, and disorders previously managed bypediatricians are often seen in neurology clinics. The era ofsubspecialization is embraced by the practicing physician. Thepresent day status of pediatric neurology and suggestions forthe future development of the specialty are subjects for furtherdiscussion.
Child neurology was recognized as a board-certified specialtyonly 40 years ago, but the contributions to our understandingof neurologic disorders of childhood span more than 100 years.Various medical disciplines were involved in these early advancesin child neurology. The history of the founding period of childneurology is long, and may be presented in 3 phases, beginningwith an early individual contributory phase, followed by anorganized training phase and an expansion phase.
Long before pediatric neurology was established as a specialty,physicians of many different disciplines were contributing tothe field. The biographies of most of these founders of pediatricneurology are included in books by Ashwal1 and Aird.2 Amongthe earliest contributors, Freud,3 the psychiatrist, directeda clinic for children with cerebral palsy and published on thedefinition and nature of this controversial disorder in 1897.Bernard Sachs, a neuropsychiatrist, wrote a textbook of pediatricneurology in 1895, and also contributed to the classificationof cerebral palsy in 1926. Ford,4 a neurologist, is rememberedfor his classic book, Diseases of the Nervous System in Infancy,Childhood and Adolescence (1937), a monumental contributionthat antedated the development of the specialty by 25 years.In pediatrics, several academicians and practitioners organizedspecialty clinics and wrote extensively on childhood epilepsy,cerebral palsy, and meningitis in the 1950s. The list of keyfounders of child neurology in the United States is long andincludes Bronson Crothers, Randolph Byers, and William Lennoxat Boston Children’s Hospital; Douglas Buchanan at Universityof Chicago; Sidney Carter at New York Neurological Institute;Philip Dodge at Massachusetts General Hospital and WashingtonUniversity, St Louis; and David Clark at Johns Hopkins. Internationalfounders include William G. Wyllie from London, England; StoboPrichard from Toronto, Canada; and Yukio Fukuyama from Tokyo,Japan.
Even obstetricians contributed to the specialty, first in drawingattention to the role of abnormal parturition, difficult labor,and prematurity in asphyxia neonatorum as one of the causesof cerebral palsy in 18625 and, a century later, as membersof the committee that launched the NIH perinatal project, whichwas in the planning stage in 1956. The perinatal project was,in part, a stimulus for the next phase of the founding of childneurology as a specialty. The director of the National Institutesof Neurological Disorders and Stroke, Pearce Bailey, realizedthe need for pediatric neurologists to evaluate infants affectedby perinatal complications, and appointed a pediatric neurologistto the NIH Clinical Center in 1955. A widening of interestsamong neurologists led to the founding of the American Academyof Neurology in 19486 and the development of sections in variousneurology specialties, including child neurology in 1960.
Child neurology as a recognized specialty began to evolve inthe 1960s, following the organization of a training grants programby the NIH. In 1957-1958, a limited number of university-basedneurology departments in the United States accepted the firsttrainees into a 3-year fellowship, especially designed as preparationfor a career in academic pediatric neurology. The fellowshipand residency training, as outlined by an NIH ad hoc committeechaired by Doctors Dodge, Carter, and Clark (1958), usuallyconsisted of successive years in clinical adult neurology, pediatricneurology, and basic sciences. The early fellowship positionswere filled by pediatricians from academia, some having attainedthe rank of associate professor. They had demonstrated an expertiseand research interest in childhood neurologic disorders andwere strong in the developmental and metabolic aspects of childneurology, but lacked knowledge of neuroanatomy, pathology,and localization of neurologic lesions. They were encouragedto complete training in neurology and obtain board certification,realizing that without this qualification, a future in the fieldof pediatric neurology would be uncertain.
Child neurology was developed as a neurologic subspecialty.The faculty for these early training programs in pediatric neurologywas drawn from university departments of neurology, and thetraining program directors were neurologists chosen for theirrapport with children and their clinical and teaching skills.The collaboration of pediatrician and neurologist was mutuallybeneficial, and was particularly advantageous for the trainees,many renewing or proceeding to university appointments aftergraduation to establish their own training programs and pursueresearch interests.
The years 1960 through the early 1980s saw a rapid expansionof the number of training programs and pediatric neurologistswho had completed training and were board eligible or boardcertified in neurology and child neurology. The Special Certificatein Child Neurology was first issued in 1967, admitting neurologistswith an interest and recently qualified pediatric neurologistsunder a grandfather clause. Subsequently, specific trainingprograms produced graduates eligible in neurology, with theadditional certificate in child neurology. Some had initialresidency in pediatrics, and others entered pediatric neurologyhaving trained in internal medicine. Divisions of neurologyestablished in children’s hospitals with a relativelysmall staff of pediatric neurologists in the early 1960s have,in some cases, now expanded their staff near eightfold or 10-foldto accommodate a much larger clinical load of patients. Theoriginal emphasis on training for positions in academia andresearch has been modified to include trainees interested inthe community practice of child neurology. The rapid expansionphase of pediatric neurology is eloquently demonstrated by dataobtained as part of a research study regarding febrile seizuremanagement.
SURVEY OF CHILD NEUROLOGISTS WHO COMPLETED TRAINING 1945-1990
In an attempt to determine a consensus among pediatric neurologistsregarding management of febrile seizures, a questionnaire surveywas mailed to all North American members of the Child NeurologySociety (CNS) in 1990.7 Founded in 1972, the CNS was a reliablesource of physicians practicing the specialty. In addition tothe focus of the survey, respondents were asked to provide informationregarding their board certification, type of practice, universityappointment, year training completed, and training institution.Of 909 pediatric neurologist CNS members, 869 received questionnaires,and 574 (66%) returned them completed. The average percentageof practice devoted to pediatric neurology was 87.6 (SD 23.3)and that involved with adult patients was 11.7 (SD 22.1). Themajority of respondents were board certified or board eligiblein child neurology (95%) and in pediatrics (85%); 48% were boardedin neurology and 26% in electroencephalography. The high percentageof respondents holding senior academic appointments at thistime is noteworthy.
The figure shows the number of respondents who completed trainingin pediatric neurology in 5-year periods from 1945 to 1990.7Of a total of 78 training centers named by 547 respondents,10 institutions accounted for the training of approximatelyhalf of all pediatric neurologists. The peak training periodwas 1980 to 1985 and 82% graduated between 1970 and 1989. Respondentsholding university appointments numbered 497 (87%); 98 wereprofessors (17.1%), 128 associate professors (22.6%), 193 assistantprofessors (33.7%), 46 instructors (8%), and 31 fellows (5.4%).Pediatric neurology practice was based in a university hospitalfor 296 (51.7%) respondents, a private office for 224 (39.1%),and a hospital for 126 (22%); some practiced in more than oneoffice setting. Of interest, despite the reported adverse effectson behavior and cognition, phenobarbital therapy was still favoredby the majority of pediatric neurologists in 1990, particularlyin the prevention of complex febrile seizures.
Figure Pediatric neurologists who completed training in 5-year periods from 1945 to 1990
Reproduced with permission from Millichap JG, Colliver JA. Management of febrile seizures: survey of current practice and phenobarbital usage. Pediatr Neurol 1991;7:243-248.7
This study demonstrates the robust expansion of training programsand the numbers entering the specialty of pediatric neurologyin the 3 decades from 1960 to 1990. This was indeed the "floweringperiod" of pediatric neurology in the United States,2 stimulatedand facilitated by the generous training program grants of theNIH. Neurology played a role by insisting on the training ofpediatricians in basic neuroanatomy and clinical neurology beforepursuing a career in pediatric neurology.
The process of specialization was not always smooth, and resistanceto the development of the specialty often voiced by senior facultyin one or another department. In the early 1950s, when pediatricianswere contributing to the field, they were supported by seniorpediatric faculty but sometimes discouraged by neurologists.Neurologists had suffered similar power struggles in their effortsto escape from the cloak of internal medicine or psychiatryand to establish an independent department and patient service.2The NIH and the United States Public Health Service Trainingand Research Grants Committees did much to encourage the deansof medical schools to resolve these issues and, apart from anisolated institution, to permit the equal status of neurologyand medicine.
Academic child neurology in the United States at the turn ofthe century was in a transition phase, the majority of programshaving a division status within the departments of pediatrics,neurology, or both. A separate patient ward service is exceptional,but in hospitals with an epilepsy service and center, beds areassigned in a unit for overnight video electroencephalography.In Europe, many institutions have raised the status of pediatricneurology to that of a department. The present day status ofpediatric neurology and suggestions for the future developmentof the specialty are subjects for further discussion.
Ashwal S. The Founders of Child Neurology. San Francisco: Norman Publishing;
Aird RB. Foundations of Modern Neurology: A Century of Progress. New York: Raven Press;
Freud S. Die Infantile Cerebrallahmung. In: Nothnagel S, ed. Specielle Pathologie and Therapie. Vienna: Holder;
Ford F. Diseases of the Nervous System in Infancy, Childhood and Adolescence. Springfield, IL: Charles C Thomas;
Little WJ. On the influence of abnormal parturition, difficult labors, premature birth, and asphyxia neonatorum, on the mental and physical condition of the child, especially in relation to deformities. Trans Obstet Soc (Lond) 1862;2:293–344.
Bailey P. The past, present and future of neurology in the United States. Neurology 1951;1:1–9.[Free Full Text]
Millichap JG, Colliver JA. Management of febrile seizures: survey of current practice and phenobarbital usage. Pediatr Neurol 1991;7:243–248.[Medline]
Top.
Abstract.
EARLY INDIVIDUAL CONTRIBUTORY...
