Neurosurgery at the Montreal Neurological Institute and McGill University Hospitals

A History of Neurosurgery in Canada

Canada existed for more than half a century before there were glimmerings of modern neurosurgical activity. Neurosurgery had advanced significantly in Europe and the United States prior to its being brought to Toronto and Montreal from American centers. The pioneers responsible for the rapid evolution in practice, teaching and research are described. The interplay of scientific, professional, demographic and economic forces with general historical trends has produced dramatic changes in the way that neurosurgery is now practiced.

Neuropathology in Canada: the first one hundred years

We describe the evolution of neuropathology in Canada, beginning with William Osler who began working in Montréal in 1874 and finishing with the major period of expansion in the 1970s. Organized services began in the 1930s, in Montréal with the neurosurgeons Wilder Penfield and William Cone, and in Toronto with Eric Linell and Mary Tom, who both began their careers as neuroanatomists. Jerzy Olszewski and Gordon Mathieson, who trained in Montréal and Toronto, drove the creation of the Canadian Association of Neuropathologists in 1960. Training guided by the Royal College of Physicians and Surgeons of Canada was formalized in 1965, with the first certifying examination in 1968 and the subsequent creation of formal structured training programs. The number of neuropathologists in Canada increased rapidly through the 1960s and 1970s, with individuals coming from both clinical neuroscience and anatomic pathology backgrounds, a pattern that persists to the present day.

Neuropathology in Canada: overview of development and current status

BACKGROUND

The expansion of neurosurgery and neurology in Montreal and Toronto in the early 20th century was th stimulus for the development of neuropathology in Canada. Rooted in the disciplines of the neurosciences and laboratory medicine, neuropathology evolved into an independent discipline with the founding of the Canadian Association of Neuropathologists in 1960, and the recognition as a specialty by the Royal College of Physicians and Surgeons in Canada in 1965, fostering the development of several successful training programs. Nonetheless, a paucity of data remains concerning the background of training, scopes of practice, and career paths.

METHOD

We conducted a survey of all physicians in Canada who have either practiced neuropathology or undergone relevant training.

RESULTS

In 2009, 53 physicians were engaged in the practice of neuropathology, either exclusively or a substantial proportion of their time. Most work in tertiary hospitals, but a few service non-academic medical centers. Three routes of training were identified: direct from medical school (often with relevant research training), indirect from another clinical neuroscience specialty, and following or in conjunction with certification in one of the other pathology specialties. Practice profiles differ slightly, and some of the neuropathologists entering from pathology have mixed anatomical pathology/neuropathology responsibilities. Many of those with prior exposure in the neurosciences are more productive with regard to research and publications.

CONCLUSIONS

Existing multiple options for neuropathology training have facilitated recruitment and allowed development of a mosaic of specialists able to fulfill the diversity of needs in Canadian medical and scientific communities.

Clarence Sumner Greene, Sr.: the first African-American neurosurgeon

Largely because of the advances of the Civil Rights movement in the mid-20th century, an increasing number of African-Americans have had the opportunity to become physicians and enter the distinguished field of neurosurgery. Many have made the most of this opportunity, becoming prominent in both academics and private practice. Unfortunately, the details regarding the first African-American neurosurgeon, Clarence Sumner Greene, Sr., have remained in relative obscurity. Born on December 26, 1901 in Washington, D.C., Dr. Greene received his M.D. from the Howard University College of Medicine with distinction in 1936. After 7 years of general surgery residency and 4 years as a professor of surgery at Howard University, he was granted the opportunity by the legendary Wilder G. Penfield to train in neurosurgery at the world-renowned Montreal Neurological Institute from 1947 to 1949. Receiving high praise from Dr. Penfield, Dr. Greene became the first African-American certified by the American Board of Neurological Surgery on October 22, 1953. Subsequently, he was appointed as chair of neurosurgery at Howard University, where he successfully treated intracranial aneurysms, brain tumors, and herniated intervertebral discs until his tragic death in 1957. The diligence and perseverance of Clarence Sumner Greene, Sr., M.D., D.D.S., F.A.C.S. enabled him to overcome incredible odds to become the first African-American neurosurgeon, trained by Dr. Penfield at the Montreal Neurological Institute. A true pioneer, his achievements have opened the door for subsequent African-Americans to enhance the field of neurosurgery.

The early years of hemispherectomy

Today, hemispherectomy is a well-established procedure for the treatment of some sorts of catastrophic epilepsies. This, however, has not always been the case. The technique was developed to deal with brain tumors; however, the initial results were not remarkable. Moreover, when its morbidity became evident, it was almost abandoned. Had it not been for a shift in its use, with a huge increase in operations on patients with infantile hemiplegia, this surgery would certainly have disappeared. This paper focuses on the facts that surrounded these early years.

Endoscopic cyst fenestration outcomes in children one year of age or less

The use of endoscopic fenestration (EF) is becoming an increasingly common treatment for symptomatic intracranial cysts. Very little data exist regarding outcomes for this procedure in children 1 year of age or younger. We retrospectively reviewed the clinical outcomes of 8 children 1 year of age or less treated at our institution with endoscopic cyst fenestration. The mean follow-up was roughly 2.5 years. These data were combined with 17 other cases obtained from the published literature. EF was successful in rendering patients shunt-free or minimizing the number of ventricular catheters in 18 of 26 operations. There were 8 outright failures -- two in 1 patient. Given the risks and complications of cerebrospinal fluid shunting in children less than 1 year of age, we advocate the consideration of EF as initial treatment of symptomatic intracranial cysts.

Osler and the "medico-chirurgical neurologists": Horsley, Cushing, and Penfield

Sir Victor Horsley's lecture "On the Technique of Operations on the Central Nervous System," delivered in Toronto in 1906, set the stage for an appraisal of Sir William Osler as a protagonist for the emerging specialty of neurosurgery. During his time at McGill University from 1871 to 1884, Osler performed more than 1000 autopsies. Hispathological reports covered the topics of cerebral aneurysm, apoplectic hemorrhage, vascular infarction, subdural hematoma, meningitis, multiple sclerosis, cerebral abscess, and brain tumor. He wrote about cerebral localization and anatomy and the relationships between the morphological characteristics of the brain and intelligence and criminality. During his continuing career at Philadelphia and Baltimore, Osler published widely on problems in clinical neurology, including monographs on cerebral palsies and chorea as well as chapters on disorders of the nervous system in the first five editions of his popular textbook, The Principles and Practice of Medicine. He became familiar with many of the outstanding figures in medical neurology of his time. Regarding neurosurgery, Osler commended the pioneer operation for a brain tumor in 1884 by Rickman Godlee and the surgery for epilepsy in 1886 by Horsley. In 1907, in discussing the state of brain surgery as reviewed by Horsley, William Macewen, and others, Osler made a plea for "medico-chirurgical neurologists, properly trained in the anatomical, physiological, clinical and surgical aspects of the subject." He played a significant role as a referring physician, mentor, and friend to his young colleague Harvey Cushing (later to become Osler's Boswell), who was breaking new ground in neurosurgery at Johns Hopkins Hospital. Beyond that Osler became an inspiring hero figure for his Oxford student Wilder Penfield, who a few decades later would establish a neurological institute at McGill University where medico-chirurgical neurology would flourish.

Harvey Cushing's Canadian connections

During his surgical career between 1896 and 1934, Harvey Cushing made eight visits to Canada. He had a broad impact on Canadian medicine and neurosurgery. Cushing's students Wilder Penfield and Kenneth McKenzie became outstanding leaders of the two major centers in Canada for neurosurgical treatment and training. On his first trip to Canada, shortly after completing his surgical internship in August 1896, Cushing traveled with members of his family through the Maritime Provinces and visited hospitals in Quebec and Montreal. Eight years later, in February 1904, as a successful young neurosurgeon at the Johns Hopkins Hospital, he reported to the Montreal Medico-Chirurgical Society on his surgical experience in 20 cases of removal of the trigeminal ganglion for neuralgia. In 1922, as the Charles Mickle Lecturer at the University of Toronto, Cushing assigned his honorarium of $1000 to support a neurosurgical fellowship at Harvard. This was awarded to McKenzie, then a general practitioner, for a year's training with Cushing in 1922-1923. McKenzie returned to initiate the neurosurgical services at the Toronto General Hospital, where he developed into a master surgeon and teacher. On Cushing's second visit to McGill University in October 1922, he and Sir Charles Sherrington inaugurated the new Biology Building of McGill's Medical School, marking the first stage of a Rockefeller-McGill program of modernization. In May 1929, Cushing attended the dedication of the Osler Library at McGill. In September 1934, responding to the invitation of Penfield, Cushing presented a Foundation Lecture-one of his finest addresses on the philosophy of neurosurgery-at the opening of the Montreal Neurological Institute. On that same trip, Cushing's revisit to McGill's Osler Library convinced him to turn over his own treasure of historical books to Yale University.