0031-3998/03/5302-0345 PEDIATRIC RESEARCH Vol. 53, No. 2, 2003 Copyright © 2003 International Pediatric Research Foundation, Inc. Printed in U.S.A. SPECIAL ARTICLE A History of Pediatric Specialties In the fourth article of this series, Drs. Ashwal and Rust describe the evolution of child neurology from its parent disciplines of Pediatrics and Neurology. They also document the advances that have been made in each of the many neurologic diseases of childhood. The advancement of technology and the genomic revolution have opened new pathways of research. The remarkable progress of Child Neurology in the 20th century has provided the foundation for further understanding, prevention, and treatment of the many neurologic disorders of childhood. Alvin Zipursky Editor-in-Chief Child Neurology in the 20th Century STEPHEN ASHWAL AND ROBERT RUST Department of Pediatrics [S.A.], Loma Linda University School of Medicine, Loma Linda, California 92350, U.S.A.; Departments of Neurology and Pediatrics [R.R.], The University of Virginia School of Medicine, Charlottesville, Virginia 22908-0394, U.S.A. ABSTRACT Although considered a relatively new subspecialty, child neurological conditions, and neuromuscular diseases. They have neurology traces its origins to the Hippocratic descriptions of also led to a better understanding of the neurobiologic basis of seizures and other neurologic conditions in children. Its true common problems such as global developmental delay, cerebral beginnings can be traced to the 1600s and 1700s with classical palsy, and autism. As remarkable as the advances have been in descriptions of chorea, hydrocephalus, spina bifida, and polio. It the past century, the accelerating pace of our understanding of was, however, the remarkable clinical and scientific advances in the fundamental mechanisms responsible for brain development neurology and pediatrics at the end of the 19th century that will lead to even greater achievements in the clinical care of helped create its scientific foundation. Like other pediatric dis- children with neurological disorders in the 21st century (Pediatr ciplines, child neurology evolved into a distinct clinical and Res 53: 345–361, 2003) scientific specialty early in the 20th century. Remarkable ad- vances in the neurosciences, particularly in the fields of genetics, Abbreviations molecular biology, metabolism, immunology and nutrition, have ABPN, American Board of Psychiatry and Neurology greatly advanced our understanding of how the brain develops CBF, cerebral blood flow and responds to environmental influences. Advances in neuro- PET, positron emission tomography imaging, electroencephalography, electromyography, muscle PKU, phenylketonuria histology, biochemistry, and neuropharmacology have consider- SMA, spinal muscular atrophy ably improved our ability to evaluate and treat children with HIE, hypoxic-ischemic encephalopathy neurological disorders. These advances have allowed new and ADEM, acute disseminated encephalomyelitis expanding approaches, unique to children, in the fields of epi- IQ, intelligence quotient lepsy, neurodegenerative and neurometabolic disorders, nervous ADHD, attention-deficit/hyperactivity disorder system infections, demyelinating diseases and tumors, neonatal MRI, magnetic resonance imaging Although formal designation as a medical subspecialty did the Hippocratic description of seizures and other neurologic not occur until the 1950s, child neurology traces its origins to conditions in children. The accumulation of a more substantial body of information and subspecialized interest in the neuro- Received October 23, 2001; accepted April 29, 2002. logic problems of children can be traced from the 16th and 17th Correspondence: Stephen Ashwal, M.D., Division of Child Neurology, Department of centuries, during which classical considerations of chorea, Pediatrics, Loma Linda University School of Medicine, 11175 Campus Street, Loma Linda, CA 92350, U.S.A.; e-mail [email protected] hydrocephalus, spina bifida, birth injuries, cerebral palsies, DOI: 10.1203/01.PDR.0000047655.66475.52 poliomyelitis, and other conditions were published. The rise of 345 346 ASHWAL AND RUST empirical clinical medicine, neuroanatomy, and of specialized- clear that subspecialization in this area would render medical, interest pediatrics, obstetrics, orthopedics, psychiatry, and neu- scientific, and social benefits. Such subspecialization was nec- rology during the 17th and 18th centuries provided the ground- essary for the sake of improved standards of practice and work on which child neurology would be based (1–4). improved skill in further investigation. Subspecialization also Foundations were laid for neuropsychological investigation afforded appropriate selection and preparation of individuals and for the amelioration of psychomotor disorders of children, who possessed the traits necessary for the formation of a often within the setting of newly constituted residential facil- professional relationship with children of different ages and ities dedicated to the care of children and adolescents. Within their parents, including the subspecialized skills necessary for such facilities arose the organized study and classification of obtaining a history and examining young children. Progress in mental retardation, paralyses, blindness, deafness, and epi- the study and treatment of the developing nervous system lepsy. Clinics with subspecialized and multidisciplinary inter- would occur far more expeditiously if a critical mass of est in childhood neurologic problems followed in short order, individuals dedicated to this family of subjects were recruited and with this came the earliest understandings of the effects of and trained, individuals who in turn could recruit successors, trauma, nutrition, and inheritance on childhood neurologic provide selected neurologic training for members of associated diseases. Advances in diagnostic testing, such as electroen- disciplines and whose zeal would encourage the devotion of cephalography, neuroimaging, electromyography, muscle his- time and resources to research, as well as improvement in tology, biochemistry and molecular biology, helped those with diagnosis and management. an interest in child neurology diagnose and treat a large array One of the major social and educational trends since the end of conditions. of World War II was the continued shift toward a society based The notion of providing urgent neurologic consultations in on information processing and sophisticated technology. Child hospitals and the establishment of wards devoted to the care of neurologists were soon asked to evaluate many children to children with neurologic diseases arose in major hospitals determine whether seizures were occurring and whether med- before World War II. Consultations in general hospitals were ications were indicated. The advent of CNS stimulants and generated with increasing frequency as the development of other medication to treat attentional, depressive, or aggressive ventilators, discovery of antibiotics, improvement of fluid re- behavioral disorders further stimulated additional referrals. suscitation, and other advances that occurred in the 1930s and After World War II, enthusiasm for the study and treatment of 1940s permitted children to survive increasingly complicated childhood neurologic diseases was reflected in the clear iden- diseases, manifesting an increasingly bewildering array of tification of specialists in neurologic disease of children. By the neurologic dysfunction. Neurologists interested in investigat- mid-1970s most medical schools had pediatric neurologists on ing and treating the birth-related, infectious, parainfectious, their faculty engaged in teaching, research, training, and caring traumatic, hereditary, and other forms of neurologic illness in for children with an ever-widening spectrum of neurologic children acquired increasing sophistication in this emerging disorders. neurologic subspecialty and assumed increasing responsibility As the number of pediatric neurologists in many countries for the acute and long-term care of children with these increased, it became obvious that separate professional societ- problems. ies representing their own political, medical, and academic The evolution of a subspecialized discipline of child neurol- interests were desirable. Such societies were established in ogy occurred over more than 100 years, as part of the contem- Japan (1961), Scandinavia (1962), England (1971), the United porary struggle to develop the professional identities of neu- States (1972), Belgium (1978), China (1985), Europe (1970), rology, psychiatry, and pediatrics. Many of the principal early and worldwide (1973). Additional evidence for the growth of figures in the development of modern clinical and basic neu- child neurology was the number of journals now devoted to rosciences and pediatrics were profoundly interested in the this field including Developmental Medicine and Child Neu- neurologic diseases and normal neurologic development of rology (1958), Neuropediatrics (1969), Brain and Develop- children. Many of these influential neurologists, psychiatrists, ment (1979), Pediatric Neurology (1985), and the Journal of and neuroscientists did not feel constrained to limit their Child Neurology (1986). Many aspects of the advances in investigations or professional practice on the basis of age. clinical and basic neurosciences pertinent to child neurology, Many influential pediatricians were unconstrained by a sense descriptions of neurologic