History

History of the Division of Neurosurgery


Ian F. Parney MD PhD, Peter B. R. Allen MD, Keith E. Aronyk MD, Kenneth C. Petruk MD PhD

Abstract
The Division of Neurosurgery at the University of Alberta has a long and distinguished history. Beginning with the arrival of Dr. H. H. Hepburn in 1920, the vision has steadily grown in size, clinical expertise, and academic output. One of the first major contributions to neurosurgical practice was Dr. Hepburn's role in developing skull traction for cervical spine fracture / dislocations in the early 1930's. Residency training in neurosurgery began in the 1940's, was formalized in the 1960's, and has continued uninterrupted since. The modern era was ushered in with the return of Dr. Peter Allen from the Mayo Clinic and the arrival of dr. Bryce Weir from the Montreal Neurological Institute in the 1960's. These two outstanding individuals established microneurosurgical techniques at the University of Alberta and fostered a supportive environment for academic pursuits. Dr. Weir's subsequent central role in defining the pathophysiology and treatment of cerebral aneurysms and subarachnoid hemorrhage is well known. This tradition of neurovascular excellence continues and is particularly well represented by the contributions of Dr. J. Max Findlay. In addition, the Division has developed strong program in molecular neuro-oncology under the direction of its current leader, Dr. Kenn Petruk. Clinically, the division continues to expand with increasing representation of complex spine surgery, pediatric neurosurgery, and epilepsy / functional neurosurgery. At the beginning of a new century, the Division of Neurosurgery at the University of Alberta is flourishing and is well positioned to continue a tradition of excellence.

Early History of the University of Alberta
The University of Alberta's beginnings date back almost to frontier days. When it was founded in 1906, Alberta had just joined confederation as Canada's eighth province the year before. The City of Edmonton's population was a meager 20 000. The first classes were held in 1908 with forty-five students and five faculty members. However, the university was ambitious and quickly grew in size and stature. The Faculty of Medicine was founded in 1913, initially offering three years of a five-year program that was to be completed at McGill University in Montreal. This was to be a brief step on the path towards an independent medical school but the outbreak of war in 1914 and its aftermath slowed the pace somewhat. However, by 1923 the faculty was able to offer clinical instruction adequate for a full degree program and the first class graduated in 1927 (2).

Neurosurgical Beginnings (1920 - 1938)
The origins of neurosurgery at the University of Alberta rest with Dr. Howard H. Hepburn (Figure 1). Dr. Hepburn received his medical degree from McGill University in 1910. Upon completing several house physician positions in Montreal, he embarked on a round the world voyage, paying his way by working as a physician and surgeon. He ended his travels in Germany in 1914, where he planned to pursue neurosurgical training. Unfortunately, the outbreak of hostilities made this impossible and he was actually imprisoned as an enemy alien. He escaped to Britain and promptly volunteered for military service. After distinguishing himself in France with the Royal Army Medical Corps during the way, in 1919 he returned to North America to get further training in neurological surgery with Dr. Alfred Adson of the Mayo Clinic in Rochester, Minnesota. In 1920, he returned to Edmonton (where he had previously worked briefly as a schoolteacher) to begin a practice centered on neurological surgery (12, 27).

Dr. Hepburn (Figure 1A) was the first Canadian neurosurgeon west of Winnipeg. For many, this isolation might have suppressed academic ambition. This was not the case for Dr. Hepburn. He continually strove to improve the care of his patients and published monographs on the treatment of head injuries and on techniques for pneumoencephalography (14, 15). He also laid the foundations for neurosurgical education in Edmonton. Among those he taught were Dr. Guy Morton, who was to join him in the practice of neurosurgery at the University of Alberta, and Dr. A. E. Walker, later Chairman of the Department of Neurosurgery at Johns Hopkins University (27). Dr. Walker was a member of the first graduating class of the Faculty of Medicine in Edmonton in 1927 and his first neurosurgical experiences would have been with Dr. Hepburn.

Unfortunately, Dr. Hepburn did not publish what may have been his most important and lasting contributions to neurosurgery. In the late 1920's, he began to use metal caliper resembling ordinary ice tongs to apply skull traction in patients with cervical spine fractures. According to local legend, he conceived these tongs based on both his previous experience reducing femur fractures during combat (13) and from watching ice blocks being stacked at the University Hospital. Although he attended a meeting of the British Surgical Society in London in the early 1930's and is thought to have discussed his tongs there (12), he never published his results. However, the first published account of skull tongs for cervical spine traction suggests that its author, Dr. W. G. Crutchfield, was aware of Hepburn's work. In his original 1933 paper on "Skeletal Traction for Dislocation of the Cervical Spine", he describes applying a pair of "Edmonton Extension Tongs" (5). Despite his failure to document his work, Hepburn has received some recognition over the years. In 1973, Dr. W. J. Gardner included Hepburn's tongs in a Smithsonian Institute Exhibit entitled "Cervical Traction Past and Present" as an example of a traction device that probably preceded Crutchfield's. In addition, the authors have recently published a manuscript detailing Hepburn's contributions to spinal traction (19).

War and Beyond (1939 - 1960)
The outbreak of renewed hostilities in 1939 again plunged the world into turmoil. Many staff from the University of Alberta Hospital were swept into action in Europe and the Far East. Not surprisingly, advances in medicine and surgery were few in Edmonton during this time. However, one grim benefit from the war was a renewed economy. This helped set the stage for a post-war economic boom in Alberta, inaugurated with the discovery of oil in Leduc (just south of Edmonton) in 1947. Post-war Alberta and its medical community were alive with the growth that prosperity brings (17).

The Division of Neurosurgery also grew. Dr. Guy Morton, a 1939 graduate of the Faculty of Medicine at the University of Alberta, returned to Edmonton from the Montreal Neurological Institute after completing neurosurgical training there. He joined Dr. Hepburn in the practice of neurosurgery in 1945. In 1951, Dr. Hepburn retired from surgical practice and Dr. Morton assumed the duties of Head, Division of Neurosurgery. Dr. Thomas Speakman (Figure 1B), also a Montreal graduate, joined the Division in 1952. Although both Dr.'s Morton and Speakman trained at the Montreal Neurological Institute, different neurosurgical giants had influenced them. Dr. Morton was a "Cohn" neurosurgeon and Dr. Speakman was a "Penfield" neurosurgeon. This led occasionally to minor friction but the best choice for the patient always won out. Dr. Speakman brought a number of new procedures to Edmonton and was responsible for the first aneurysm clippings, arteriovenous malformation resections, and carotid-cavernous fistula disconnections performed at the University of Alberta. Dr. Speakman succeeded Dr. Morton as head of the Division in 1965.

The clinical caseload grew steadily. Sixty-five major cases were performed in 1941 but this had increased to 202 by 1952. Three hundred and seventy-four cases were performed in 1961 (27) (P 227). In addition, a heavy diagnostic burden fell upon Dr.'s Hepburn, Morton, and Speakman. The primary cerebral imaging modality available throughout this period was a neurosurgeon-driven technique for pneumoencephalography developed by Dr. Hepburn in the 1930'2 (15). Thankfully, this was increasing supplanted by cerebral angiography and 400 cerebral angiograms per year were performed by the Radiology Department by 1960 (277) (P 227). This era also marked steady progress neurosurgical training. Dr. David Albertson and Dr. Peter Allen both received portions of their neurosurgical training in Edmonton in the late 1950's and early 1960's. Dr. Allen's return to the University of Alberta in 1963 after completing his neurosurgical training at the Mayo Clinic marks the beginning of the modern neurosurgical practice in Edmonton.

Into the Modern Era (1961 - 1980)
Dr. Allen's return from the Mayo Clinic corresponded with an era of rapid change in neurosurgical practice in Edmonton that mirrored similar changes across the globe. Dr. Allen's enthusiasm, passion for teaching, and drive to see neurosurgery in Edmonton flourish were major factors contributing the Division's growth. In 1967, the Division consisted of Dr. Speakman, Dr. Morton, and Dr. Allen. The clinical caseload was growing and efforts were initiated to recruit a fourth surgeon. The ideal candidate was to be skilled in microsurgery, someone with the academic drive to advance the frontiers of neurosurgery. After an extensive search, Dr. Bryce Weir (another Montreal Neurological Institute graduate) agreed to take up a faculty position in 1968. On arricing, Dr. Weir introduced the operating microscope to neurosurgical practice. This advance was enthusiastically received and adopted by his colleagues. It was just as revolutionary in Alberta as it was elsewhere.

Shortly after Dr. Weir's arrival, the Division was shaken by tragedy. In 1969, Dr. Speakman suffered a massive cerebrovascular accident, dying suddenly and unexpectedly at the age of 45. In the aftermath, Dr. Allen became Divisional Head. He, Dr. Morton, and Dr. Weir continued to build the Division. In Dr. Speakman's last years has head of the Division, formal residency training in neurosurgery had been introduced. In 1970, Dr. Jack Barlass was the first resident to successfully complete his Royal College Fellowship exams after taking neurosurgical training entirely in Edmonton. Dr. Thomas Ayres completed his training shortly after and took up a position as a staff neurosurgeon in 1971. These early graduates were the first of many. The residency program took hold and flourished in the years that followed. It has continued uninterrupted since and has been responsible for training, in whole or in part, over fifty neurosurgeons in the past 32 years. A complete list of physicians who have completed some or all of their neurosurgical training at eh university of Alberta is shown in Table 1. A Divisional photograph circa 1974 is shown in Figure 2.

Dr. Weir's influence on neurosurgery at the University of Alberta and, indeed, around the world grew steadily after his arrival in 1968. He published highly regarded manuscripts on a variety of topics including chronic subdural hematoma pathophysiology, astrocytoma prognosis, and lumbar disc surgery outcomes (32 - 34). However, his major contributions were in neurovascular surgery. He built an exceptional laboratory research group investigating the pathophysiology of cerebral vasospasm after subarachnoid hemorrhage and published numerous seminal reports on this topic (3, 23, 24). His 1978 clinical study of the time course of vasospasm in man remains definitive (31) and helped spur the debate on early vs. late aneurysm surgery (30).

This academic explosion paid educational dividends. Residents were exposed to the leading edge of neurosurgical practice. Prominent neurosurgeons from around the globe began to accept invitations to speak at the University of Alberta. In part to encourage neurosurgical residents and fellows to help carry out research, Dr. Weir developed graduate education through the Division of Experimental Surgery. Dr. Ramon Erasmo was awarded the first MSc through this program in 1969 and Dr. Kenn Petruk received the first PhD in 1973. This graduate school has thrived alongside the residency program and has resulted in a total of 17 MSc's and 13 PhD's being awarded to date. A complete list of PhD and MSc graduates through the Division of Neurosurgery at the University of Alberta is shown in Table 2.

Steady Growth (1981 - 1990)
The Division continued to grow. In 1980, it consisted of Dr. Morton, Dr. Allen, Dr. Weir, Dr. K. C. Petruk (joined 1975), and Dr. J. D. S. McKean (joined 1979). After a long and distinguished career, Dr. Morton retired in 1981. In 1982, Dr. Allen became Vice-President (Medical) for the University of Alberta Hospital and Dr. Weir assumed duties as Head of the Division. The Division was joined by two more graduates of the residency program over this decade, Dr. Robert Broad (1983) and Dr. Keith Aronyk (1984). In 1986, Dr. Weir became the Chairman of the Department of Surgery and Dr. Petruk became Head of the Division of Neurosurgery.

Dr. Weir's academic profile continued to rise. His attention turned increasingly from vasospasm pathophysiology to vasospasm treatment. he played a key role in introduction nimodepine to improve outcome after subarachnoid hemorrhage (6, 25). With the introduction of intracisternal and intraventricular recombinant tissue plasminogenactivator after aneurysm SAH, Dr. Weir helped chart some of the first steps of what is now called molecular neurosurgery (9, 10). His 1987 book "Aneurysms Affecting the Nervous System" remains a scholarly classic (29). A steady stream of fellows and residents passed through his laboratory at this time. Several have since gone on to significant academic acclaim of their own, including Dr. J. Max Findlay (University of Alberta) and Dr. Loch Macdonald (University of Chicago).

The rest of the Division also flourished. Members began to develop subspecialty interests, including complex spine and skull base surgery (Dr. R. W. Broad), pediatric neurosurgery (Dr. K. E. Aronyk), and functional and epilepsy surgery (Dr. J. D. S. McKean). Dr. Kenn Petruk began to strike out academically on his own, coordinating a clinical trial for autologous adrenal medullary transplants in Parkinson's patients and, along with Dr. K. D. S. McKean, establishing a basic neuro-oncology laboratory (11, 16, 26). Throughout all of this, Dr. Allen continued in his role as senior neurosurgical partner, with a busy practice that truly touched on almost every aspect of clinic neurosurgery.

Flux (1991 - 2000)
The Division of Neurosurgery at the University of Alberta entered the 1990's as one of the premier neurosurgical institutions in Canada, a dynamic and vibrant group with an established international reputation. They were further strengthened by the addition of two new faculty members, Dr. J. M. Findlay (1991) and Dr. D. E. Steinke (1992), who were well positioned to continue the tradition of excellence in clinical and academic neurosurgery. A photograph of the members of the Division in 1990 is shown in Figure 3. Despite these optimistic beginnings, this decade proved to the tumultuous, with many highs and lows.

Alberta has benefited mightily from rich oil deposits but this has tightly linked our economy to the price of crude oil. When this price drops, as it did precipitously in the late 1980's and early 1990's, the economy stalls and government revenues shrink. This has major implications for publicly funded programs including healthcare. In the early 1990's, government cutbacks led to massive medical restructuring. Many hospitals were "downsized" or even closed altogether. Operating room time was increasingly scarce. Virtually no large capital projects went ahead. This uncertain environment hit the Division hard. Waiting lists ballooned and incomes dropped. Although these were not the only factor involved, neurosurgeons began to leave Edmonton. In 1990, Dr. Keith Aronyk accepted Dr. David McLone's invitation to come to Children's Memorial Medical Center (Northwestern University, Chicago, Illinois) as a pediatric neurosurgeon. In 1993, after 25 years at the University of Alberta, Dr. Weir left to become Chairmen of the Department of Neurosurgery at the University of Chicago. Neurosurgery in Edmonton contracted from four hospitals in 1990 to two hospitals in 1994 and one hospital in 1996.

Despite these setbacks, there were many bright spots for the Division. In particular Dr. J. M. Findlay became a m ajor figure in neurosurgery. Continuing work begun with Dr. Weir, he published the definitive randomized control trail of intracisternal recombinant tissue plasminogen-activator after aneurismal subarachnoid hemorrhage (7). He published laboratory studies about balloon angioplasty on vasospastic cerebral vessels (4, 18) and clinical works about the role of transcranial dopplers and CT angiography after SAH (1, 28). His studies concerning carotid endarterectomy techniques, indications, and results established him as an expert in this field (8, 35). This impressive academic output was combined with an extremely busy clinical practice. Not surprisingly, Dr. Findlay was appointed Head of the Division in 1995, a position he held until 1999 when he left Edmonton briefly for a sojourn as the Head of the Division of Neurosurgery at the University of Western Ontario. Thankfully for the University of Alberta, Dr. Findlay chose to return to Edmonton in 2000.

There were other significant highlights. Dr. Petruk increasingly established himself as an authority on molecular and immune-mediated therapies for gilomas (21, 22). In 1998, he initiated the first clinical gene therapy trial in Western Canadian history (20). Dr. Keith Aronyk returned to the University of Alberta in 1993 and quickly re-established a large pediatric neurosurgical practice. The residency program continued to grow. Dr. Richard Fox, a 1997 graduate, took up a staff position in 1998 after completing fellowship training in complex spine surgery.

Present and Future
After a seesaw decade in the nineties, neurosurgery at the University of Alberta has regained a measure of stability in the new century. Although fiscal restraint remains the rule and competition for surgical resources is fierce, the program continues to grow. In 2001, Dr. peter Allen retired after 38 years of continuous neurosurgical practice. Happily, he remains active within the Division as Professor Emeritus. Three new neurosurgeons were hired shortly after Dr. Allen's retirement (Dr. B. M. Wheatly, Dr. I. F. Parney, and Dr. V. Mehta), prompting the not entirely facetious observation that it took three people to replace Peter Allen. A picture of the current faculty members is shown in Figure 4. The Division remains busy clinically, with 2000 cases performed in 2001. Increasing subspecialization is the rule, and the Division is well represented in neurovascular, neurosurgery. Academic productivity is high. From humble beginnings in a dusty Canadian prairie town, the Division of Neurosurgery at the University of Alberta has grown into a progressive, vibrant institution. Its influence on the larger neurosurgical world has been significant. This is all the more impressive given the Division's relatively small size and isolation. After a period of uncertainty, the Division is once again well positioned to continue its long tradition of excellence. Long may it do so.

Acknowledgements
The authors wish to thank all members of the Division of Neurosurgery at the University of Alberta past and present for their helpful comments concerning this manuscript.