The First Hundred Years The Centennial of the American
Only
Dec 15, 1874, a letter was widecirculated among those interested in neurological medicine inviting participation in the formation of the American Neurological Association, a society to be devoted to "the cultivation of neurological science in its normal and pathological relations." The charter members who signed the letter were seven: William A. Hammond of New York, Roberts Bartholow of Cincinnati, Meredith Clymer and T. M. B. Cross of New York, James S. Jewell of Chicago, Edward C. Seguin of New York, and James J. Putnam of Boston. Twentyeight others immediately responded, including S. Weir Mitchell of Philadelphia, J.K. Bauduy of St. Louis, S.G. Webber of Boston, Edward R. Hun of Albany, Henry D. Schmidt of New Orleans, Swan Burnett of Knoxville, Francis T. Miles and John Van Bibber of Baltimore, William Pepper and Horatio C. Wood of Philadelphia, Walter Hay and Henry M. Bannister of Chicago, and ten others from New York, all of whom thus became found¬ ing members. The first meeting duly took place in the Young Men's Chris¬ tian Association Hall at the corner of Fourth Avenue and Twenty-Third Street, New York, on the second day of June, 1875. Dr. Weir Mitchell was elected President, Dr. James Jewell first vice-president, and Dr. Seguin secretary and treasurer. Dr. Weir Mitchell had been unable to attend
Neurological
Association
meeting and the following day re¬ quested his name to be withdrawn the
from the list of officers. Dr. Jewell was then elected the first president of the association. Dr. Mitchell's critical views concerning medical societies were voiced when he agreed to be the president of the Philadelphia Neuro¬ logical Society at its formation in 1884. He eventually accepted the presidency of the American Neuro¬ logical Association 35 years later. At that first meeting, a lively scien¬ tific program occupied the remainder of the first day and part of the sec¬ ond. There were discussions of mye¬ litis (Webber), athetosis (Hammond), and ten other papers on subjects as diverse as brachial plexus injury (Put¬ nam), quadriplegia with remarkable recovery (Miles), fracture of the odon¬ toid process (Hun), cephalic neuralgia (Lente), and malarial pigmentation of the brain (Hammond). Dr. Ham¬ mond entertained all the members of the new association at a dinner at his home. Thus began the first national neu¬ rological organization in the world, for the Neurological Society of Brit¬ ain was founded in 1886, the Société de Neurologie de Paris in 1899, and the Deutsche Gesellschaft für Neuro¬ logie in 1907. It was the fourth na¬ tional medical specialty society formed in the United States, follow¬ ing the American Ophthalmological Society (1864), the American Otologi-
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/18/2015
cal Society (1866), and the Association of Hospital Superintendents (1844), which later became the American Psychiatric Association. The charter members of the associ¬ ation were a most remarkable group. Hammond, who was clearly the prime
mover, was an enormously energetic person with a talent for organization.
He inaugurated the first meeting of the New York Neurological Society the same year. Having earned his MD from New York University in 1848, he entered the US Army as assistant surgeon and served on various fron¬ tier stations, participating in Indian campaigns. He occupied his leisure time chiefly with physiological inves¬ tigations. In 1860, he resigned from the Army and taught anatomy and physiology at the University of Mary¬ land until the outbreak of the Civil War, when he returned to military service. He was assigned to adminis¬ trative work in the organization of hospitals, where his competence was soon recognized, leading to his ap¬ pointment as Surgeon-General. His forceful administration, which intro¬ duced a large number of excellent changes in military medicine, in¬ cluding the establishment of the Army Medical Museum, unfortu¬ nately clashed with the autocratic ad¬ ministration of Secretary of War Stanton, who ultimately ordered Hammond's court-martial and dis¬ missal, a totally unjust sentence that
later reversed by Congress. Ham¬ mond was a fluent writer and, besides was
early physiological papers, wrote on military medicine and on insanity. He is best known for his book, Diseases of the Nervous System (1871). The second edition of this first American neurological text appeared treatises
within a year. He became Professor of Diseases of the Mind and Nervous System at Bellevue Hospital, and re¬ tired to live in Washington, DC, after 1878. Bartholow graduated from the Uni¬ versity of Maryland in 1852 and spent four years as an army surgeon among the Mormons and Indians in the time of Brigham Young, before further military experience in the Civil War. He then settled in Cincinnati and be¬ came interested in materia medica and public health. He founded and edited The Clinic and wrote a Prac¬ tice of Medicine. He is now remem¬ bered only for his report on the result of stimulating the exposed dura ma¬ ter in a conscious patient with erod¬ ing skull tumor, confirming in man with movement of opposite limbs that Fritsch and Hitzig had reported in the dog the previous year. An outcry about such human experimentation led Bartholow to move to Phila¬
delphia.
Jewell1 of
Chicago was a strong evangelical personality who, like Hammond, was a facile writer. With Bannister, he organized and edited the Journal of Nervous and Mental
Disease in 1874, which has continued ever since. He was particularly inter¬ ested in epilepsy, in the sympathetic nervous system, and in athetosis and other involuntary movements. He died in his 50th year from chronic tubercu¬ losis. Seguin was the most accomplished clinical neurologist among the found¬ ers. He had graduated in New York in 1864 and by 1870 became the first professor of our specialty (at the College of Physicians and Surgeons, where he began clinicopathological studies and founded the first out¬ patient clinic for neurology, which later expanded to form the Vanderbilt Clinic in 1888). Putnam was also an accomplished clinical neurologist. He gave the first
American
descriptions of nutritional neuropathy and of combined system disease. In later life, he became greatly interested in neurosis and personality disorder. He introduced Sigmund Freud to America in 1909. Clymer had been prominent in psy¬ chiatry and neurology, but resigned in 1876 when he retired from practice. Seven others, including Cross, re¬ signed in the next four years, but new members with more neurological zeal were recruited to fill their places. The Catalytic Effect of the Civil War
The founding of the American Neu¬ rological Association served to crys¬ tallize a need for more knowledge re¬ garding the nervous system that had become evident in many ways during
the Civil War. Prior to 1860, text¬ books of medicine had dealt cursorily with diseases of the nervous system,
recognizing only general symptoms as apoplexy, hemiplegia, chorea, epilepsy, tetanus, myelitis, and neu¬ ralgia. The list appears in the texts of Dunglison (1842), Dickson (1859), and Austin Flint, Sr. (1866). Romberg had produced the first textbook of neurol¬ ogy in Germany in 1840, and Duchenne was publishing his studies of muscular atrophy (1853) and tabes (1858) and his great work De such
VElectrisation Localisée in three edi¬ tions (1855, 1861, 1872). Charcot's fa¬ mous Leçons began to appear only in 1872, and the texts of Gowers ap¬ peared much later (1886). Up to the time of the Civil War, physicians in the New World were not particularly interested in the problems of neurol¬ ogy. The miseries of that conflict were heightened, not only by medical unpreparedness for enormous num¬ bers of the types of wounds caused by new weapons such as shrapnel and high velocity missiles, but also by great prevalence of infections of un¬ known cause such as gas gangrene, tetanus, and meningitis, for which no treatment existed. The sense of in¬ adequacy and frustration regarding infections of the nervous system is well reflected in the memoirs of Jo¬ seph Jones, who had practiced in Sa¬ vannah, Ga, before the war and had surveyed hospitals and prison camps
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/18/2015
of the Confederate Army for Surgeon General Preston Moore. Though he was a pathologist, Jones found it nec¬ essary to begin the first volume of his memoirs of military medicine (1876) with a 140-page review of all that was known of physiopathology of the ner¬ vous system at that time. The well-known studies of Weir Mitchell, Morehouse, and Keen at the military hospital at Turner's
Lane, near Philadelphia, immediately heightened interest in nerve wounds,
but there were a number of other less well-known reports on miltary neu¬ rology, such as that of Michel of Charleston, SC, in 1874 on cranial injuries in Confederate hospitals. Francis Miles, the second president of the American Neurological Associa¬ tion, had practiced in Charleston be¬ fore and after his war service, but felt the need to have further study with Charcot in Paris and Gowers and Jackson in London before returning to practice in Maryland in 1869. The
Early Clinics
neurology be¬ largely a consultative specialty, with weekly outpatient clinics. As early as 1872, the Philadelphia Gen¬ eral Hospital was unique in setting In the next 50 years,
came
aside
beds, and later whole wards, for
acute and chronic
neurological
cases
under the charge of Charles K. Mills. A neuropathological laboratory for Spiller was established in 1895 and enlarged in 1904. In New York, neu¬ rology was taught in outpatient clin¬ ics until Dana was given neurological beds in Bellevue Hospital in 1898, and Bernard Sachs a complete service of 12 beds in Mount Sinai Hospital in 1900. By 1909, the first Neurological Institute had been established by Jo¬ seph Collins and Pearce Bailey, joined later by Dana, Peterson, Eisberg, Sachs, and that superb clinician Ram¬ say Hunt. The Montefiore Hospital, was opened in 1884 and became a large hospital with many neurological beds in 1910, but mostly for chronic cases until the 1950s. In Boston, Baltimore, Chicago, and St. Louis outpatient clinics flourished in the last quarter of the 19th cen¬ tury. By 1909, Boston City Hospital had set aside a few beds for neurol-
ogy with
one house officer; University Hospital, Ann Arbor, Mich, did so in 1912. So the growth of neurology con¬ tinued through the 1920s. In 1929, the Neurological Institute in New York moved to the new Columbia-Presby¬ terian Medical Center, where the staff was greatly enlarged and re¬
search activities in anatomy and pa¬ thology were instituted. The Expansion of Training Facilities
Riley notes that, in 1923, eight in¬ dependent neurological departments
existed in American medical schools, and 13 in 1947, whereas the number had risen to 73 in 1974. In the 1920s and 1930s, nearly all residents in training were aiming for a career in neuropsychiatry or neurosurgery. The possibility of a career in neurology was extremely limited before the 1940s. The American Board of Psychi¬ atry and Neurology was approved in 1934. In 1936, there were 16 hospitals that had approved programs for res¬ idency training in neurology (as dis¬ tinct from "neuropsychiatry"), seven of them in New York, offering a total of 49 residency places. In 1974, the number of residents in training was 1,005, with 1,025 full-time faculty and 761 part-time faculty. In 1948, in re¬ sponse to a need for an organization to represent all neurologists and to provide a forum for the "young Turks" of neurology, the Academy of Neurology was launched. It has been enormously successful. In 1974, it had 4,275 members. The most important change was the institution of full-time academic appointments with department status and independent budget, first at Boston City Hospital (Harvard University, 1928) then the New York
Hospital (Cornell University, 1932),
followed by the University of Chicago (1936), the Neurological Institute (1939), Montefiore Hospital (1944), and gradually many others. Severinghaus listed 18 full-time profes¬ sors in 1950 and 64 by 1965. Increase in part-time staff was much slower. Several factors relate to the expan¬ sion of neurological medicine. There has been a great expansion in all medical services in the same period, in relation to an enormous increase in
the general population (nearly five¬ fold since 1875). Not only have meth¬ ods of treatment of many neurolog¬ ical conditions become available, but the value of neurological assessment in relation to many general medical and surgical diseases has become rec¬ ognized. In addition, as psychiatry became more psychoanalytically ori¬ ented, fewer young psychiatrists could afford time for neurological training. The genus "neuropsychiatrist" gradually became scarce. Only three or four exceptional individuals were certified in both psychiatry and neurology after 1950. By 1945, private clinics were already establishing staff appointments for neurologists. The Veterans Administration hospi¬ tals, through the Deans' Committee
Plan, rapidly expanded neurological
facilities in relation to regional aca¬ demic centers during the 1950s. By far the largest stimulus came from the establishment of the Na¬ tional Institute of Neurological Dis¬ eases and Blindness in 1951 and the lay societies that prompted its forma¬ tion. In 1968, its title was changed to Neurological Diseases and Stroke. Its budget rose from $1.9 million in 1951 to $130 million in 1974. The institute has enormously influenced the devel¬ opment of neurology, chiefly in two ways. First, it enabled an enormous expansion of the basic sciences, in¬ cluding neuropathology, both in the medical schools and in the hospitals.
Secondly, through training grants, expanded existing training
which
programs and set up many
others, it
provided a large number of additional residencies, fellowships, and junior staff appointments. The institute also set up many interdisciplinary field studies, of which the best known are
the extensive surveys of neonatal brain damage, cerebrovascular dis¬ ease, and certain genetically deter¬ mined disorders.
Changing Pattern of Neurological Concepts and Disease The
One of the most remarkable fea¬ century of progress has been the changing spectrum of and attitudes toward neurological disease. We can touch only briefly on this as¬ pect. For a very long time there was tures of this
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/18/2015
great uncertainty neurosis. In
as
to the nature of
spite of a brilliant
paper
by George M. Beard at the second meeting of the association, it was
than 30 years before Babinski showed clearly the effects of sugges¬ tion and countersuggestion. There was at first a very strong emphasis on neuroanatomy. Nine of the early neu¬ rologists were also professors of anat¬ omy, a tendency continued into the more
present century by Keiller, Barker,
and Wilbur Smith. In the first 50 years, there was an in¬ creasing understanding of infections of the nervous system, but it is ex¬ traordinary that the sole means of measuring inflammation of the ner¬ vous system, examination of the spi¬ nal fluid, came only after 1908. The fundamental quantitative standards were not established until 1937 (Merritt and Fremont-Smith). Though po¬ liomyelitis had been described in Europe as early as 1784 and its char¬ acteristic paralysis discussed by Heine (1840) and Duchenne (1860), the epidemic character of the disease became apparent in Sweden only in 1887. The tragic American outbreaks in 1907 and in the 1920s and 1930s were a tremendous scourge until vac¬ cine was introduced in 1955. In 1918, the epidemic of lethargic encephalitis produced a flood of unprecedented neurological syndromes, at first com¬ plex compulsions and tics, later a new type of chronic progressive parkin¬ sonism. The neurological literature changed almost overnight. In the 1920s, fever therapy was introduced, and the hot-box and malarial blood became a prominent part of the neu¬ rologists armamentarium. Improved
Tilney, Riley,
neurosurgical technique greatly re¬ duced operative mortality and wid¬ ened the application of elective op¬ erations for chronic pain and, more recently, for symptomatic relief of some movement disorders. Pituitary tumors became better understood.
Pneumoencephalography, ventricu¬ lography, arteriography, and new scanning isotope methods have enor¬ mously facilitated neurological and neurosurgical diagnosis and have re¬ moved much of the mystique of "cere¬ bral localization." The possibility of operative cure of hemangiomatous
cysts, of cerebellar astrocytoma,
prolapsed discs, and certain types of neuroma and meningioma raised hopes for cure of the common glioblastoma, which unfortunately have
yet been realized. The demonstra¬ tion that some effects of cerebro¬ vascular disorder are reversible was followed by improved medical and not
surgical treatment. Meanwhile, the discovery of anti¬
biotics revolutionized the treatment of all infections, including syphilis, and removed the formerly common complications of mastoid disease. In the 1930s, the electroencephalogram began a totally new approach to the understanding of epilepsy, comple¬ mented by the discovery of infinitely
potent medicinal substances to control its manifestations. The intro¬ duction of muscle biopsy as a regular method of clinical investigation and of improved vital staining has opened up a whole new view of muscle dis¬ ease. Improvement in recording the more
electromyogram and, more recently, in measuring nerve conduction in
man
have at last brought the neumethods into the
rophysiologist's
clinic.
Through the whole period, classical neuropathology has continued to pro¬ vide better understanding of neuro¬ logical disease. Autopsy verification
of disease processes is still the essen¬ tial control of clinical diagnosis and management. Autoimmune processes have been explored. The development of the electron microscope in the 1950s has, however, added another di¬ mension, for the mitochondria, mem¬ branes, and synapses that play such an essential part in all nervous pro¬ cesses can now be directly seen, with greatly improved understanding of their disorders. In the last 25 years, the chemistry of myelin, the brain proteins, and neurotransmitters has been delineated and a beginning made in knowledge of the chemistry of growth and dissolution of nervous tissue. Some aspects of the invasion of the
system by viruses, partic¬ ularly by slow viruses, and of the nervous
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breakdown of neuronal immunity to herpes and measles are among the most promising of recent advances. The development of new staining techniques with silver and vital stain¬ ing with peroxidase and procion yel¬ low have revolutionized the charting of pathways by the neuroanatomist. There are a great many out¬ standing problems. The nature of some of the best known neurological
disorders, multiple sclerosis, amyo¬ trophic lateral sclerosis, and muscular
dystrophy still eludes
us.
Conversely,
aspects of these diseases that
ap¬
peared insoluble only ten years ago are beginning to respond to new methods. The technical possibilities of even currently available methods is by
no means
at
an
DEREK
end.
DENNY-BROWN, MD
Cambridge, Mass References
1. Denny-Brown D, Rose AS, Sahs AL (eds): Centennial Anniversary Volume, American Neurological Association. New York, Springer Publishing Co, 1975.
Only
Dec 15, 1874, a letter was widecirculated among those interested in neurological medicine inviting participation in the formation of the American Neurological Association, a society to be devoted to "the cultivation of neurological science in its normal and pathological relations." The charter members who signed the letter were seven: William A. Hammond of New York, Roberts Bartholow of Cincinnati, Meredith Clymer and T. M. B. Cross of New York, James S. Jewell of Chicago, Edward C. Seguin of New York, and James J. Putnam of Boston. Twentyeight others immediately responded, including S. Weir Mitchell of Philadelphia, J.K. Bauduy of St. Louis, S.G. Webber of Boston, Edward R. Hun of Albany, Henry D. Schmidt of New Orleans, Swan Burnett of Knoxville, Francis T. Miles and John Van Bibber of Baltimore, William Pepper and Horatio C. Wood of Philadelphia, Walter Hay and Henry M. Bannister of Chicago, and ten others from New York, all of whom thus became found¬ ing members. The first meeting duly took place in the Young Men's Chris¬ tian Association Hall at the corner of Fourth Avenue and Twenty-Third Street, New York, on the second day of June, 1875. Dr. Weir Mitchell was elected President, Dr. James Jewell first vice-president, and Dr. Seguin secretary and treasurer. Dr. Weir Mitchell had been unable to attend
Neurological
Association
meeting and the following day re¬ quested his name to be withdrawn the
from the list of officers. Dr. Jewell was then elected the first president of the association. Dr. Mitchell's critical views concerning medical societies were voiced when he agreed to be the president of the Philadelphia Neuro¬ logical Society at its formation in 1884. He eventually accepted the presidency of the American Neuro¬ logical Association 35 years later. At that first meeting, a lively scien¬ tific program occupied the remainder of the first day and part of the sec¬ ond. There were discussions of mye¬ litis (Webber), athetosis (Hammond), and ten other papers on subjects as diverse as brachial plexus injury (Put¬ nam), quadriplegia with remarkable recovery (Miles), fracture of the odon¬ toid process (Hun), cephalic neuralgia (Lente), and malarial pigmentation of the brain (Hammond). Dr. Ham¬ mond entertained all the members of the new association at a dinner at his home. Thus began the first national neu¬ rological organization in the world, for the Neurological Society of Brit¬ ain was founded in 1886, the Société de Neurologie de Paris in 1899, and the Deutsche Gesellschaft für Neuro¬ logie in 1907. It was the fourth na¬ tional medical specialty society formed in the United States, follow¬ ing the American Ophthalmological Society (1864), the American Otologi-
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/18/2015
cal Society (1866), and the Association of Hospital Superintendents (1844), which later became the American Psychiatric Association. The charter members of the associ¬ ation were a most remarkable group. Hammond, who was clearly the prime
mover, was an enormously energetic person with a talent for organization.
He inaugurated the first meeting of the New York Neurological Society the same year. Having earned his MD from New York University in 1848, he entered the US Army as assistant surgeon and served on various fron¬ tier stations, participating in Indian campaigns. He occupied his leisure time chiefly with physiological inves¬ tigations. In 1860, he resigned from the Army and taught anatomy and physiology at the University of Mary¬ land until the outbreak of the Civil War, when he returned to military service. He was assigned to adminis¬ trative work in the organization of hospitals, where his competence was soon recognized, leading to his ap¬ pointment as Surgeon-General. His forceful administration, which intro¬ duced a large number of excellent changes in military medicine, in¬ cluding the establishment of the Army Medical Museum, unfortu¬ nately clashed with the autocratic ad¬ ministration of Secretary of War Stanton, who ultimately ordered Hammond's court-martial and dis¬ missal, a totally unjust sentence that
later reversed by Congress. Ham¬ mond was a fluent writer and, besides was
early physiological papers, wrote on military medicine and on insanity. He is best known for his book, Diseases of the Nervous System (1871). The second edition of this first American neurological text appeared treatises
within a year. He became Professor of Diseases of the Mind and Nervous System at Bellevue Hospital, and re¬ tired to live in Washington, DC, after 1878. Bartholow graduated from the Uni¬ versity of Maryland in 1852 and spent four years as an army surgeon among the Mormons and Indians in the time of Brigham Young, before further military experience in the Civil War. He then settled in Cincinnati and be¬ came interested in materia medica and public health. He founded and edited The Clinic and wrote a Prac¬ tice of Medicine. He is now remem¬ bered only for his report on the result of stimulating the exposed dura ma¬ ter in a conscious patient with erod¬ ing skull tumor, confirming in man with movement of opposite limbs that Fritsch and Hitzig had reported in the dog the previous year. An outcry about such human experimentation led Bartholow to move to Phila¬
delphia.
Jewell1 of
Chicago was a strong evangelical personality who, like Hammond, was a facile writer. With Bannister, he organized and edited the Journal of Nervous and Mental
Disease in 1874, which has continued ever since. He was particularly inter¬ ested in epilepsy, in the sympathetic nervous system, and in athetosis and other involuntary movements. He died in his 50th year from chronic tubercu¬ losis. Seguin was the most accomplished clinical neurologist among the found¬ ers. He had graduated in New York in 1864 and by 1870 became the first professor of our specialty (at the College of Physicians and Surgeons, where he began clinicopathological studies and founded the first out¬ patient clinic for neurology, which later expanded to form the Vanderbilt Clinic in 1888). Putnam was also an accomplished clinical neurologist. He gave the first
American
descriptions of nutritional neuropathy and of combined system disease. In later life, he became greatly interested in neurosis and personality disorder. He introduced Sigmund Freud to America in 1909. Clymer had been prominent in psy¬ chiatry and neurology, but resigned in 1876 when he retired from practice. Seven others, including Cross, re¬ signed in the next four years, but new members with more neurological zeal were recruited to fill their places. The Catalytic Effect of the Civil War
The founding of the American Neu¬ rological Association served to crys¬ tallize a need for more knowledge re¬ garding the nervous system that had become evident in many ways during
the Civil War. Prior to 1860, text¬ books of medicine had dealt cursorily with diseases of the nervous system,
recognizing only general symptoms as apoplexy, hemiplegia, chorea, epilepsy, tetanus, myelitis, and neu¬ ralgia. The list appears in the texts of Dunglison (1842), Dickson (1859), and Austin Flint, Sr. (1866). Romberg had produced the first textbook of neurol¬ ogy in Germany in 1840, and Duchenne was publishing his studies of muscular atrophy (1853) and tabes (1858) and his great work De such
VElectrisation Localisée in three edi¬ tions (1855, 1861, 1872). Charcot's fa¬ mous Leçons began to appear only in 1872, and the texts of Gowers ap¬ peared much later (1886). Up to the time of the Civil War, physicians in the New World were not particularly interested in the problems of neurol¬ ogy. The miseries of that conflict were heightened, not only by medical unpreparedness for enormous num¬ bers of the types of wounds caused by new weapons such as shrapnel and high velocity missiles, but also by great prevalence of infections of un¬ known cause such as gas gangrene, tetanus, and meningitis, for which no treatment existed. The sense of in¬ adequacy and frustration regarding infections of the nervous system is well reflected in the memoirs of Jo¬ seph Jones, who had practiced in Sa¬ vannah, Ga, before the war and had surveyed hospitals and prison camps
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/18/2015
of the Confederate Army for Surgeon General Preston Moore. Though he was a pathologist, Jones found it nec¬ essary to begin the first volume of his memoirs of military medicine (1876) with a 140-page review of all that was known of physiopathology of the ner¬ vous system at that time. The well-known studies of Weir Mitchell, Morehouse, and Keen at the military hospital at Turner's
Lane, near Philadelphia, immediately heightened interest in nerve wounds,
but there were a number of other less well-known reports on miltary neu¬ rology, such as that of Michel of Charleston, SC, in 1874 on cranial injuries in Confederate hospitals. Francis Miles, the second president of the American Neurological Associa¬ tion, had practiced in Charleston be¬ fore and after his war service, but felt the need to have further study with Charcot in Paris and Gowers and Jackson in London before returning to practice in Maryland in 1869. The
Early Clinics
neurology be¬ largely a consultative specialty, with weekly outpatient clinics. As early as 1872, the Philadelphia Gen¬ eral Hospital was unique in setting In the next 50 years,
came
aside
beds, and later whole wards, for
acute and chronic
neurological
cases
under the charge of Charles K. Mills. A neuropathological laboratory for Spiller was established in 1895 and enlarged in 1904. In New York, neu¬ rology was taught in outpatient clin¬ ics until Dana was given neurological beds in Bellevue Hospital in 1898, and Bernard Sachs a complete service of 12 beds in Mount Sinai Hospital in 1900. By 1909, the first Neurological Institute had been established by Jo¬ seph Collins and Pearce Bailey, joined later by Dana, Peterson, Eisberg, Sachs, and that superb clinician Ram¬ say Hunt. The Montefiore Hospital, was opened in 1884 and became a large hospital with many neurological beds in 1910, but mostly for chronic cases until the 1950s. In Boston, Baltimore, Chicago, and St. Louis outpatient clinics flourished in the last quarter of the 19th cen¬ tury. By 1909, Boston City Hospital had set aside a few beds for neurol-
ogy with
one house officer; University Hospital, Ann Arbor, Mich, did so in 1912. So the growth of neurology con¬ tinued through the 1920s. In 1929, the Neurological Institute in New York moved to the new Columbia-Presby¬ terian Medical Center, where the staff was greatly enlarged and re¬
search activities in anatomy and pa¬ thology were instituted. The Expansion of Training Facilities
Riley notes that, in 1923, eight in¬ dependent neurological departments
existed in American medical schools, and 13 in 1947, whereas the number had risen to 73 in 1974. In the 1920s and 1930s, nearly all residents in training were aiming for a career in neuropsychiatry or neurosurgery. The possibility of a career in neurology was extremely limited before the 1940s. The American Board of Psychi¬ atry and Neurology was approved in 1934. In 1936, there were 16 hospitals that had approved programs for res¬ idency training in neurology (as dis¬ tinct from "neuropsychiatry"), seven of them in New York, offering a total of 49 residency places. In 1974, the number of residents in training was 1,005, with 1,025 full-time faculty and 761 part-time faculty. In 1948, in re¬ sponse to a need for an organization to represent all neurologists and to provide a forum for the "young Turks" of neurology, the Academy of Neurology was launched. It has been enormously successful. In 1974, it had 4,275 members. The most important change was the institution of full-time academic appointments with department status and independent budget, first at Boston City Hospital (Harvard University, 1928) then the New York
Hospital (Cornell University, 1932),
followed by the University of Chicago (1936), the Neurological Institute (1939), Montefiore Hospital (1944), and gradually many others. Severinghaus listed 18 full-time profes¬ sors in 1950 and 64 by 1965. Increase in part-time staff was much slower. Several factors relate to the expan¬ sion of neurological medicine. There has been a great expansion in all medical services in the same period, in relation to an enormous increase in
the general population (nearly five¬ fold since 1875). Not only have meth¬ ods of treatment of many neurolog¬ ical conditions become available, but the value of neurological assessment in relation to many general medical and surgical diseases has become rec¬ ognized. In addition, as psychiatry became more psychoanalytically ori¬ ented, fewer young psychiatrists could afford time for neurological training. The genus "neuropsychiatrist" gradually became scarce. Only three or four exceptional individuals were certified in both psychiatry and neurology after 1950. By 1945, private clinics were already establishing staff appointments for neurologists. The Veterans Administration hospi¬ tals, through the Deans' Committee
Plan, rapidly expanded neurological
facilities in relation to regional aca¬ demic centers during the 1950s. By far the largest stimulus came from the establishment of the Na¬ tional Institute of Neurological Dis¬ eases and Blindness in 1951 and the lay societies that prompted its forma¬ tion. In 1968, its title was changed to Neurological Diseases and Stroke. Its budget rose from $1.9 million in 1951 to $130 million in 1974. The institute has enormously influenced the devel¬ opment of neurology, chiefly in two ways. First, it enabled an enormous expansion of the basic sciences, in¬ cluding neuropathology, both in the medical schools and in the hospitals.
Secondly, through training grants, expanded existing training
which
programs and set up many
others, it
provided a large number of additional residencies, fellowships, and junior staff appointments. The institute also set up many interdisciplinary field studies, of which the best known are
the extensive surveys of neonatal brain damage, cerebrovascular dis¬ ease, and certain genetically deter¬ mined disorders.
Changing Pattern of Neurological Concepts and Disease The
One of the most remarkable fea¬ century of progress has been the changing spectrum of and attitudes toward neurological disease. We can touch only briefly on this as¬ pect. For a very long time there was tures of this
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/18/2015
great uncertainty neurosis. In
as
to the nature of
spite of a brilliant
paper
by George M. Beard at the second meeting of the association, it was
than 30 years before Babinski showed clearly the effects of sugges¬ tion and countersuggestion. There was at first a very strong emphasis on neuroanatomy. Nine of the early neu¬ rologists were also professors of anat¬ omy, a tendency continued into the more
present century by Keiller, Barker,
and Wilbur Smith. In the first 50 years, there was an in¬ creasing understanding of infections of the nervous system, but it is ex¬ traordinary that the sole means of measuring inflammation of the ner¬ vous system, examination of the spi¬ nal fluid, came only after 1908. The fundamental quantitative standards were not established until 1937 (Merritt and Fremont-Smith). Though po¬ liomyelitis had been described in Europe as early as 1784 and its char¬ acteristic paralysis discussed by Heine (1840) and Duchenne (1860), the epidemic character of the disease became apparent in Sweden only in 1887. The tragic American outbreaks in 1907 and in the 1920s and 1930s were a tremendous scourge until vac¬ cine was introduced in 1955. In 1918, the epidemic of lethargic encephalitis produced a flood of unprecedented neurological syndromes, at first com¬ plex compulsions and tics, later a new type of chronic progressive parkin¬ sonism. The neurological literature changed almost overnight. In the 1920s, fever therapy was introduced, and the hot-box and malarial blood became a prominent part of the neu¬ rologists armamentarium. Improved
Tilney, Riley,
neurosurgical technique greatly re¬ duced operative mortality and wid¬ ened the application of elective op¬ erations for chronic pain and, more recently, for symptomatic relief of some movement disorders. Pituitary tumors became better understood.
Pneumoencephalography, ventricu¬ lography, arteriography, and new scanning isotope methods have enor¬ mously facilitated neurological and neurosurgical diagnosis and have re¬ moved much of the mystique of "cere¬ bral localization." The possibility of operative cure of hemangiomatous
cysts, of cerebellar astrocytoma,
prolapsed discs, and certain types of neuroma and meningioma raised hopes for cure of the common glioblastoma, which unfortunately have
yet been realized. The demonstra¬ tion that some effects of cerebro¬ vascular disorder are reversible was followed by improved medical and not
surgical treatment. Meanwhile, the discovery of anti¬
biotics revolutionized the treatment of all infections, including syphilis, and removed the formerly common complications of mastoid disease. In the 1930s, the electroencephalogram began a totally new approach to the understanding of epilepsy, comple¬ mented by the discovery of infinitely
potent medicinal substances to control its manifestations. The intro¬ duction of muscle biopsy as a regular method of clinical investigation and of improved vital staining has opened up a whole new view of muscle dis¬ ease. Improvement in recording the more
electromyogram and, more recently, in measuring nerve conduction in
man
have at last brought the neumethods into the
rophysiologist's
clinic.
Through the whole period, classical neuropathology has continued to pro¬ vide better understanding of neuro¬ logical disease. Autopsy verification
of disease processes is still the essen¬ tial control of clinical diagnosis and management. Autoimmune processes have been explored. The development of the electron microscope in the 1950s has, however, added another di¬ mension, for the mitochondria, mem¬ branes, and synapses that play such an essential part in all nervous pro¬ cesses can now be directly seen, with greatly improved understanding of their disorders. In the last 25 years, the chemistry of myelin, the brain proteins, and neurotransmitters has been delineated and a beginning made in knowledge of the chemistry of growth and dissolution of nervous tissue. Some aspects of the invasion of the
system by viruses, partic¬ ularly by slow viruses, and of the nervous
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breakdown of neuronal immunity to herpes and measles are among the most promising of recent advances. The development of new staining techniques with silver and vital stain¬ ing with peroxidase and procion yel¬ low have revolutionized the charting of pathways by the neuroanatomist. There are a great many out¬ standing problems. The nature of some of the best known neurological
disorders, multiple sclerosis, amyo¬ trophic lateral sclerosis, and muscular
dystrophy still eludes
us.
Conversely,
aspects of these diseases that
ap¬
peared insoluble only ten years ago are beginning to respond to new methods. The technical possibilities of even currently available methods is by
no means
at
an
DEREK
end.
DENNY-BROWN, MD
Cambridge, Mass References
1. Denny-Brown D, Rose AS, Sahs AL (eds): Centennial Anniversary Volume, American Neurological Association. New York, Springer Publishing Co, 1975.
