early american professorships in neurology

HISTORY OF NEUROLOGY

Christopher G. Goetz, MD, and Eric J. Pappert, MD

American universities recognized and institutionalized the emerging importance of neuroscience in medicine by establishing neurological professorships as early as the 1860s. Nearly 20 years before Charcot assumed his celebrated chaired professorship for Diseases of the Nervous System in France, Harvard University created a professorship of Physiology and Pathology of the Nervous System (1864), naming Brown-Skquard as its recipient. In 1867, the new Bellevue Hospital Medical School established a combined neurology/psychiatry chair with William A. Hammond as professor, and the University of Pennsylvania created a clinical professorship devoted specifically to neurology in 1875, naming Horatio C. Wood. Although modest in their university power base and their clinical research/laboratory programs, these Ameri- can posts were internationally unique for their time and solidly entrenched neurology as a specific division in early US medical education.

Goetz CG, Pappert EJ. Early American professorships in neurology. Ann Neurol 1 996;40:258-263

J.-M. Charcot is largely considered the world’s first professor of clinical neurology. In the late 1880s and until his death in 1893, the Charcot service at the Sal- pitrikre hospital in Paris was the stable and uncon- tested international center for the study of neurology [ 11. Prior to Charcot’s professorship, however, neurology in the United States had already become a bur- geoning field that gained rapid and solid university recognition [2]. Select medical schools incorporated neurological study into their curriculum, attempting to provide an innovative and stable format for consistent neurological teaching. This article examines the early medical and administrative priorities set by American schools as they established neuroscience as an autonomous medical division through the development of university professorships.

The Emerging Concept of American Medical Specialties In the mid and late 188Os, a general movement toward specialization in medicine emerged internationally, with supporters and vocal dissenters [3] . The German universities and Paris, with its longer history of specialty hospital services and medicdl school courses in areas of specialization, were the primary European centers for the support and developmmt of professorships in medical specialties. Prior to active discussions on a neurological chair, the French government had sup- ported chaired professorships in other specialty areas, including psychiatry [4]. Support for specialization was voiced in Great Britain as well, and, against the hesi-

tancy of critics, Paget [5] emphasized: “If the field of any specialty in science be narrow, it can be dug deeply. In science as in mining, a very narrow shaft, if only it be carried deep enough, may reach the richest stores of wealth. . . .”

In the United States, this movement toward “specialism” was fostered by the rapid growth of postbel- lum American cities with their densely concentrated populations, and the ability of a growing wealthy class of the Industrial Revolution to support specialized treatment of their ailments. Initially, however, many American general practitioners of the era resisted specialization, as a challenge to the established practice of medicine. One physician in 1886 commented that “the specialist . . . flaunt[s] in front of the hard-working general practitioner of years the idea that he is not competent to do what the self-styled specialist can do. This is folly . . . and the specialist must go. We have no use for them” [6]. Despite this condemnation, an increasing number of American medical institutions made it financially possible for physicians to restrict their practices to a particular specialty by fostering lec- tureships and professorships in the academic sphere and by opening specialty clinics and services in the hospital system [7].

Harvard Medical School and Brown-Skquard American university consciousness of neuroscience as a medical specialty began in the 1860s at Harvard Medi- cal School [8]. The faculty and administrators chose the area of neurophysiology and neuropathology as a

From the Rush Medical College, Rush-Presbyterian-Sr. Luke’s Medical Centei-, Chicago, IL. Received Drc 6. 1935, and in revised form Jan 22, 1776. Accepted for publicarion Jan 22, 1996.

Address correspondence to Dr Goerz, Rush-l’resbyteriaii-St. Luke’s Medical Center. 1725 W. Harrison, Ste 1106, Chicago, 1L 60612.

258 Copyright 0 1996 by the American Neurological Association

specific area in order to improve the academic curriculum and incorporate the Betnardian concept of “experimental medicine” into American education [9]. For- merly, teaching had focused on general anatomy and pathology in the preclinical phase and clinical appren- ticeships with experienced physicians thereafter [ 101. Experimental neuroscience, and specifically experimental neurophysiology and neuropathology were institutionalized on June 1 1, 1864, when the president and fellows of Harvard College voted to “proceed to the election of a professor of physiology and pathology of the nervous system,” and to name Brown-Stquard to the post [ I l l . The chair was not attached to a salary nor carried specific security, since the professor’s vari- able stipend was based directly on student lecture ticket sales. The professorship position was not associated with an assistant or additional support [12].

Although the primary and possibly only university expectation of the professorship was a regular series of lectures, the actual realization of even this obligation was complicated by Brown-Stquatd’s peripatetic nature and fitful behavior. Initially accepting the post with enthusiasm, he later met with the dean, as he was un- able to prepare his upcoming lectures [13; Sep 5 , 18641. In November, still having given no lectures, Brown-Stquard wrote that “after prolonged reflection, I have definitely come to the conclusion that I ought to resign the professorship” [13; Nov 12, 18641. The letters between the dean and Brown-Stquard, as well as the minutes and records of faculry meetings, demon- strate the patience and determination of Dean Shat- tuck, as he tried to incorporate Brown-Stquard’s new professorship into educational programs of Harvard College. Letters of resignation were written, nullified, rewritten, and again withdrawn [ 13-1 51.

By March 1865, despite the absence of delivered lectures, the concept of the professorship expanded. Brown-SCquard proposed that Harvard “establish a Physiological and Pathological Institute, combining the most important features of Virchow’s, DuBois- Reymonds, and Valentine’s institutes with those of Claude Bernard’s laboratory, an institute on a larger scientific and practical scale than that of any in the Old World” [13]. In spite of having received no concrete evidence of the chair’s feasibility, the medical college complied with a willingness to further consider the ex- pansive request [13; Apr 4, 18651. The Dean tempo- rized, but still encouraged the overall plan: “Putting up a new building may be more expedient in a year’s time” [16].

After more than 2 years of the professorship, Brown- Siquard finally gave his introductory lecture on No- vember 7, 1866. The lecture, entitled “Advice to Students,” emphasized the importance of student self- initiative and encouraged the formation of small groups

for in-depth discussions of medical topics [ 171. Brown- Skquard stressed the primacy of an experimental ap- proach to medical study and the need for critical think- ing [ 18). However, he also admonished American medicine as backward, even primitive, likely alienating at least some of his listeners and New World colleagues [17]: “How can we learn to make scientific or practical investigations in physiology or medicine in a country like this, where the teaching of these sciences is yet only rudimentary?”

Brown-Skquard finally delivered his series of 13 lectures, covering a wide variety of clinical neurological topics including meningitis, apoplexy, and injuries of the eighth cranial nerve. Student notes from the series document the extensive detail and comprehensive treatment of these subjects from both a clinical and an experimental perspective [ 191. However, after this very solid and encouraging start, Brown-SPquard again resigned, this rime definitively, and had no fiirther direct involvement with the chaired professorship created for him. The chair reverted to a general physiology professorship and neurological topics were not specifically taught in an organized sequence again at Harvard until the 1870s [lo]. James Putnam became lecturer on the application of electricity in nervous diseases in 1872 and lecturer on diseases of the nervous system in 1874. The lectures and demonstrations were given under the auspices of the Department of Clinical Medicine, of which neurology was necessarily a branch. Gradually rising in the medical school’s hierarchy, Putnam became an instructor in 1885 (101. The Harvard chair devoted to diseases of the nervous system was not established until 1893, the year of Charcot’s death. At that point, the neurological professorship entailed responsibilities for supervision of neurological teaching at both the Massachusetts General Hospital and the affili- ated Boston City Hospital with two appointed junior in- structors. The professor himself taught primarily third- year medical students who elected neurological study.

Bellevue Hospital Medical College and William A. Hammond The Bellevue Hospital in central New York City established its reputation for excellence in clinical medical teaching in the 1840s [20]. A medical school was first discussed in 1860 by the medical board and Bellevue Hospital Medical College commenced its first courses in the spring of 1861. From the school’s inception, the medical faculty were experienced physicians and teachers, who served as professors of anatomy, chem- istry, physiology, medicine, surgery, and obstetrics/ pediatrics. After the Civil War, the successful school expanded its faculty to include areas of medical specialization. At this time, the former Surgeon General, Wil- liam A. Hammond, returned to New York City seeking

History of Neurolog: Goetz and Pappert: American Professorships 259

to establish a medical practice focusing on nervous diseases. While no permanent positions for neurological instruction existed in New York City in 1864, Ham- mond served briefly as a lecturer on diseases of the mind and nervous system in the College of Physicians and Surgeons during the winter term of 1866-1867 1211, and at the same time established an outpatient “nerve” clinic as part of the “Outdoor Department” at the Bellevue Hospital [22]. Hammond maintained his interaction with the Bellevue Medical College and in 1866 proposed to link the school closer to the New York Medical Journal. In the minutes of the faculty council on February 23, 1866, Austin Flint, Jr, reported to the other professors on interviews and correspondence (marked as “on file” but no longer attached) related to Hammond’s joining their ranks. Later that evening, “Dr. Flint Jr. moved that Dr. William A. Hammond be appointed Professor of Diseases of the Mind and Nervous System in the Bellevue Hospital Medical College which was seconded. The ayes and naes were then called upon this motion and it was passed unanimously” [23].

In the first year of his tenure, Hammond delivered a full series o f didactic and practical lectures on mental and nervous diseases, including an introductory lecture entitled “The Proper IJse of the Mind” that considered the “mind and nervous system in their relations of de- rangement and disease” [24]. In this lecture, Hani- mond [24] warned his students that they “must . . . sacrifice something on the altar of expediency if [they] wish to be s~iccessful in a material point of view . . . [and to] . . . take care that you preserve your love for science, and that you pay no more tribute to the ele- gancies and the frivolities of life than will suffice to make society regard you as one of themselves.” The main lectures covered a wide range of neurological subjects such as cerebral anemia and hemorrhage, aphasia, facial paralysis, epilepsy, and sciatica [25] often with an accompanying patient presentation. Students pur- chased tickets, printed on brightly colored cardboard, and turned these in at the door for admission (New York University Medical archives). During the college’s spring term, Hammond also taught- a series of specialty topics, covering sleep disorders in 1868 and electro- therapy in 18.69 and 1870. In addition to course lectures, students studied the works of Henry Maudsley, Robert Bently Todd, and Handfield Jones, in addition to later publications by G. Fielding, Blandford, and S. W. Mitchell [26]. In 1869, Hammond also established Bellevue’s clinic “for the treatment and illustra- tion of the different forms of insanity” [27]. Held at the college on Saturdays at 3:30 I’M, this clinic was open to the profession and repraented the only in- stance of focused study on this class of disorders from a neurological perspective in America.

Hamniond was an overwhelmingly popular teacher, in part due to “the sincerity and directness of his lan- guage, his clearness of thought and his evident mastery o f the subject which he presented” [28]. His lectures were logically presented and “there was something al- ways essentially interesting and attractive in his man- ner, no matter what the topic was which he brought up” [28]. Hammond did not dogmatize or theorize in any undue sense “. . . nor expound therapeutical fads or obsessions in the domain of pathology” [28].

In the middle of Hammond’s professorship, the department’s staff was expanded to include one (R. A. Vance) and later two (T. M. B. Cross and C. T. Why- brew) full-time assistants, who were postgraduate medical doctors [23]. Hammond was later appointed to the chair of Materia Medica and Therapeutics on March 6 , 1872, and held this post until August 11, 1873, when he resigned after a series of negative interactions with the faculty council, all detailed in the college’s executive minutes [29]. First, at a time when other chairs were being created, his suggestion to create a chair for Diseases of the Throat was rejected, along with his nominee. Next, he was instructed to repri- mand his assistant, Dr Cross, for discussing one of Hammond’s cases with a newspaper reporter. Finally, on June 9, 1873, the faculty professors voted to ask him to yield one lecture hour each week from his Ma- teria Medica course to the obstetrics department and simultaneously to relinquish the sum of $500 from his faculty stipend. He declined and at the meeting of Au- gust 11, 1873, Flint introduced the following resolution, which was seconded by Dr Van Buren: “Resolved that the department of Diseases of the Mind and Ner- vous System be and is hereby abolished in the HMC” [23]. Hammond, who was present, left the room and the following occurred [29]:

During the discussion of the resolution, it was stated by several members of the faculty that Dr. Hammond had been disloyal to the college in not attending the meetings called to take action against the proposed removal of Bellcvue Hos- pital and in remarking to persons not members of the faculty that the Hospital was infested and should be destroyed. On motion, an informal vote was taken, which resulted in favor of the resolution. O n motion, Dr. Van Buren was requested to communicate the result of the informal vote to Dr. Ham- mond. Dr. Van Buren, having communicated the result to Dr. Hammond, reported that Dr. Haniniond announced his intention of resigning his connection with the college.

The resignation was definitive, and to fill the void in the curriculum, Edward G. Janeway was appointed as a lecturer. However, for a few years thereafter, there was no longer a professor specifically associated with neurological study. Janeway joined the full faculty in

260 Annals of Neuroloby Vol 40 No 2 August 1996

1874 as a professor of pathological and practical anatomy and assumed his chair of Diseases of the Nervous System in 1876, one year after a separate chair of Psy- chological Medicine and Medical Jurisprudence had been established.

University of Pennsylvania and Hotatio C. Wood In Philadelphia, medical education at the University of Pennsylvania was organized in two tiers that separated university and hospital faculty. In most, but not all, instances, “professors” were involved in preclinical do- mains, anatomy, pathology, materia medica, and pharmacy, whereas the title “clinical professor” related to the hospital hierarchy [30]. In 1S75, the entire university had 43 professors, of which 9 were in the medical school, and these members served with full faculty vot- ing privileges. In the 1876- 1877 catalog, university professors and hospital professors were listed separately, with only minor overlap of personnel [31]. M’ mutes from the Board of Trustees meetings in these years reveal without subtlety the elitism of the university title over the hospital professorships and the conscious re- striction of the number of full university professorships [32]. In rejecting a proposed union between the two faculties, a special committee of the full medical professors concluded in March 1876 [33]:

. . . to do so would be open to the serious objection of placing thc teachers of several special and subordinate subjects upon an equality with the professors who teach branches of medicine which include these vey subjects. . . . To this suggestion, the Faculty would object that to multiply unnecessarily the professors would operate to repel students from the school.

Within the context, the University of Peiinsylvania nonetheless recognized the need for specialty training and therefore used its hospital appointments to create a number of new positions. In a letter dated January 1875, William Goodell and William Pepper repre- sented faculty members in requesting the creation of new chairs connected with the hospital, specifically in nervous and cutaneous diseases [34]:

During the present session, the courses of Lectures upon these subjects have been regularly delivered and have a[- tracted large groups of students, so that in addition to the intrinsic importance of these branches in any full curriculum of medical study, they seem to have such practical value in the scheme of teaching conducted in connection with the University Hospital as to cause them to be regarded as permanent features of such instruction and therefore entitled to be awarded a position of equal dignity with the other special branches.

The minutes of the subsequent faculty meeting on Feb- ruary 27, handwritten in a parkinsonian, micrographic script, confirm the support of this motion, and on April 6, 1875, the Board of Trustees created three new clinical professorships in the hospital, including one for nervous diseases. Dr Horatio C. Wood was elected [32]. Primarily a pharmacologist with a post in the Department of Botany, Wood had been a lecturer in nervous diseases as a member of the auxiliary department of medicine faculty involved in teaching “collat- eral branches of science” [35]. He moved immediately into the hospital post, but the next year, he was more appropriately elected to occupy an additional, full university faculty chair, Professor of Materia Medica and Pharmacy. That year, the catalog listed him twice, ac- curately noting the full faculty post in pharmacology and the hospital appointment in neurology [36]. In the next year’s catalog, the distinction was less clear, and Wood was listed once as professor of materia medica and pharmacy and clinical professor of nervous diseases

Documents in the university archives do not provide extensive information on laboratory space, clinical of- fices, staffing, or special privileges attached to Wood’s professorship in nervous diseases. It does not appear that specific neurological laboratories for research were developed or that Wood directed experimental research programs. While still a lecturer, Wood had established an outpatient dispensary and clinic specifically for the study of nervous diseases in 1871 under the everyday management of an assistant, Dr Morris Longstreth [38]. During Wood’s professorial years, this post was occupied by his successor, Charles K. Mills. The dispensary, located in West Philadelphia, was part of the new hospital built at that time and consisted of two rooms, a waiting area, and a combined examination, treatment, and electrical diagnostic room.

The inpatient neurology service, a men’s ward of 12 beds, was not fully occupied for several years. O n the service were patients with aphasia, sciatica, cerebral hy- peremia, and various forms of paralysis [39]. Women patients were housed among the general women’s wards, and the entire service for the neurological professor and his assistants numbered approximately 12. The Philadelphia General Hospital neurology service, established by Mills in 1877, supplied 20 to 40 additional inpatients, but there was little patient turnover in this group, as patients in the public hospital stayed for months or years [37].

The teaching responsibilities atrached to the neurological professorship involved amphitheater lectures to third- and fourth-year medical students as well as ward and postgraduate instruction. In his memoirs, George Norris wrote of Woods arresting methods of examin- ing students [40]: “On one occasion, having asked the

[371.

History of Neurology: Goetz and Pappert: American Professorships 261

student to be seated, the latter was horrified to see his teacher fall to the ground and have a convulsion.

Yet, Charcot was not named as a university professor of diseases of the nervous system until 1882 [I]. Dur-

Thereafter having retimed to his seat, he asked: ‘What did you observe? What kind of a convulsion was that? What would you have examined?’ ’‘

Wood was not alone in these teaching responsibilities, and Mills received the university post of lecturer in electrotherapeutics in 1877- 1878 and later became lecturer of mental diseases and electrotherapeutics in 1880-1881 [41]. He also taught largely at the Phila- delphia General Hospital, and the close proximity of the two hospitals provided ease of access for lectures or ward teaching to take place successively in either setting [36]. A second assistant university post, desig- nated as “Instructor in Nervous Diseases,” was created in 1883 for Francis X. Dercum, and an added instructor position was created in 1883. These staff numbers remained unchanged until after 1900 [38].

Because of his second medica media professorship in the medical school, Wood was able to have a full voice in faculty votes and thereby represent neurology indirectly in all faculty issues. The double chair and the resultant power of neurology in the faculty counsel may explain in part the natural evolution of neurology’s place in the medical school in the subsequent generation: After Wood’s retirement, Mills became the professor of neurology, the term “clinical” being dropped from the title in 1903, with resultant full faculty professorship privileges [41].

International Contrasts In a worldwide context, the American professorships were remarkably early and no comparable academic positions existed in Europe at the time. Whereas Euro- pean centers produced important neuroscientists of the same era, none succeeded in establishing independent professorships of such early autonomy and focus. In London, the National Hospital, Queen Square, had been founded in 1860, and by 1886, Hughlings Jack- son, Gowers, Horsley, Beevor, Marcus Gunn, and Fer- rier were among the celebrated staff [42]. 111 contrast to the American university model, however, the National Hospital had no direct link with a university system. Strong overlaps between neurology and psychiatry existed in German universities, and neurology did not successfully emerge as an autonomous field worthy of its own professorship until 1911 [43]. German con- temporaries who worked in the neurosciences either were termed “neuropsychiatrists,” like Wernicke in Breslau aid Westphal in Berlin, or remained internists with neurological interest, like Erb in Heidelberg [44].

The French neurological professorship model offers the most striking contrast with the. early American ex- amples. Nineteenth-century clinical neurology reached its international pinnacle in Paris with Jean-Martin Charcot and his celebrated School of the Salpttritre.

ing the 1860s, at the time when the first American university post was being established, neurology was not recognized at the university level in France. As Brown-Skquard gave his first professorial lectures in neurology in 1866, Charcot was a newly elected associ- ate professor (agrtgk) and his teaching responsibilities included largely general medical topics. By the time Wood assumed the professorship of neurology in Phila- delphia in 1875, Charcot was a professor of pathological anatomy, but his lecture responsibilities still covered the gamut of general medical disorders [45].

In spite of the lag in university recognition, however, neurology had been nonetheless actively developing in France outside the university system. The unique two- tier medical hierarchy of university posts on the one hand and hospital services on the other permitted Charcot to develop an extensive and well-funded neurological program within the public health system of Paris without specific university backing [46]. The Sal- pttritre increasingly became a haven for study of nervous system disorders with large clinical, laboratory, and neuropathology facilities, and Charcot effectively established his neurological celebrity through hospital teaching, publications, and international travel [47]. The university professorship therefore was a crowning recognition of work and stature already largely at- tained, and unlike the American professorships, was never specifically a vehicle for the inception or development of neurology as a new medical field [48].

The Legacy of the Early American Professorships Encompassing the responsibilities of regular, organized teaching and patient care, American neurological professorships became a primary vehicle for textbook pub- lication. Hammonds A Treutise on Diseases o f the Ner- vous System [1871] [49], and Wood’s Nervous Diseuses and Their Diagnosis [1886] [50] were among the first comprehensive neurological textbooks ever published and were important international reference sources. In spite of apparent strong university backing, however, neither the Boston nor the New York post developed fully, largely because Brown-Skquard and Hammond left after short tenures. Whereas both men were active researchers and embodied in different ways the concept of clinical scientists who likely could have formed a full neurological program of teaching, patient care, and research, their inconstancy and inability or unwilfing- ness to work within a single university setting thwarted these developments. In contrast, Wood showed con- stancy and stability, but these attributes were not matched with a research vision, and he never integrated a strong laboratory or neurological investigative interest into his professorship. In the subsequent generation,

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these programs developed further, the number of neu- 23. Minutes of the Faculty Council, Bellevue Hospital Medical College, 1866. New York University Medical Archives, New rology professorships expanded, and with wider repre- _ _ .

sentation in several US cities, the American neurological school emerged as an international force.

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