Emergence of Neurology as a Specialty in the United States

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         As a new medical specialty, American neurology developed in the mid- and late-nineteenth century under the influence of three primary forces: European Medicine and Scientific Advances, the American Civil War and the particular American penchant for Medical Specialization or Specialism. Founded in European traditions, American neurology developed and expanded rapidly with the greatest concentration of activity in Philadelphia, Boston and New York. Whereas Americans interested in advanced specialty training originally traveled to Paris, Berlin, London, or Vienna, by 1900, important neurological hospitals, laboratories, and outpatient specialty services in the United States attracted American students and physicians to remain in this country for their training. Furthermore, the reverse flow of Europeans coming to study in the United States began.

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European Training

         The scientific and medical infrastructure of American neurology was European in origin, although Americans borrowed eclectically and modified the European traditions. The Bernardian concept of Experimental Medicine was crystallized in America by Brown-Séquard who visited the United States on multiple occasions and served briefly on the faculty at Harvard Medical School in 1866 and 1867. Medically, neurology in Europe grew from two distinct models, as an outgrowth and subdivision of internal medicine as seen prototypically in France, and as an ally and anatomically-based offspring of psychiatry, as typified by the Viennese school. J.M. Charcot, perhaps the most celebrated nineteenth century neurologist, was trained as an internist, and his early research and testing effort focused on rheumatological and geriatric medicine. Charcot's studies of rheumatoid arthritis and tabetic (Charcot) joints led him to investigate peripheral and central nervous system pathology. Meynert, on the other hand, entered neurological research from the primary vantage point of psychiatry, the field to which the Germanic and Prussian schools had heretofore designated the study of general paresis of the insane, epileptic fits, and most encephalopathies.

These two European traditions were simultaneously incorporated in the United States to form early neurological programs particular to America in the form of neurological professorships, teaching services, and research efforts. Working simultaneously from the two disciplines of internal medicine and psychiatry, American neurology sculpted itself with close links to both traditions, creating some neurological activities directly out of medical departments, and creating others out of psychiatric asylums and other institutes. The titles of early American neurological professorial chairs, the names of early journals and societies, and the background of physicians who eventually became known as neurologists are all clear testimony to the double-image, or Janus evolution, of American neurology in its early years.

Drawing of Charcot

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In Paris, American post-graduates interested in neurology studied under Charcot. While daily rounds were typically reserved for Charcot and his inner circle of assistants, the occasional American apprentice was also included in these exercises that sometimes lasted late into the day, particularly when autopsies were performed.

Meynert and Chiari

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American apprentices working under Meynert in Vienna and Chiari in Prague received three or five weekly lectures on clinical, anatomic, and pathophysiologic aspects of neurological disease. At the end of the lecture, the professor commonly exhibited two or three patients and elicited the telling of clinical signs.

American Neurologists who Studied in Europe

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Click to left to see chart of American Doctors and where they trained in Europe.

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American Civil War

         The American Civil War was incontestably the primary local historical event pivotal to the development of neurology in the United States. The gamut of neurological injuries seen among soldiers on both sides and the coalescing of an identified group of US physicians interested in neurological studies provided the setting for distinctive American contributions to the developing field. Shortly after William A. Hammond was named US Surgeon General, he became acutely aware of the breadth of war-related peripheral and central nervous system injuries among Union soldiers. Administratively, Hammond contributed fundamentally to the institutionalization of neurology in the United States by establishing Turner's Lane Hospital in Philadelphia, the site of S. Weir Mitchell's, Keen's, and Morehouse's seminal work on various nervous system disorders during the war. In developing a hospital devoted specifically to neurological military injuries and their study, Hammond provided the first American site for focused neurological investigation. This war-time model was incorporated to post-war Philadelphia medicine in the form of the celebrated Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases. The Civil War provided American physicians with case material for journal and monograph publications on peripheral nerve injuries, post-traumatic epilepsy, neurasthenia, malingering, and many other areas of neurological study. These publications brought international attention to American neurologists in the post-war era. During the reconstruction period, Hammond and Mitchell carried their war-time organizational skills and commitment to neurology in other civilian settings and helped to develop new neurological services, educational programs, journals and textbooks that solidified American neurology in the international medical arena.

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American Civil War Soldiers

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The Civil War was associated with innumerable injuries of the head and extremities causing a gamut of central and peripheral nervous system lesions. The soldiers formed a cohort of neurologically impaired patients and the study of their injuries became a hallmark of early American neurology.

Turner's Lane Hospital, 1862

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Assigned by Surgeon General William A. Hammond to work in the military hospital system at Turner's Lane Hospital in Philadelphia, Mitchell meticulously documented peripheral nerve lesions encountered in battle and studied post-traumatic disorders like phantom limb and causalgia.

Frontpiece of Injuries of Nerves

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Mitchell's spirit of personal mentorship and responsibility for training younger neurological colleagues began even during the Civil War years. W. Keen recalled:

Observe his broad-minded generosity. Instead of planning the work for himself and Morehouse, and in a preface expressing in complimentary terms their obligation to myself as their assistant, he had all three of us work together in consultation. The books and papers which he wrote were by "Mitchell, Morehouse and Keen", and any which I wrote were - mirabile dictu "Keen, Mitchell and Morehouse." My name, that of an unknown medical "kid" only two years after my graduation in medicine, preceded both of theirs.

William A. Hammond

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Surgeon General, United States Army

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Specialization

         During the second half of the nineteenth century, two primary medical factors fostered the emergence of neurology as a separate clinical specialty. First, and largely due to European scientists, an unprecedented and exponential growth of neurological knowledge occurred during this period. Second, a general movement towards subdivisions of medical practice internationally was already in full development in France, Great Britain, and the Prussian states. Initially, many American general practitioners of the era resisted specialization, and specifically neurological specialization, as a challenge to the established practice of medicine. In a sarcastic 1881 editorial, Specialism on the Rampage, one such clinician stated:

         We noticed the appointment of a very worthy physician in an eastern city as 'Neurologist of the Hospital' which title he assumes in writing as an author. Cannot some other specialties be created to give positions to other aspiring gentlemen? Why not have a Pneumatologist to attend to the lungs -- a Thermatologist to observe temperature -- a Narcotizer to see that the patients sleep well -- a Defecator to attend to the bowels?

         Despite this condemnation, select American medical institutions embraced the initiative to support specialists and established lectureships, specialty clinics, and services devoted specifically to neurology. The growing wealthy class of the Industrial Revolution willingly supported specialized treatment of their ailments and made specialization financially rewarding. Without accreditation mechanisms in place at the local or national level, however, marketing strategies, rather than in-depth education, created some American "specialists" of questionable qualifications. This dilemma led to substantial re-evaluation of specialization movements at the very end of the nineteenth century, and neurology, along with other new specialties, realigned themselves with general medicine or consolidated their specialties with alliances to other specialties. In the case of neurology, early efforts to separate from psychiatry were partially reversed by this concern of isolationism, and closer ties were established in the early years of the twentieth century, a movement that ultimately culminated in the unification of a single Board of Psychiatry and Neurology in the mid-1900's

Advertisements

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Advertisements like those shown here appeared in medical journals.

Cruveilhier

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European anatomists and pathologists, studied the gross anatomy of the nervous system, and later armed with newly invented staining methods, more clearly delineated the microscopic anatomy of the nervous system. These efforts helped to identify neurological study as a separate entity among medical sciences.

Claude Bernard

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Neurophysiologists conducted experiments pivotal to the eventual elucidation of such concepts as neuronal doctrine, synaptic function, reflex action, autonomic nervous system control and cerebral function localization. Claude Bernard pioneered animal physiological experiments that drew students to Paris from centers in the United States as well as Europe. Neurophysiology, like neuroanatomy and neuropharmacology became vocabulary words that delineate neurological studies as areas of specific specialization.

America's Original Neurologists:

SW Mitchell & WA Hammond

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Silas Weir Mitchell

         Silas Weir Mitchell developed his neurological career in the midst of the American Civil War. Assigned by the Surgeon General, William A. Hammond, to work in the military hospital system in Philadelphia, Mitchell meticulously documented peripheral nerve lesions encountered in battle and studied post-traumatic disorders like phantom limbs and causalgia. After the war, he helped establish the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases and developed an extensive private practice of patients with neurological illness. His interest in pharmacology and toxicology led him to write extensively on new treatments in neurology. Like Jean-Martin Charcot in France, he developed an interest in hysteria, although he focused primarily on therapy, rather than clinical description. In addition, he published extensively on neuropharmacology and neurotoxicology. In spite of his international recognition and extensive publication record, Mitchell never held a university professorship.

         Mitchell held a long-standing, though highly individualized, relationship with the American Neurological Association. He was one of the charter members, but when elected to serve as its first president, he declined. He presented papers on occasion, but then retired from active membership in 1909. Unaware of the constitutional rules that only active members could serve as president, CK Mills nominated his colleague for president, and he was elected by the membership a second time. By contemporary accounts, this time he accepted with evidenced pleasure. WA Hammond accosted Mills to point out the constitutional infraction, but Mills urged Hammond's silence, and Mitchell served as the ANA president from 1909-1910.

         Mitchell spent his entire career in Philadelphia, although he traveled to Europe and was known for his wry humor. His meeting Charcot was peculiar, even theatrical, as Mitchell visited the neurologist as an anonymous patient:

        Dr. Charcot examined him and gave a few simple directions, and then turning to him asked him where he was from. Dr. Mitchell told him he was from Philadelophia. Then Dr. Charcot said: "You have a man in Philadelphia who knows more about run-down nervous conditions than anyone else I know of, and I will give you a letter to Dr. S. Weir Mitchell, whom you must consult." The situation was so ludicrous that Dr. Mitchell laughed, and when Charcot asked him what he was laughing about, Dr. Mitchell handed him his card".

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Mitchell with a patient and colleagues

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In his capacity as a teacher and preceptor, Mitchell gave numerous conversational clinics and conferences, in addition to teaching his assistants individually or in small groups.

Mitchell

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While never obtaining a university appointment, Mitchell was one of the thirty-five original members of the American Neurological Association, and was elected the first president. He was also an active member of the Philadelphia Neurological Society. In these organizations, Mitchell influenced the content and form of continuing neurological education provided by these medical societies.

Meticulous guidance provided by Mitchell

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The meticulous guidance provided to the apprentices by Mitchell was forceful and direct:

"A clinical assistant saw her and laid her out on the bench and made a cursory examination. The attack was thought to be an ordinary hysterical seizure. About this time Dr. Mitchell came in and asked what was the matter with the girl. He was told that she simply had an hysterical attack. He went over to her, rapidly examined her reflexes, asked a few questions of her companion and sent for the superintendent to take her up-stairs and admit her, and turning to the assistant, said: 'You are certainly wrong. This woman is in the last stages of a brain tumor, and will die before morning."

 With those words, Mitchell sent the assistant to re-examine the patient completely, after which the diagnosis was confirmed and, as Mitchell predicted, the patient died that evening. (Recounted by B. Tucker).

Mitchell's Idle Moments

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"Most afternoons that he did not go to the hospital, or often on his way there, he came in (to the College). Often he came to seek and consult some book, but sometimes to linger a little and chat as though he felt it the pleasantest place he knew to bestow his scanty idle moments." - Jackson

Mitchell's office

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Interior and exterior of S.W. Mitchell's office, 1524 Walnut Street in Philadelphia.

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William A. Hammond

         William A. Hammond graduated from the University Medical College in New York in 1848 and during military service, met SW Mitchell. In 1860, Hammond resigned from the army and accepted a position as Professor of Anatomy and Physiology at the University of Maryland Medical School. He re-enlisted at the start of the Civil War. He was soon promoted to Inspector of Hospitals and was appointed Surgeon General of the Medical Department in 1862. He was discharged from the military in 1864 following a court-martial related to fabricated charges.

Hammond returned to New York City seeking to establish a medical practice focusing on nervous diseases. Whereas no permanent positions for neurological instruction existed in New York City in 1864, Hammond served briefly as a lecturer on diseases of the mind and nervous system at the College of Physicians and Surgeons during the winter term of 1866-67 and at the same time established an outpatient "Nerve" clinic as part of the Outdoor Department at the Bellevue Hospital.

         In 1867, Hammond received the newly created post, Professor of Diseases of the Mind and Nervous System at Bellevue Medical College. His introductory lecture on "The Proper Use of the Mind" considered the "mind and nervous system in their relations of derangement and disease." Hammond was a popular teacher known for clear presentations and interesting subject matter. Leaving formal medical school settings in 1873, Hammond founded the New York State Hospital for Diseases of the Nervous System and later was instrumental in the formation of the New York Post-Graduate Medical School, where he served as a faculty member until his departure from New York in 1888.

         In addition to training neurologists, Hammond saw two other primary educational challenges for establishing neurology as its own medical specialty: enhancing the public consciousness of neurology and fostering the acceptance of neurology among the general masses of American practitioners. For the first, Hammond personally involved himself in many medical-legal cases that brought the issues of brain function to the public. He wrote in popular journals like Nation, Popular Science Monthly, and North American Review. Like Mitchell, he wrote several novels that included a wide variety of neurological and mental illnesses among the characters. For the second, he actively campaigned among psychiatrists and generalists, but his arrogance and flamboyancy were counterproductive and in fact alienated his non-neurological colleagues. Among the more explicit comments published, a psychiatric colleague described Hammond as "a moral monster, whose baleful eyes glare with delusive light, whose bowels are but bags of gold, to feed which, spider-like, he casts his loathsome arms about a helpless prey."

Hammond was the primary impetus behind the founding of the American Neurological Association and his signature was the first listed on the original membership invitation letter of 1874. His testy and often argumentative comments in response to platform presentations at the early meetings set an expected ambience of lively, even tough peer critique. These discussions were published in the early Transactions of the American Neurological Association.

William A. Hammond

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William A. Hammond became Professor of the Diseases of the Mind and Nervous System at Bellevue Hospital Medical College shortly after his arrival in New York in the post-Civil War years.

New York Post Graduate Medical School

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Hammond was instrumental in the formation of the New York Post-Graduate Medical School, where he served as a faculty member until his departure from New York in 1888. Post-doctural students who attended the neurological courses for six consecutive months at the New York Post-Graduate Medical School and Hospital, qualified to sit for an examination, and if successful, received a certificate of proficiency. This type of post-graduate structured didactic and clinical training endured as an important resource well into the twentieth century for those American medical graduates interested in advanced expert neurological training, but unable to obtain a house-physician position or afford the time and expense of preceptorship at home or abroad.

Hammond's Neurological Extract

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During the late nineteenth century, extracts of various animal organs were used to treat the cognitive effects of aging and muscle defects of other disorders. The one shown here was produced by Hammond's company.

William A. Hammond

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Hammond was an uncommonly tall and large man with a voice so powerful that it could be heard up-wind in a hurricane. As lecturer, playwright and novelist he had the opportunity of exercising to the full his penchant for theatrical action. There was a substantial dash of Paracelsus in him. Not only was he an outstanding leader and talented organizer, but he was also an aristocrat among the laborers in the neurological field.

The Founding of the American Neurological Association

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         The American Neurological Association was the first national neurological association of the world and was founded in 1875. William A. Hammond took the initial step in 1874 and, with several other colleagues, sent a letter of intent to United States physicians with potential interest in the organization, outlining a desire to form a small body of devotees to "the cultivation of Neurological Science." The letter was signed by Hammond and six other colleagues from New York, Cincinnati, Chicago and Boston. Twenty-eight physicians, all men, sent letters of acceptance, and along with the senders, became the first members of the ANA.

         A series of organizational meetings took place in Hammond's and EC Sequin's private homes in late 1874 and early 1875. With a first draft of the Constitution and By-laws prepared beforehand, and circulated to the early members in April, the first meeting of the organization took place on June 2, 1875 at 2 p.m., in the lecture room of the Young Men's Christian Association Hall located at the corner of Fourth Avenue and Twenty-third Street in New York City. Eighteen of the thirty-five charter members attended, drawn primarily from New York, Boston, Philadelphia, and Chicago, although New Orleans, Knoxville, and St. Louis were also represented on the early membership list. No members lived in the Far West. At the first meeting, M. Clymer presented the proposed Constitution and By-Laws for review, and with slight modifications, these were adopted. A nominating committee recommended a slate of officers:

SW Mitchell

JS Jewell

EH Clark

JJ Mason

EC Seguin

JWS Arnold

President

First Vice President

Second Vice President

Corresponding Secretary

Recording Secretary and Treasurer

Curator

         Mitchell was informed of his election, but declined the office, and Jewell therefore became the first president. Mitchell assumed presidency of the ANA thirty-five years later. At the first meeting, lasting two days, the scientific session included Hammond's presentation of his original case of athetosis and a lengthy discussion of myelitis and the topic of spinal cord congestion. In total, twelve papers were presented including reports by Putnam, Hamilton, and Miles.

         As part of the meeting activities, Hammond invited the members to his home for dinner and began a social tradition within the organization that was important to its overall function. In addition, the meeting included the election of GM Beard whose work on neurasthenia and the strong interface between neurology and psychological medicine brought these two disciplines in close juxtaposition within the early ANA. At the second meeting in 1876, Beard made his first presentation, titled "The influence of the mind in the causation and cure of disease and the potency of definite expectation." Preceding the more famous monograph, Faith cure, by J.-M. Charcot by nearly twenty years, this work dealt with many of the same themes of suggestion and expectation in the genesis and therapy of neurological symptoms and signs. The presentation, both in its controversial content and thorough treatment, set a tone and tradition within the early ANA as a forum for critical peer-review and for discussion of new and unconventional concepts within the field of neurology. Though the report was politely received by some, Hammond ascerbically responded that accepting Beard's view amounted to "throwing his diploma away and joining the theologians." The ANA members took this occasion to enter into discussion of larger scientific issues of informed consent, patient deception by the physician even in the interest of therapy, and the definition of science and scientific experimentation. This tradition of using a specific presentation to launch into wider medical and social topics during the open membership discussion session was an important hallmark of the early ANA meetings.

Invitation

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The official invitation for membership to the American Neurological Association.

ANA By-laws

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The original draft of the American Neurological Association By-Laws was composed by M. Clymer and corrections and additions were approved at the first meeting in June 1875.

Y.M.C.A.

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The old YMCA Building on 23rd Street in which the first meeting of the ANA was held.

Athetosis/Original papers

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Original neurological papers were delivered at the first ANA meeting in 1875, including Hammond's case of athetosis.

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ANA Membership

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         When the ANA was founded, its membership was limited to 50 active members residing in the United States, and 25 foreign-based associate members. Annual dues were $5.00. In 1887, the by-laws were amended to permit 100 active members, and subsequent increases occurred as the ANA grew in prestige. Other membership categories were added, including Honorary rank for senior contributors to neuroscience, and Corresponding status for foreign physicians . The definition of associate membership was modified in the 1930's to include US-based non-physician scientists.

         In the early years of the ANA, nominations for new members were brought to the general meeting by existing active members. Prior to further consideration, the candidate must have submitted a paper on a subject connected with neurological science that the Council reviewed. The Council then verified that nominees fulfilled membership qualifications and made a recommendation of membership which was then voted on at the annual meeting. A majority vote from the members present at that meeting in favor of the candidate led to election.

         The scientific essay that formed a necessary part of the application originally included published works. However, in 1890, the Constitution was amended to require that the work be an original and previously unpublished thesis. This tradition lived on as part of the membership requirement through the mid 1900's. The theses were submitted as a single copy that was reviewed by one Executive Council member who made a recommendation to the Executive Council. The manuscripts were not kept by the ANA, because the single copy was returned to the author who, in most instances, was preparing a full manuscript for publication.

         Even in its early years, the ANA emphasized its mission to cultivate neurological science in a broad sense, and therefore gave full membership to non-neurologists, including psychiatrists, neurosurgeons, and laboratory researchers.

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George Miller Beard (1839-1883)

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The first elected member of the ANA was George Beard, the noted New York physician who was celebrated for his studies of neurasthenia, the disorder referred to by Charcot as the American illness. Facsimile of the minutes of the first meeting, 1875. (ANA Archives.)

Chart of the First Honorary Members of the ANA

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In the very first years of the ANA, Honorary members were senior neurological figures from Europe, but by 1887, Hammond himself had been elevated to this status.

Active Membership

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"X"- 1973 marked the date that the ANA eliminated a fixed maximal membership number and the requirement for an original thesis. In previous years, membership approximated the maximal limit permitted by the ANA Constitution of the time.

Early ANA Meeting 1896

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Group portrait of the attendees of the 1896 ANA Meeting.

Women in the ANA

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Women membership in the ANA has always lagged far behind the numbers of men in the organization. Early in the ANA's history, however, the New York physician, Sarah J. McNutt was elected (1887). The more celebrated woman physician with a strong neurological interest, Mary Putnam Jacobi, was not elected to the ANA, although her career included a very active participation in the New York Neurological Society.

Neurosurgeons of the ANA

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In the early years of American neurology, the distinction between neurology and neurosurgery was indistinct, but from the ANA's inception, surgical specialists were welcome in the organization. Roberts Bartholow, president of the ANA in 1881 and one of its founding members, was the first physician to apply electrodes to the human cortex. Other neurosurgeons who were members of the ANA and served as president included: H Cushing, W Penfield, AE Walker, PC Busy and CA Elsberg.

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Early ANA Presidents

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James S. Jewell

James Stewart Jewell (1837-1887)

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James Stewart Jewell was the most celebrated physician with neurological interests in the Midwestern United States. He attended Rush Medical College in Chicago, was professor of Anatomy at the Chicago Medical College (1862-1869), and then became Professor of Nervous and Mental Diseases at Northwestern University in 1872. In 1874, Jewell and Henry M. Bassister founded and jointly edited the Chicago Journal of Nervous and Mental Diseases. Two years later, the journal name was changed to Journal of Nervous and Mental Diseases. This publication is the longest standing neurological journal in the United States. Jewell was one of the seven original organizers of the American Neurological Association and, when S. Weir Mitchell declined the responsibility of undertaking the post of first president, Jewell served.

Jewell died in the middle of an active career, at age 50, of pulmonary tuberculosis, one year after starting a second national journal, The Neurological Review. Jewell's reading knowledge of French, German, and Italian permitted him to interact with international colleagues, and his regular American travels kept him in the leading circles of American neurology throughout his brief career.

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Francis Turquand Miles

Francis Turquand Miles (1827-1903)

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At the School of Medicine of the University of Maryland, Dr. Francis Turquand Miles was appointed Professor of Anatomy in 1869. Miles organized a series of clinical lectures on neurological diseases in his first year of professorship. As part of an expansion effort at the university and renovations of the Baltimore Infirmary, a new post of Clinical Professor of Diseases of the Nervous System was initiated in 1870. At the faculty meeting of April 23, Miles was appointed to the chair, and the post with his name was listed in the university catalog of that year. As part of the responsibilities tied to the chair, Miles delivered lectures to medical students and spoke on neurological illnesses. He established an afternoon clinic in the Baltimore Infirmary with electrodiagnostic and electrotherapeutic support staff. Taking on the Chair of Physiology in 1880, the multifaceted Miles continued to lecture on nervous system illness through the end of the nineteenth century, but provided an increasingly physiological emphasis to the previous anatomically-based lectures. As the second president of the American Neurological Association (1879-1880), he was well-known and an influential teacher.

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Charles Karsner Mills

Charles Karsner Mills (1845-1931)

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Charles K. Mills, a Philadelphian, made several significant contributions to neurology: Administratively, he helped develop the neurology service at the city's charity hospital, Philadelphia General Hospital, and in 1877, directed the 20 bed unit for men and women inpatients. One year later, the service expanded to 35 patients and by the early 1900's the inpatient service numbered 400. Academically, he performed important studies on aphasia and cortical localization patterns of parietal lobe dysfunction. In 1886, he described alcohol-related polyneuropathy with behavioral symptoms, preceding Koraskoff's work by one year. He described unilateral progressive ascending paralysis due to degeneration of the pyramidal tract in 1900, and the condition became known as "Mills' Syndrome". He also described the clinical syndrome associated with unilateral occlusion of the superior cerebellar artery. With poor vision and unable to read for most of his adult life, he maintained a close surveillance of international neurological issues, and was president of the American Neurological Association twice, in 1886 and 1924 as its semicentennial leader.

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James J. Putnam

James Jackson Putnam (1846-1918)

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James Jackson Putnam was the primary native Bostonian of early American neurological history. Having studied with Rokitansky, Hughlings Jackson, and Meynert, he returned to Boston to become the "electrician" of the Massachusetts General Hospital. Clinical physiological skills were transferred to the laboratory where he conducted several studies on cortical stimulation in the dog with William James. His major clinical contributions related to the description of neurological abnormalities in combined system diseases, although he did not recognize a relationship with either anemia or vitamin deficiency. A founding member of the American Neurological Association, Putnam led the organization as president in 1888. He was one of the early neurologists who closely worked in neurology and psychiatry, and like his close colleague, Adolph Meyer, placed emphasis on the two fields' overlap rather than stressing their differences. Neurasthenia, termed by Charcot as the "American illness", was a particular topic of interest to Putnam.

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Edward Constant Sequin

Edward Constant Seguin (1843-1898)

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Whereas most of the early American neurologists were born and raised in the USA, Sequin was born in Paris, though he emigrated from France with his family as a child. He returned to France for part of his advanced training, working with Brown-Séquard, Cornil, and Charcot. He became Professor of Diseases of the Nervous System at the College of Physicians and Surgeons in New York and was president of the ANA in 1889. He authored several articles on aphasia, paralysis and cerebral localization, and introduced thermometry to the United States. His active liaison throughout his career with French colleagues was pivotal to expanding relationships among French and US neurologists, thereby breaking down strict national schools and creating a greater international neurological movement.

Sequin entered several publishing ventures to advance a broader scope of neurology. He collaborated with Brown-Séquard to create the short-lived Archives of Scientific Practice and Surgery, and was the editor of a series called Archives of Medicine.

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Edward Charles Spitzka

Edward Charles Spitzka (1852-1914)

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Spitzka embodied the concept of "self-made man", being the son of US immigrants, educated in urban public schools without contacts or resources to attend prestigious institutions. After graduation from medical school in New York City, he returned to Eastern Europe and studied in Leipzig and Vienna, gaining extensive training in embryology. He entered and won the essay contest established within the ANA by William Hammond in 1876, and slowly thereafter moved into the inner circles of the intellectual elite of New York neurology. With continued activities within the organization, he was elected president of the ANA in 1890. He was the editor of the American Journal of Neurology and Psychiatry, and served as the chief liaison for neurology at the Ninth International Medical Congress (1887) and the Congress of Arts and Sciences (1904).

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Charles L. Dana

Charles L. Dana (1852-1935)

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Charles L. Dana studied with Austin Flint and Edward Janeway at New York's Bellevue Hospital and maintained a close association with this medical center throughout his career. In 1884, following the tradition set by WA Hammond, he was appointed as Professor of Diseases of the Mind and Nervous System at the New York Post-Graduate Hospital, and served in this post until 1895. Three years later, he became the first Professor of Diseases of the Nervous System at the newly founded Cornell University Medical College. Active in physiological studies, Dana made important contributions to the study of epilepsy and narcolepsy. His major educational contribution was his comprehensive monograph, Textbook of Nervous Diseases and Psychiatry for the Use of Students and Practitioners of Medicine, first appearing in 1892 with ten subsequent editions. In addition to his scientific contributions, Dana also was active in New York and medical literary circles and was one of the founders (along with Bernard Sachs) of the celebrated Charaka Club. This elite group eventually included S. Weir Mitchell, Pearce Bailey, SE Jelliffe, Harvey Cushing, and Foster Kennedy.

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Bernard Sachs

Bernard Sachs (1858-1944)

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Bernard Sachs studied in the United States, but traveled extensively in Europe as a post-graduate physician to study with Meynert in Vienna, J. Hughlings Jackson in London, Jean-Martin Charcot in Paris, and Westphal in Berlin. He returned to Mt. Sinai Hospital in New York, where he spent his full career. Sachs became consulting neurologist at the hospital in 1893 and although there was no specific neurological service in the hospital, he had continual access to the entire hospital for patient material and research. In 1885, he published a translation of Meynert's textbook on psychiatry and in the same year took on the co-editor post of the Journal of Nervous and Mental Diseases. One year later he became the full editor and maintained this post until 1891. Active in national neurological circles, Sachs was elected as president of the American Neurological Association in 1894. In 1896, he wrote his seminal paper on amaurotic familial idiocy, and the eponym, "Tay-Sachs disease" was later used to honor him as well as Warren Tay, who earlier had described the typical eye findings. In 1895, Sachs wrote the first comprehensive pediatric neurology textbook, A Treatise on the Nervous Diseases of Children.

Activities of the ANA

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         From its inception, the ANA's primary focus was its annual congress. The first several meetings were held in New York City, the first at the local YMCA, then at the College of Physicians and Surgeons, and later at the New York Academy of Medicine. The modest attendance rarely passed fifteen members. The ANA meetings were an official forum for scientific discussion and an important vehicle for establishing neurology in the medical and political community.

         At the third annual meeting, Jewell delivered a brief talk in his capacity as president, and this event inaugurated the ever-present tradition within the organization of the Presidential Address. The topic he chose, Specialization in Medicine, was a carefully argued justification of neurology as its own field and focused on a subject of great debate in the larger medical arena of the time. His choice set a tradition for the Presidential Address to be a topic allied to the president's own interest area and also one that was of current national importance.

         A consciousness of the public and political climate led to the ANA's direct involvement in the drafting of statements related to medical reforms of neurological import. In 1884, the ANA developed a Nomenclature committee that served to advise on terminology. In 1892, the organization took a strong stand on encouraging the development and support of specialized institutions for epileptics, pressuring local and state institutions to remove these neurologically disabled patients from asylums or almshouses where the primary focus was on indigency, psychiatric illnesses, and social disabilities. Among other activities, the early ANA sponsored prizes for excellence in neurological research. In 1877, William Hammond initiated this effort by offering $200 to the best essay on the Anatomical and Physiological Effects of Strychnine on the Brain, Spinal Cord, and the Nerves.

         As one of the missions of the ANA, education was the driving force behind the Transactions of the ANA, published annually after each meeting. As a small and elite group, the ANA restricted attendance to its meetings, but widely circulated its Transactions that included the presentations as well as the commentary afterwards. Although this format is not widely used in contemporary neurology publishing, these direct transcriptions of the discussions breath with vibrancy and serve as the closest first-hand documents concerning the early meetings. They reveal the wide variety of topics considered neurological and show the consistent argumentative tenor to the meetings.

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Assassination of President Garfield

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Many of the early ANA members involved themselves in social and medical-legal topics of the time and thereby expanded the public awareness of neurology. WA Hammond was particularly involved in criminal cases, and both EC Spitzka and G Beard were key experts in the trial of the assassinator of President Garfield. CK Mills likewise published a paper on criminal lunacy and brain disorders making special reference to the celebrated Guiteau trial. Along with C Dana, Mills attended the execution and autopsy examination.

Transactions of the ANA

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The early ANA actively supported the development of the Congress of American Physicians and Surgeons as a competitor to the American Medical Association. LC Gray served as the representative from the ANA to the new organization.

Report of the ANA

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Throughout its history the ANA actively participated in the generation of reports on diverse neurological issues related to public health and government policy. Among the most important was the 1935 document on sterilization among neurologically impaired citizens where the ANA advocated against broad sterilization programs except in highly select disorders.

"A Tragedy" as presented by the ANA

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At some dinners during the twentieth century, the president was regularly the subject of a skit or "roast" engineered by his younger colleagues. These events were known to be baudy and often appreciated only by members of the president's "inner-circle." From the Appian Way to Winersnitzel or Libido Sempervirens or History Repeats: A Tragedy was presented at the 60th annual meeting in 1934.

Entertainments at the Annual ANA Meetings

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Paradies and adaptation of popular songs into a neurological venue were also well received, including a neurological spoof based on songs from My Fair Lady (My Fair Neuro) "The pain of back sprain lies mainly in the brain" and "Just you wait Hiram Houston" were among the selections.

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