The conflicts of Ray Adams and Joe Foley with Abe Baker: The neurology and neuropathology of liver failure (1949-1963) and the founding of the American Academy of Neurology (1948)

This article examines disagreements among three giants of twentieth-century American neurology: Raymond Adams, Joseph Foley, and Abraham Baker. The disagreements Adams and Foley had with Baker concerned two issues: (1) the neurologic and neuropathological manifestations of liver failure with hepatic encephalopathy as expounded from the late 1940s to the early 1960s, and (2) the founding of the American Academy of Neurology in 1948 as an inclusive medical society under the principal leadership of Baker. The conflicts are examined from transcribed meeting debates (1949-1963), salient original publications (1949-1963), public addresses of protagonists touching on these issues (1971, 1984), and oral histories and less formal interviews of the protagonists and their associates (1979-2014). Contributing to these conflicts were contrasting personalities and outlooks on American neurology in the mid-twentieth century. Adams and Foley prevailed with their characterization of the neurologic and neuropathologic features of liver failure, whereas Baker triumphed with the need for and importance of an inclusive neurological society that would develop continuing medical education for neurologists at a national level, garner federal financial support for neurology training programs, and facilitate the development of neurology as a strong, independent medical discipline in the United States.

The collaboration of Francis Forster and Wilder Penfield in the management of a girl with 'reflex epilepsy'

In the era after World War II, Francis (Frank) Forster (1912-2006) became a preeminent American neurologist and epileptologist, with international prominence in the study of reflex epilepsy. Forster's interest in reflex epilepsy began with a chance observation of the condition, in 1946, in a four-year-old girl. When medical measures failed to control her somatosensory-evoked seizures, Forster recommended surgery, and then facilitated transfer to Canadian neurosurgeon Wilder Penfield (1891-1976) at the Montreal Neurological Institute. Forster traveled to Montreal for the child's surgery. The surgery on February 27, 1948, proved to be curative for the child, and Forster's interactions with Penfield and epileptologist Herbert Jasper (1906-1999) made a lasting impression. This study reviews the medical and surgical history of this case, which strongly influenced Forster's career.

The medieval cell doctrine: Foundations, development, evolution, and graphic representations in printed books from 1490 to 1630

The medieval cell doctrine was a series of related psychological models based on ancient Greco-Roman ideas in which cognitive faculties were assigned to "cells," typically corresponding to the cerebral ventricles. During Late Antiquity and continuing during the Early Middle Ages, Christian philosophers attempted to reinterpret Aristotle's De Anima, along with later modifications by Herophilos and Galen, in a manner consistent with religious doctrine. The resulting medieval cell doctrine was formulated by the fathers of the early Christian Church in the fourth and fifth centuries. Printed images of the doctrine that appeared in medical, philosophical, and religious works, beginning with "graphic incunabula" at the end of the fifteenth century, extended and evolved a manuscript tradition that had been in place since at least the eleventh century. Some of these early psychological models just pigeonholed the various cognitive faculties in different non-overlapping bins within the brain (albeit without any clinicopathologic evidence supporting such localizations), while others specifically promoted or implied a linear sequence of events, resembling the process of digestion. By the sixteenth century, printed images of the doctrine were usually linear three-cell versions with few exceptions having four or five cells. Despite direct challenges by Massa and Vesalius in the sixteenth century, and Willis in the seventeenth century, the doctrine saw its most elaborate formulations in the late-sixteenth and early-seventeenth centuries with illustrations by the Paracelsan physicians Bacci and Fludd. Overthrow of the doctrine had to await abandonment of Galenic cardiovascular physiology from the late-seventeenth to early-eighteenth centuries.

Representations of the olfactory bulb and tracts in images of the medieval cell doctrine

This article presents a collection of previously overlooked, stereotyped, abstract, anatomical representations of the olfactory bulbs and tracts that were printed as part of schematic woodcuts of the medieval cell doctrine, generally in the early-sixteenth century but extending into the seventeenth century and, in at least one case, to the mid-nineteenth century. A representation of the olfactory bulbs is incorporated into many of these woodcuts, beginning with an illustration by German physician, philosopher, and theologian Magnus Hundt in 1501 in his Antropologium, which showed central projections of the two olfactory bulbs joining in the meshwork of the rete mirabile. German physician and anatomist Johann Eichmann, known as Johannes Dryander, modified Hundt's figure for his own monograph in 1537 but retained the representation of the olfactory bulbs. In 1503, German Carthusian humanist writer Gregor Reisch published an influential and highly copied woodcut in his Margarita philosophica, showing connections from the olfactory bulbs overlying the bridge of the nose (as well as from other special sense organs) to the sensus communis in the anterior cell or ventricle. In the following centuries, numerous authors derived similar figures from Reisch's original schematic illustration of the medieval cell doctrine, including Brunschwig (1512, 1525), Głogowczyk (1514), Romberch/Host (1520), Leporeus/Le Lièvre (1520, 1523), Dolce (1562), Lull/Bernardus de Lavinheta (1612), and Elliotson (1835). Similar representations were provided by Peyligk (1518) and Eck (1520). These stereotyped schematic images linked the olfactory bulbs to olfaction before the advent of more realistic images beginning in the mid-sixteenth century.

Eugène-Louis Doyen and his Atlas d'Anatomie Topographique (1911): Sensationalism and gruesome theater

French surgeon and anatomist Eugène-Louis Doyen (1859-1916) was a focus of controversy and scandal throughout his career, an innovative surgeon of great technical skill whose unsurpassed abilities were offset by narcissistic and frequently unethical behavior. Doyen produced the most controversial atlas of human anatomy of the early-twentieth century, his Atlas d'Anatomie Topographique. He used a chemical process to fix whole cadavers, then used a motorized band saw with a sliding table to precisely cut sequential slices in all three anatomic planes. His intentionally arresting images of the nervous system in situ (using heliotypes in his atlas and projected images of prepared specimens in his lectures) made for gruesome theater, directed more at the public than the medical profession, which Doyen disdained and delighted in antagonizing. Although photography and photomechanical reproduction facilitated the rapid production of Doyen's atlas, many of the fine details were lost. In addition, although he developed tissue fixation techniques that preserved the natural colors of tissues, this was not evident in the monochrome images of the printed atlas. Doyen's atlas is compared with other anatomic atlases of the late-nineteenth century that included serial sections of the central nervous system, either from sections of entire cadavers, the isolated head, or the excised brain. In retrospect, Doyen's fevered activity, including his efforts to depict the topographic anatomy of the nervous system, produced only modest benefits, and often produced significant costs for his patients, his colleagues, the medical profession, and his own reputation.

Neuropathological images in the great pathology atlases

In the period between Morgagni's De Sedibus (1761) and Cruveilhier's Anatomie pathologique (1829-1842), six pathology atlases were published, in which neuropathological subjects were discussed and depicted. It was a period of transition in medical, technical, and publishing areas. The first three (by Matthew Baillie, Robert Hooper, and Richard Bright) were mainly atlases derived from pathological museum specimens. They were selective rather than comprehensive. Of the other three (by Jean Cruveilhier, James Hope, and Robert Carswell), most of the observations were made during autopsies. These illustrations required special arrangements so they could be executed during the autopsies. These were available in Paris rather than in London, which is the reason why Hope and Carswell made many of the drawings in France. The plates in these three were color lithographs. Baillie's book contains only figure descriptions. Bright's and Cruveilhier's atlases provide case descriptions. Hooper and Hope provide theoretical texts and figure legends. Carswell's book has 12 theoretical sections, each followed by plates. The relative cost of the atlases varied with the number of plates. Although the authors made use of artists and engravers, several were talented artists themselves. Many common neurological diseases were depicted.

Summarizing the medieval anatomy of the head and brain in a single image: Magnus Hundt (1501) and Johann Dryander (1537) as transitional pre-Vesalian anatomists

Of the early-sixteenth century pre-Vesalian anatomists, Magnus Hundt in 1501 and Johannes Eichmann (known as Johann Dryander) in 1537 both attempted to summarize the anatomy of the head and brain in a single complex figure. Dryander clearly based his illustration on the earlier one from Hundt, but he made several improvements, based in part on Dryander's own dissections. Whereas Hundt's entire monograph was medieval in character, Dryander's monograph was a mixture of medieval and early-modern frameworks; nevertheless, the corresponding illustrations of the anatomy of the head and brain in Hundt (1501) and Dryander (Dryandrum 1537) were both essentially medieval. This article examines in detail the symbology of both illustrations within the context of the medieval framework for neuroanatomy and neurophysiology. These two woodcuts of the head and brain provide the most detailed pictorial representation of medieval cranial anatomy in a printed book prior to the work of Andreas Vesalius in 1543.

Cross-sectional representations of the central nervous system in Pirogov's "Ice Anatomy"

Russian surgeon Nikolay Ivanovich Pirogov (Pirogoff; 1810-1881) introduced the teaching of applied topographical anatomy in Russia. Pirogov's monumental four-part atlas, Anatome topographica sectionibus per corporis humanum congelatum triplici directione ductis illustrate (An Illustrated Topographic Anatomy of Saw Cuts Made in Three Dimensions Across the Frozen Human Body), colloquially known as the "Ice Anatomy," was published in Latin in folio in the 1850s. Pirogov sought to investigate "the normal and pathological positions of different organs and body parts using sections made in the three principal directions [anatomical planes] … throughout all regions." To accomplish this, he froze cadavers "to the density of the thickest wood" and then cut them into thin plates with a special mechanical saw. His approach was reportedly inspired by his observations of butchers sawing across frozen pig carcasses at the meat market in St. Petersburg during winter. Pirogov systemically obtained full-size representations of more than 1,000 sections. A painter made a representative copy of the cross-sectional contours of each section, using ruled glass overlain on the sections. The final lithographs were of high artistic quality and execution, resembling modern high-resolution medical imaging (i.e., CT or MRI). Moreover, structures were serially sectioned and systematically illustrated along all three anatomical planes, something that had never previously been attempted. This allowed clinicians and anatomists to scrutinize the spatial relationships of structures from multiple perspectives and at a much more detailed level than was previously possible, although the cost, massiveness, and complexity of the completed work precluded wide dissemination.

Evolution of the myth of the human rete mirabile traced through text and illustrations in printed books: The case of Vesalius and his plagiarists

Andreas Vesalius initially accepted Galen's ideas concerning the rete mirabile in humans. In 1538, Vesalius drew a diagram of the human rete mirabile as a plexiform termination of the carotid arteries, where the vital spirit is transformed into the animal spirit, before being distributed from the brain along the nerves to the body. In 1540, Vesalius demonstrated the rete mirabile at a public anatomy, using a sheep's head (due to his nascent realization that he could not demonstrate this adequately in a human cadaver, potentially eliciting ridicule). By 1543, Vesalius had fully reversed himself, denied the existence of the rete mirabile in humans, and castigated himself for his prior failure to recognize this error in Galen's works. Vesalius nevertheless illustrated both the Galenic conception of the rete mirabile in humans and a schematic of the rete mirabile in ungulates. He intended the 1543 diagram of the human rete mirabile as an example of a mistake that resulted from Galen's overreliance on animals as models of human anatomy. However, in spite of Vesalius's intentions, for more than a century afterward, his figure was repeatedly and perversely plagiarized by advocates for Galenic doctrine, who misused it as a purportedly realistic representation of human anatomy and generally omitted the contrary opinions of Berengario da Carpi and Vesalius. The protracted use of stereotyped representations of the rete mirabile in extant printed illustrations provides tangible documentation of the stagnation in anatomical thought in the sixteenth and seventeenth centuries.

On old Olympus? Oliver Wendell Holmes and the origin and evolution of a mnemonic couplet for the cranial nerves

A mnemonic couplet to help students learn the names of the cranial nerves has been in use in the United States since the mid-nineteenthth century. The original in iambic tetrameter is attributed to Oliver Wendell Holmes, Sr. Using a systematic search, more than 40 variants have been identified and, where possible, ordered in time. Variations depended in part on evolving preferred names for individual cranial nerves, regional geographic features, and idiosyncratic choices. Some inferior variants ignored critical features of the original (e.g., meter, number of poetic feet, or even the rhyme). Others strove to have a memorable couplet with the basic features of the original but without resorting to disparaging phrases. However, with the modern names for the cranial nerves, few of the extant versions of the mnemonic make sense, or preserve iambic tetrameter and rhyme, while avoiding derogatory or lewd expressions. Two new versions are suggested that meet these constraints.

Raymond D. Adams and Joseph M. Foley: Elaborating the neurologic manifestations of hepatic encephalopathy (1949-1953)

This article compares and contrasts different versions of the pioneering work Raymond Adams and Joseph Foley concerning the neurological and neurophysiological manifestations of liver disease. These versions were presented by the protagonists in publications from 1949 to 1953, and later in various oral histories conducted separately from 1988 to 2014. The general framework of the various versions is fairly consistent, but numerous differences in the details emerged over time, some reflecting the vagaries of memory over periods as long as six decades (e.g., with fluctuations in the versions told by a single protagonist in different interviews, under different circumstances, and at different ages), others reflecting a form of egocentric recall bias (as, for example, when both of the protagonists recalled that they were responsible for a particular observation).

Western European influence on the development of Russian neurology and psychiatry, part 1: Western European tours of early Russian neurologists and psychiatrists

Beginning in the 1860s, two major centers of neurology and psychiatry arose in Russia: Imperial Moscow University (IMU) and Imperial Medical and Surgical Academy in St. Petersburg (IMSA). Both centers were strongly influenced by Leading Western European schools and specialists, through the clinical and research training regimes of both Russian universities, strongly influenced these centers of learning. In this study, we elaborate the Western European training of the first Russian specialists in the fields of neurology and neuropsychiatry from IMU and IMSA during the period from the late 1850s to 1900. Although prior studies emphasized the influence of French mentors and institutions, the Western European tours of early Russian specialists often included multiple destinations in Germany, France, and Austria. The most commonly visited cities (in descending order) were Paris, Berlin, Leipsig, and Vienna. The most commonly visited training centers (in descending order) were Hoôpital Salpêtriêre (Paris), Friedrich-Wilhelms-Universität (Berlin), Charité (Berlin), Universität Leipzig, First Psychiatric Clinic (Vienna), and Hôpital Sainte-Anne (Paris). The most commonly visited mentors, in descending order, were Charcot (Paris), Flechsig (Leipzig), Westphal (Berlin), Meynert (Vienna), and Magnan (Paris). Training of Russian specialists in Western Europe facilitated the emergence and development of the neurological and psychiatric schools in Moscow and St. Petersburg.

Clarence J. Gibbs Effect and the "Creutzfeldt-Jakob Disease" Eponym

In 2014, American neurologist and Nobel laureate Stanley Prusiner reported that microbiologist Clarence Joseph Gibbs at the US NIH had intentionally, systematically, and mischievously used the eponym Creutzfeldt-Jakob disease, rather than Jakob-Creutzfeldt disease, because of the correspondence with Gibbs' own initials, to imply "Clarence Joseph disease." The present study examines temporal trends in the use of "Creutzfeldt-Jakob" and "Jakob-Creutzfeldt" in scientific articles and monographs from 1946 to 2019 to assess whether there was a "Clarence J. Gibbs effect" that influenced the general use of a specific eponym by the scientific community. During Gibbs' period of publication on Creutzfeldt-Jakob disease (CJD), there was an abrupt, dramatic, and steady increase in use of the CJD eponym while use of the Jakob-Creutzfeldt disease (JCD) eponym remained at a low level. In the period after Gibbs ceased to publish, there was a corresponding marked fall-off in use of the CJD eponym. Surviving collaborators thought Gibbs may have been joking, but in 1991 Gibbs had admitted what Prusiner reported. Regardless of motive, Gibbs strongly influenced the preferred eponym for this human prion disease by (1) publishing a seminal and highly referenced initial article in a high-profile journal; (2) sustained output of further important studies published in high-quality journals over more than 30 years; (3) professional affiliation with an esteemed national laboratory where he worked with a large number of high-profile colleagues; and (4) extensive collaborations with a large number of colleagues, who published multiple further articles using the eponym Gibbs preferred.

Cruveilhier's Unrecognized Case (c1831) of Dyke-Davidoff-Masson Syndrome

In his serially published atlas of pathology, Anatomie Pathologique du Corps Humain (1829-1842), French anatomist and pathologist Jean Cruveilhier (1791-1874) provided an early clinical-pathologic description of Dyke-Davidoff-Masson syndrome. Cruveilhier's case was initially published around 1830, more than a century before the clinical and radiologic report of Dyke and colleagues in 1933 based on a series of patients studied with pneumoencephalography. Although Dyke and colleagues were apparently unaware of Cruveilhier's prior description, Cruveilhier's case manifested all of the key osseous and neuropathological features of Dyke-Davidoff-Masson syndrome as later elaborated by Dyke and colleagues: (1) cerebral hemiatrophy with ex vacuo dilation of the lateral ventricle, (2) ipsilateral thickening of the diploe of the skull, and (3) ipsilateral hyper-pneumatization of the frontal sinuses. In addition, Cruveilhier noted crossed cerebral-cerebellar atrophy in his case and correctly inferred a "crossed effect" between the involved cerebral hemisphere and the contralateral cerebellum. Cruveilhier's pathological case from 1830 clearly anticipated both the cases reported more than a century later by Dyke and colleagues based on pneumoencephalography and the more recent case reports recognized with computed tomography or magnetic resonance imaging.

In memoriam: Henry Szczȩsny Schutta, MD (1928-2020)

Polish-American neurologist and neurologic historian Henry Szczȩsny Schutta, MB BS, MD (1928-2020), was born in the Free City of Gdańsk. After surviving the trauma and devastation wrought on his family and his native country during World War II, Schutta met the love of his life in war-torn Bonn, Germany. Schutta completed premedical studies in Bonn, then medical school in Sydney, Australia, and neurology residency at the National Hospital, Queen Square, London. He then joined the faculty at the University of Pennsylvania (1962-1973), where he became a recognized authority on electron microscopy of the nervous system and muscle, particularly concerning bilirubin encephalopathy, brain swelling, and papilledema. He was subsequently appointed as the inaugural chair of neurology at Downstate Medical Center in Brooklyn (1973-1980) and then chair of neurology at the University of Wisconsin (1980-1995). His academic career spanned four countries on three continents, and included substantive contributions to basic research, clinical care, administration, and teaching. He was most proud of his contributions to education and mentoring. He pushed his trainees to excel, and modeled for them the traits of caring, compassion, dedication, diligence, reasonableness, and fidelity-leavened with wit, charm, and a penchant for humorous historical anecdotes. Many of Schutta's witticisms on rounds ("Schutta-isms") have been retold by subsequent generations of trainees. This biography provides first-person accounts of Schutta's struggles and successes based on his own autobiography, a formal oral history for the American Academy of Neurology Oral History Project, and supporting accounts of his family, trainees, and colleagues.

The development and evolution of "cerebral thermometry": Clinical applications of a nineteenth-century approach to cerebral localization and neurological diagnosis

Surface thermometers were developed in the latter half of the nineteenth century. In 1877, Broca, already famous for his contributions to the cerebral localization of nonfluent aphasia, presented his first clinical observations on cranial surface temperatures: In two cases, cranial surface temperatures were decreased over a middle cerebral artery infarction, and increased in surrounding areas, which Broca attributed to "compensatory hyperaemia." As Broca made apparent in a later report in 1879, he had used a "thermometric crown," an apparatus consisting of six to eight large-reservoir mercury thermometers strapped against the head. Following Broca's report, American neurologists reported cases in which cranial surface temperatures were increased either locally over a superficial brain tumor or globally with a cerebral abscess. Despite promising anecdotal reports, contemporaries recognized that significant technical and practical problems limited its accuracy, reliability, and clinical utility. Advocates never demonstrated that this technology provided significant marginal benefit to the medical history and physical examination. The technique fell out of fashion before 1900, though some early advocates promoted it into the early twentieth century. It was ultimately replaced by more effective technologies for cerebral localization and neurological diagnosis.

The assessment of Perkins' patent metallic "tractors": Abandonment of an 18th-century therapeutic fad following trials using sham instruments

From 1799 to 1801, with the instigation of John Haygarth, physicians in England evaluated the claims of Elisha and Benjamin Perkins that their patented "metallic tractors" could cure a wide variety of disorders. Previous therapies were typically judged based on experience and authority, whereas Perkinism was evaluated using a series of clinical trials of varying methodological sophistication, most employing sham instruments (all but those involving infants or horses), with a variety of trial designs, inconsistent use of contemporary controls, and different approaches to blinding subjects to the treatment administered. Haygarth and his colleagues collectively demonstrated that tractors and sham instruments produced equivalent effects in adults, and, by inference, that the tractors had no special therapeutic properties. Other trials using only genuine tractors demonstrated no effects in infants and horses, subjects who could not reasonably be influenced by suggestion and the imagination. These collective results provided strong support for the rival hypothesis that the observed effects were due to suggestion and the imagination of the subjects. Despite fallacy-laden counterattacks and counterarguments from Benjamin Perkins and his supporters, the trials eroded support for this therapy and led to abandonment of the "Metallic Practice" as a treatment in Britain and elsewhere.

Perkins's patent metallic "Tractors": Development, adoption, and early dissemination of an eighteenth-century therapeutic fad

The metallick Tractors were patented by Elisha Perkins, a Connecticut physician, in 1796, for the treatment of various ailments, particularly those associated with pain. They were subsequently rapidly and widely disseminated on the basis of testimonials and aggressive marketing tactics. Dissemination was facilitated by endorsements from prominent physicians, politicians, and clergy, by quasi-theoretical explanations of efficacy based on then-current experiments of Galvani and others, and by the apparent simplicity and safety of the procedure. Abandonment of this ineffective therapy was later prompted by the application of blinded placebo-controlled trials using sham devices.

The development and evolution of "cerebral thermometry": The physiology underlying a nineteenth-century approach to cerebral localization and neurological diagnosis

Surface thermometers were developed in the latter half of the nineteenth century. From the 1850s through the 1880s, collaborations between physicians, research scientists, and instrument makers produced clear improvements in the technology to measure cranial surface temperatures, with development of self-registering mercury surface thermometers resistant to pressure and little influenced by ambient temperature, apparatus for recording cranial surface temperatures from multiple stations simultaneously, and development of thermoelectric apparatus. Physiologic studies of cranial surface thermometry were conducted over a quarter century from 1861 to 1886. Beginning in the 1860s Albers in Bonn, Germany, and Lombard at Harvard and later in England systematically investigated surface temperatures on the head using surface thermometers and thermoelectric apparatus; they demonstrated that head temperatures were variable over time and across individuals and were not clearly influenced by thinking or muscular contraction but were influenced by ambient air temperature. In 1880 Amidon in the United States claimed that cranial surface thermometry during exertion produced localized increases in surface temperature on the contralateral scalp in a specific pattern ("external motive areas") indicating underlying brain areas responsible for each movement. Amidon's results were not reproduced by experienced physiologists in England or France. Contemporaries recognized that significant technical and practical problems limited the accuracy and reliability of cranial surface thermometry. Physiological studies of cranial surface thermometry ended in the mid 1880s, although some clinicians who were early advocates promoted its use in clinical contexts into the early twentieth century.

Antecedents, development, adoption, and application of Duchenne's trocar for histopathologic studies of neuromuscular disorders in the nineteenth century

Duchenne de Boulogne was one of the founders of clinical neurology. His name has been eponymically linked to the most common form of muscular dystrophy, originally described by him as pseudo-hypertrophic muscular paralysis or myo-sclerotic paralysis. Obtaining muscle biopsy specimens was essential to gain insight about the etiopathogenensis of the disease. Duchenne invented a novel instrument: l'emporte-pièce histologique, also known as "Duchenne's trocar," to perform muscle biopsies. Following Duchenne's design and instructions, a Parisian company, Charrière, constructed the first instrument probably in 1864. That instrument was essential for Duchenne's description of the histopathological abnormalities typical of pseudo-hypertrophic muscular paralysis. The innovative needle-biopsy technique enabled physicians to analyze the spectrum of pathological changes at varying stages of different neuromuscular diseases. Duchenne's trocar was a forerunner of several types of modern muscle-biopsy needles. His invention was instrumental in the development of the disciplines of muscle pathology and clinical myology.

Abe Baker: Visionary and organizational leader of the American Academy of Neurology

American neurologist and neuropathologist Abraham Bert (Abe) Baker (1908-1988) was instrumental in founding the American Academy of Neurology and served as a catalyst for the emergence of neurology as a strong, independent medical discipline in the United States in the second half of the twentieth century. Baker served as the first president of the Academy from 1948 to 1951. He was also instrumental in garnering support for the National Institute of Neurological Diseases and Blindness, which was founded in 1950 and later evolved into the National Institute of Neurological Disorders and Stroke. Baker's leadership was also essential in developing continuing medical education for neurologists at a national level and in garnering federal financial support for neurology training programs.

The Four Horsemen (and their Nags): Recollections of the founding and early years of the American Academy of Neurology

"The Four Horsemen" was the nickname given to the four neurologists-Abraham Baker, Francis Forster, Russell DeJong, and Adolph Sahs-who were most instrumental in founding and developing the American Academy of Neurology (AAN) beginning around 1948. Forster later humorously added "and their nags" to the epithet to reflect the cohesion of the founders and their wives. This article presents the personal recollections of these founders from correspondence and oral histories. When the AAN was founded, private-practice neurologists and residents were excluded from the academically oriented and restrictive American Neurological Association (ANA). Baker conceptualized the AAN as an inclusive professional society that would accept all neurologists of whatever age and level of training, and that would strive to strengthen their knowledge, competencies, and skills through continuing medical education and guideline development. Baker recruited supportive colleagues to help create and develop the organization. Their intention was not to compete with or subvert the ANA, but to offer an inclusive professional organization for all neurologists. Nevertheless, their efforts produced opposition among ANA members. To defuse the antagonism, neurologist Alphonse Vonderahe proposed an influential House-Senate formulation of the AAN-ANA relationship, modeled after the U.S. Congress, both as a supporting rationale for the AAN and as a conceptual model for the functional relationship between the two organizations. The inclusive approach greatly augmented the ranks of the fledgling AAN, whereas those of the ANA stayed relatively stagnant, with the AAN ultimately becoming the dominant neurological society. These neurologic pioneers laid the groundwork for an invigorated, well-trained, scientifically based specialty of neurology in the second half of the twentieth century.

Francis Forster, the last Horseman: A career in academic neurology

American neurologist and epileptologist Francis M. Forster (1912-2006) was the last survivor of the "Four Horsemen," a nickname given to the four neurologists-Forster, Abe Baker, Russell DeJong, and Adolph Sahs-who were most instrumental in founding the American Academy of Neurology under Baker's leadership in 1948. Forster was a consulting physician for many high-profile patients, including President Dwight Eisenhower, President Quirino and Archbishop Reyes of the Philippines, Provisional President Lonardi of Argentina, and Cardinal Albert Meyer of Chicago. Forster was also an expert witness for the prosecution in the trial of Jack Ruby, who killed Lee Harvey Oswald. Forster's greatest legacy, though, was as a teacher: During his career as chairman of two robust academic neurology departments, he trained more than 100 residents, at least 17 of whom went on to become chairmen of neurology departments in the United States, Europe, Asia, and South America.

Jumping Frenchmen, Miryachit, and Latah: Culture-Specific Hyperstartle-Plus Syndromes

In the late 19th century, jumping (French Canadians in Maine, USA), miryachit (Siberia), and latah (Southeast Asia) were among a group of similar disorders described around the world, each of which manifests as an exaggerated startle response with additional late-response features that were felt by some to overlap with hysteria or tics. The later features following the exaggerated startle reaction variably include mimesis (e.g., echopraxia, echolalia) and automatic obedience. These reaction patterns tended to persist indefinitely in affected individuals. Because of their dramatic stimulus-driven behaviors, affected individuals were prone to be teased and tormented by being repeatedly and intentionally startled. Despite clinical overlap between jumping and Tourette syndrome, these entities are now recognized as distinct: in jumping, the key feature is an abnormal startle response, the abnormal reaction is always provoked, and tics are absent, whereas in Tourette syndrome, the key feature is spontaneous motor and vocal tics, although patients with Tourette syndrome may occasionally also have an exaggerated startle response. These disorders have been conceptualized from anthropological, psychodynamic, and neurobiologic perspectives, with no complete resolution to date. Attempts at treatment have been generally unsuccessful, including attempts with bromization and hypnosis, although anecdotal reports of successful deconditioning have been published. In population groups affected, these disorders are usually considered as behavioral peculiarities and not as diseases per se, and there is no apparent tendency to develop disabling mental illness or neurodegenerative disorders. The genesis of these disorders, their cultural and social components, and their interactions with the presumed underlying physiological substrate need further study. Careful descriptive and analytic epidemiological studies are also lacking for all of these disorders.

The Alice-in-Wonderland Syndrome

In 1955, English psychiatrist John Todd defined the Alice-in-Wonderland syndrome (AIWS) as self-experienced paroxysmal body-image illusions involving distortions of the size, mass, or shape of the patient's own body or its position in space, often accompanied by depersonalization and/or derealization. AIWS had been described by American Neurologist Caro Lippman in 1952, but Todd's report was the most influential. Todd named the syndrome for the perceptual disorder of altered body image experienced by the protagonist in Alice's Adventures in Wonderland (1865) by Lewis Carroll (Charles Lutwidge Dodgson). In Carroll's original story, Alice experienced several dramatic changes in body size and shape (e.g., shrinking to 10 inches high, growing unnaturally tall but not any wider, and growing unnaturally large). Todd reported 6 cases of AIWS, all of whom had episodic body-image distortions like those experienced by Lewis Carroll's Alice character; some also had visual perceptual disturbances, but none had visual perceptual disorders without body-image distortions. Therefore, AIWS may be accompanied by visual perceptual disorders (e.g., micropsia, macropsia, telopsia, pelopsia), but basing the diagnosis of AIWS on isolated visual perceptual disorders, as has subsequently been done by a number of authors, is inaccurate and misleading. Cases of isolated visual illusions without self-perceived distortions of body size, shape, or form, do not meet Todd's original criteria, nor are they commensurate with the experiences of the protagonist in Alice's Adventures in Wonderland. Furthermore, such cases differ by age and etiology from those that involve somesthetic perceptual disorders. Therefore, the use of the term AIWS for isolated visual illusions is problematic and should be discouraged. Although Todd's and Lippman's cases were adolescents or adults, AIWS is most commonly reported in children. Reported causes include infection (especially with Epstein Barr virus), migraine, epilepsy, depression, and toxic and febrile delirium.

The Klüver-Bucy Syndrome

In 1937, Heinrich Klüver and Paul Bucy described a dramatic behavioral syndrome in monkeys after bilateral temporal lobectomy. The full Klüver-Bucy syndrome (KBS) - hyperorality, placidity, hypermetamorphosis, dietary changes, altered sexual behavior, and visual agnosia - is evident within 3 weeks following operation. Some KBS features (i.e., hyperorality, placidity, hypermetamorphosis) persist indefinitely, whereas others gradually resolve over several years. Klüver and Bucy were initially unaware of an earlier report of KBS by Sanger Brown and Edward Schäfer in 1888. Human cases were recognized in the 1950s, as surgeons employed bilateral temporal lobectomies to treat seizures. Various attempts were made to localize the component features to specific areas of the temporal lobe, with mixed success. Bilateral ventral temporal ablations and bilateral temporal lobectomies produced marked impairment in visual discrimination, whereas lateral resections or unilateral lesions did not. Discrete bilateral lesions of the lateral amygdaloid nucleus produced a permanent "hypersexed state." By the 1970s, it was clear that the major symptoms of KBS are produced by destroying either the temporal neocortex or the amygdala bilaterally. KBS is now thought to be caused by disturbances of temporal portions of limbic networks that interface with multiple cortical and subcortical circuits to modulate emotional behavior and affect. The clinical features of KBS in man are similar to those in monkeys, but the full syndrome is rarely seen, probably because the anterior temporal lobe dysfunction is usually less severe than that following total temporal lobe ablation in monkeys. Human KBS does not occur in isolation, but is typically part of a complex behavioral syndrome that almost always includes amnesia and aphasia, and that may also include dementia and seizures. The treatment of KBS is difficult and often unsatisfactory.

Vitamin A-Deficiency Eye Disease Among Soldiers in the U.S. Civil War: Spectrum of Clinical Disease

During the U.S. Civil War, nutritional night blindness was a common problem among soldiers forced to subsist of nutritionally inadequate diets, but medical officers typically attributed this complaint to malingering and did not suspect or appreciate a dietary basis. More than 8,000 cases of night blindness were recorded among Union troops, but many cases were not tabulated because of incomplete data for black soldiers and prisoners of war. From 1864 to 1865, during which comparable data were available for both whites and blacks, the average annual cumulative incidence of night blindness was 4.3 per 1,000 troops for whites, compared with 11.0 per 1,000 troops for blacks. Affected patients had dilated pupils that were poorly responsive to candle light. Approximately 30 cases of keratomalacia were also reported among severely malnourished and emaciated soldiers with chronic diarrhea, generally within 2 weeks before death. The reported clinical manifestations are characteristic of the full range of vitamin A deficiency eye disease from night blindness to corneal ulceration and perforation. Although medical officers typically accused affected soldiers of malingering, malingering cannot account for either the observed abnormalities of pupillary reflexes, or the corneal epithelial pathology and mortality recorded in severe cases.

Elaboration of the Visual Pathways from the Study of War-Related Cranial Injuries: The Period from the Russo-Japanese War to World War I

As a result of the wars in the early 20th century, elaboration of the visual pathways was greatly facilitated by the meticulous study of visual defects in soldiers who had suffered focal injuries to the visual cortex. Using relatively crude techniques, often under difficult wartime circumstances, investigators successfully mapped key features of the visual pathways. Studies during the Russo- Japanese War (1904-1905) by Tatsuji Inouye (1881-1976) and during World War I by Gordon Holmes (1876-1965), William Lister (1868-1944), and others produced increasingly refined retinotopic maps of the primary visual cortex, which were later supported and refined by studies during and after World War II. Studies by George Riddoch (1888-1947) during World War I also demonstrated that some patients could still perceive motion despite blindness caused by damage to their visual cortex and helped to establish the concept of functional partitioning of visual processes in the occipital cortex.

The Influence of the Two World Wars on the Development of Rehabilitation for Spinal Cord Injuries in the United States and Great Britain

During World War I, physical and occupational therapies became important adjuncts to surgical practice, particularly for orthopedic casualties, but there was little progress in the management of severe brain and spinal cord injuries (SCIs), largely because of the very high mortality of such injuries at that time. During World War II (WWII), rehabilitation was greatly expanded into an integrated, comprehensive multidisciplinary program in the U.S. military, largely because of the efforts of Howard Rusk (1901-1989), initially in the Army Air Corps and later across all of the services. With Bernard Baruch's (1870-1965) assistance, Rusk was also successful in swaying President Franklin Delano Roosevelt (1882-1945) to support rehabilitation for injured veterans and to give official standing to rehabilitation medicine in the military and the Veterans Administration after WWII. Such WWII developments in rehabilitation medicine had a profound effect on the care, functional outcomes, and survival of veterans with SCIs. Neurosurgeon Donald Munro's (1898-1978) prototype SCI unit at Boston City Hospital in 1936 influenced the U.S. Army to establish several SCI centers during WWII and influenced urologist Ernest Bors (1900-1990) to pioneer SCI care in Veterans Administration medical centers after WWII. In Britain, the organizational leadership of George Riddoch (1888-1947) led to the development of SCI units that saw their greatest development by Ludwig Guttmann (1899-1980) at Stoke-Mandeville Hospital in Aylesbury, near London. These SCI centers provided a comprehensive spectrum of care, including medical, neurological, and surgical management; psychological counseling; and rehabilitation focused on improving self-care, mobility, and re-assimilation into society. After WWII, military developments in comprehensive rehabilitation were promulgated to and developed in the revitalized Veterans Administration and then disseminated to civilian populations.

The Dercum-Muybridge Collaboration and the Study of Pathologic Gaits Using Sequential Photography

In the late 1870s and 1880s, prior to the development of movie cameras or projectors, English-American photographer Eadweard Muybridge (1830-1904) photographed sequential images of people and animals in motion, using arrays of sequentially triggered single-image cameras. In 1885, Philadelphia neurologist Francis Dercum (1856-1931) collaborated with Muybridge at the University of Pennsylvania to photograph sequential images of patients with various neurological disorders involving abnormal movements, and particularly various gait disorders, including both the sensory ataxic gait of tabes dorsalis and various spastic gaits. Dercum used tracings of sequential photographic images to plot trajectories of limbs as a way to characterize and distinguish pathologic gaits. The Dercum-Muybridge collaboration produced the first motion-picture sequences of neurological gait disorders ever filmed. These sequences and the trajectory-based studies that derived from them were a milestone in studies of pathologic gaits.

Seasonal variation in night blindness incidence among Union soldiers in the US Civil War

BACKGROUND

During the US Civil War, medical officers typically attributed night blindness among soldiers to malingering. A dietary basis was not generally suspected or appreciated.

DESIGN/METHODS

Incident cases of night blindness, scurvy, and diarrheal diseases, as well as mean troop strength among Union troops, were abstracted by month and race from tabulations of the US Surgeon General for the period from July 1861 through June 1866. Monthly incidence rates and annual incidence rates are presented as time series by race.

RESULTS

Night blindness incidence was seasonal. Seasonal patterns of night blindness incidence were similar for white and black soldiers, although the peak incidence rates were approximately 2-3 times higher in black soldiers. The seasonal effect for white Union soldiers increased progressively to 1864. The seasonal pattern for night blindness roughly parallels that for scurvy and for diarrheal diseases. The peak season for night blindness incidence was summer, and the next highest season was spring. The mode of monthly incidence rates for diarrheal diseases slightly anticipated that for night blindness and scurvy. In addition, there was greater relative variation in monthly incidence for night blindness and scurvy than for diarrheal diseases.

CONCLUSIONS

Nutritional night blindness occurred in a seasonal pattern among soldiers forced to subsist on nutritionally inadequate diets. The seasonal pattern is consistent with seasonal variations in the availability of foodstuffs with high vitamin A or provitamin A content, superimposed on marginal vitamin A reserves, and possibly exacerbated by co-occurring seasonal patterns of diarrheal disease.

Vesalius on the anatomy and function of the recurrent laryngeal nerves: medical illustration and reintroduction of a physiological demonstration from Galen

The purpose of this article is to review the anatomical illustrations and physiological demonstrations of sixteenth-century Flemish-born anatomist and physician Andreas Vesalius concerning the recurrent laryngeal nerves. Although Vesalius was primarily an anatomist, he also used vivisection as a pedagogical device to help his students understand the function of structures within the fabric of the body that they had previously studied in anatomical detail. Vesalius's masterwork, De humani corporis fabrica or simply the Fabrica (1543, 1555), was ostensibly an anatomy text, but Vesalius included textual and figural references to his use of vivisection to explicate the function of specific structures. Even as he began to criticize the errors in Galen's anatomical works, Vesalius nevertheless adopted some of Galen's classic physiological demonstrations, in particular the ligation (and subsequent release) of the recurrent laryngeal nerves of a pig to demonstrate their role in generating the pig's squeal. Vesalius's illustrations concerning the recurrent laryngeal nerve in the Fabrica were of two types: elegant anatomical woodcut plates-unsurpassed for their clarity, accuracy, and detail - and the distinctly inelegant historiated initial Q, depicting a throng of putti busily engaged in vivisecting a pig. Vesalius' anatomical plates were heavily plagiarized while the historiated initials, showing the rough work of an anatomist or surgeon, were largely ignored and remain little recognized today. While Vesalius' anatomical illustrations of the recurrent laryngeal nerves contained some errors, they were a dramatic departure from prior meager efforts at medical illustration and indeed far surpassed all contemporary published illustrations by others. Vesalius was also influential in reviving Galen's approach to vivisection, at least for pedagogical purposes, if not really then yet as a full-fledged investigative technique.

Early Controversies Over Athetosis: II. Treatment

BACKGROUND

Athetosis has been controversial since it was first described by William Hammond in 1871; many aspects of Hammond's career were equally controversial.

METHODS

Primary sources have been used to review treatment controversies in the 50-year period following the initial description of athetosis.

RESULTS

The treatments used most commonly employed available pharmaceutical agents and modalities (e.g., galvanism). Initial anecdotal reports of success were seldom confirmed with subsequent experience. Several novel invasive therapies were also developed and promoted, all of which damaged or destroyed either upper or lower motor neuron pathways, and were also often associated with high mortality rates. In general, these therapies substituted paresis for abnormal spontaneous movements. These included peripheral nerve stretching, excision of a portion of the precentral gyrus, rhizotomy, nerve "transplantation" (i.e., neurotomy and nerve-to-nerve anastomoses), and "muscle group isolation" (i.e., alcohol neurolysis). There was no agreement on the appropriateness of such high-risk procedures, particularly given the intentional generation of further neurological morbidity.

DISCUSSION

Pharmaceutical agents and modalities initially employed for athetosis had little a priori evidence-based justification and no biologically plausible theoretical framework to guide empiric treatment selection. Subsequently, all the invasive procedures employed were directed at lessening or removing the manifestations, rather than the underlying cause, of the abnormal central nervous system "irritation," usually by imposing paresis or paralysis. Factors contributing to the disparity in outcomes between favorable initial reports and the often-disappointing results of later studies included reliance on anecdotal reports or small uncontrolled case series, placebo effects, biased observation, misdiagnosis, and biased reporting.

Early Controversies over Athetosis: I. Clinical Features, Differentiation from other Movement Disorders, Associated Conditions, and Pathology

BACKGROUND

Since the description of athetosis in 1871 by American neurologist William Alexander Hammond (1828-1900) the disorder has been a source of controversy, as were many aspects of Hammond's career.

METHODS

Primary sources have been used to review controversies in the 50-year period since the initial description of athetosis, in particular those concerning clinical features, differentiation from other movement disorders, associated conditions, and pathology. Controversies concerning treatment will be addressed in a subsequent article.

RESULTS

Hammond struggled to establish athetosis as a distinct clinical-pathological entity, and had successfully predicted the striatal pathology in his initial case (albeit somewhat serendipitously). Athetosis was, nevertheless, considered by many neurologists to be a form of post-hemiplegic chorea or part of a continuum between chorea and dystonia. European neurologists, and particularly the French, initially ignored or discounted the concept. Additional controversies arose over whether the movements persisted during sleep, whether athetosis was, or could be, associated with imbecility or insanity, and how it should be treated.

DISCUSSION

Some controversies concerning athetosis served to identify areas where knowledge was insufficient to make accurate statements, despite prior self-assured or even dogmatic statements to the contrary. Other controversies illustrated established prejudices, even if these biases were often only apparent with the greater detachment of hindsight.

Medieval and Renaissance anatomists: the printing and unauthorized copying of illustrations, and the dissemination of ideas

The vanguard that began to question Galenic anatomical dogma originated in northern Italy in the latter half of the thirteenth century, and not coincidentally this was where human dissection was introduced, which in turn eventually fostered the origins of realistic anatomical illustration in the late fifteenth century. With the advent of the printing press and moveable type at this time, printed books began to supersede hand-copied medieval manuscripts, and labor-intensive techniques were soon developed to integrate text and illustrations on the printed page. The same technology was used to pirate the illustrations of prior authors with varying fidelity. Specific medieval and Renaissance anatomical illustrations can often be traced from their inceptions through different stages of development to the final printed images, and then through subsequent pirated versions in various abridgements or other compendia. The most important milestone in the development of anatomy and anatomical illustration was the publication in 1543 by Andreas Vesalii of De humani corporis fabrica (On the Fabric of the Human Body), commonly referred to simply as the Fabrica. With this work, Vesalii succeeded in coordinating a publication production team (author, artists, block cutters, publisher, and typesetters) to achieve an unprecedented integration of scientific discourse, medical illustration, and typography. However, despite Vesalii's valiant efforts to prevent unauthorized duplication, the illustrations from the Fabrica were extensively plagiarized. Although Vesalii found such piracy frustrating and annoying, the long-term effect was to make Vesalii's ideas known to a wider readership and to help solidify his own revolutionary contributions to anatomy.