Emergence of Neurology as a Specialty in the United States

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.

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

American Civil War

	American Civil War Soldiers 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 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 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 Surgeon General, United States Army

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:

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

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	Cruveilhier 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 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.

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