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An Attempt to Use Algorithm in an Early 20th Century Textbook of Neurology SPENCER WEIG MD UNC DEPT. OF NEUROLOGY Outline and Objectives Explore the influence of one unusual family on the history of neurology in the US in the 19th century Look in detail at a very unusual textbook written by perhaps the most unusual member of this unusual family Discuss what significance if any this might have for medical education in the 21st century. The Hun Family of Albany NY DRS. THOMAS, EDWARD AND HENRY The Hun Family of Albany Fort Orange, Dutch trading post, established 1624 Harmen Hun comes from Holland to Beverwyck by 1660 In 18th century family are agents for Patroon von Renssaelaer By late 18th century, Abraham Hun graduates from Columbia College and is a wealthy businessman, landowner, and lawyer His son Thomas born in 1808 attends Albany Academy, Union College and then obtains MD from University of Pennsylvania in 1830. Family has sufficient wealth for Thomas to spend 5 years in Paris, studying diseases of the nervous system, 1833-38 Hun Family Town Home and Farmland, 1805 Albany NY, 21st largest city in the US in 1880 Thomas Hun MD (1808-96) the Patriarch Returns from Europe and helps found Albany Medical College in 1839 Professor of the Institutes of Medicine Dean of the College 1876-96 Scholarly, philosophical medical writings: “Thoughts on the Relation of Physiology to Psychology”, “Medical Systems, Medical Science and Empiricism (both 1848), “A Case of Amnesia” (1851) is one of the earliest case reports arguing for cerebral localization Edward Reynolds Hun MD (1842-80) The Short-lived Elder Son Albany Academy, Harvard, MD from Columbia P&S, 1 yr in Paris Joins the College and in 1876 becomes Professor of Diseases of the Nervous System Pathologist for NYS Lunatic Asylum Very short career, dies age 38 Writings more clinically oriented than Thomas’s : “Trichina spriralis” (1869), Haematoma Auris (1870) “The Pulse of the Insane” (1870) “The Pulse of the Insane”, an early attempt at biological psychiatry? Henry Hun MD (1854-1924) Child of privilege, “to the manor born” Albany Academy, Sheffield Scientific School (Yale), Harvard Medical School (1879) While at SSS, begins a long chain of correspondence with Thomas. Letters in archives of the Albany Institute of Art and History. The 3-yr premedical program at SSS emphasized botany and zoology, which his father strongly supported Nineteenth Century Botanists at Harvard and Yale Daniel Cady Eaton, Professor of Asa Gray, Eaton’s professor at Botany at Yale Harvard, most prominent 19th century US botanist Asa Gray and the Science of Botany With Eaton’s help, Gray wrote popular text: Introduction to Structural and Systematic Botany. Seems quite likely Hun would have used this book while at SSS. Two key elements in Gray’s approach to botanical classification: • Before you can classify, you need to have detailed knowledge fo the plant’s anatomy and physiology • Actual classification involves algorithmic elimination of sequential options in a binary fashion, until at the end you have identified the unknown plant. • 40 years later, Hun would employ this 2-step approach to arrive at neurological diagnoses. European Study 1880-82 Like many well to do graduates of US The Narrenturm at Vienna General medical schools, Hun then went ‘abroad’ for 2 years. Hospital While Thomas and more recently Edward had studied in Paris, Henry joined the influx of US students in Austria and Germany Spent majority of his time in Vienna Studies not limited to neurology. Strong interest in obstetrics. One professor in particular caught his attention: Theodor Meynert. Over objections of Thomas, spent last 6 months in Paris and had some contact with Charcot Meynert and Charcot Theodor Meynert, wrote on cerebral localization and mental illness. Now considered a pioneer in biologic psychiatry. Jean-Martin Charcot leading a demonstration at the Salpêtrière. Proponent of descriptive neurology and case series, not a scientist. “A Guide to American Medical Students in Europe” 1883 “Medical Students” are all postgraduate MDs Introductory chapter on travel & perfecting aural/oral German. Book lists every university medical teaching program in UK and western Europe. For each program, lists all the individual lecturers, as well as the time and place of sessions. Even has details on lodgings and meals Book was popular, but soon outdated. Hun’s Career at Albany Medical College Joined faculty in 1883, and appointed Professor of Diseases of the Nervous System in 1885. Remained there until 1914. A comment from a biographical piece written after his death in 1924 by one of his students: “From the outset of his professional career he had all the advantages that can accrue to a member of an unusually prominent family—easy circumstances, high social connection and desirable professional contacts.” Like most academic faculty, his income came from 2 sources: his share of tuition fees and the fees generated by a substantial consultant practice. Had privileges at Albany Hospital as well as St. Peter’s, the Catholic Hospital in Albany Although he concentrated on neurology, also had a sizeable practice in pulmonology and obstetrics (where he delivered his own 4 children). Hun’s Bibliography In addition to two textbooks, he wrote on other topics, both in neurology and general medicine Three types of publications in neurology: • Case Reports: “Two Cases of Traumatic Hysteria” (1891) and “Hysterical Paraplegia in Children” (1892) • Review articles: “The Outlines of Insanity” (1891) and “Myasthenia Gravis” (1892) • Detailed clinicopathologic case descriptions: “A Clinical Study of Cerebral Localization” (1887), “Gliomatous Hypertrophy of the Pons” (1887), “Pathology of Acute Ascending (Landry’s) Paralysis” (1891), plus his only memorable work on a form of brainstem stroke. “Analgesia, Thermic Anesthesia, and Ataxia, Resulting from Foci of Softening in the Medulla Oblongata and Cerebellum, Due to Occlusion of the Left Inferior Posterior Cerebellar Artery, A Study of the Course of the Sensory and Coordinating Tracts in the Medulla Oblongata” (1897). Hun published the first clinical and pathological description of what is today called “lateral medullary syndrome” Hallmark is crossed sensory changes with loss of facial sensation ipsilateral to the lesion with loss of sensation in the contralateral arm and leg. Most frequent cause is an infarction in the territory of the posterior inferior cerebellar artery So Why is It Called Wallenberg Syndrome? In 1895, Wallenberg published 1st report of lateral medullary syndrome. He did not publish the pathology though until 1901, 4 years after Hun Life not being fair, the eponym went to the German, not the ‘Albanian’ Changes in Medical Education in the 30 years of Hun’s Tenure ENTRANCE REQUIREMENTS: In 1885, entering student needed the a HS diploma or to pass a qualifying exam (similar to today’s GED) given by NYS or by the College. By 1895, 10% entering class with college degree. In 1908, needed 60 hrs (2 yrs) of college credit GRADUATION REQUIRMENTS: In 1883, increased from a 2-year to a 3-yr program. First 4-year class admitted in 1899. COURSE OF STUDIES: Gradually over this time frame, the current division of learning basic sciences in the first 2 years and then doing clinical rotations in the 3rd and 4th years took shape. Changes in the Neuroscience and Neurology Curriculum 1885-1914 In 1883, when Hun joined the faculty, neuroanatomy covered in anatomy and neurophysiology in physiology courses. One hour clinical lecture per week. By 1893, a new faculty member teaches neuroanatomy/physiology in 2nd year, and Hun gives 2 lectures/wk, 1 didactic & 1 clinicalThere is also a weekly ‘recitation session’. This pattern does not change over the next 20 years. By 1905, with 4-yr curriculum in place, 4th year students now work up and present a patient during the weekly clinical lecture. Nothing that resembles a clerkship, which was becoming the gold standard. Neurology Textbooks, 1885-1914 From before Edward Hun’s brief tenure, catalog lists a required textbook for Diseases of the Nervous System each year. Hun continues that. His choices all recent editions of readily available texts, updated every 3-4 years. In 1902, Hun publishes his own ‘text’ as part of his weekly didactic lecture: A Syllabus of a Course of Lectures on the Diseases of the Nervous System, Designed as a Notebook for the Use of Students The text is essentially a 2-volume workbook, with each chapter devoted to a lecture topic. Hun provides some outlines, but student’s role is to write down the lecture notes quickly, memorize them and then be quizzed at the weekly recitation session. Teaching is unidirectional and student is passive. Hun’s Syllabus: Student as Scribe The Flexner Report of 1910: A Shockwave & Severe Reprimand Carnegie Foundation funded a study of all US and Canadian medical schools in 1910 Abraham Flexner, an educator from KY, visited every institution His opinion of the majority of schools, Albany Medical College included, was that they should close their doors. Using Johns Hopkins, founded in 1892 as a model, he was looking for 3 characteristics in evaluating medical faculty: • Are they full-time and salaried? No private consultative practices. • Do they have adequate time for research, preferably at the bench? • Have they adopted progressive educational theories as put forth by Dewey? The Clinical Clerkship is an indispensable component. An Atlas of the Differential Diagnosis of the Diseases of the Nervous System: Analytical and Semeiological Neurological Charts The Atlas In 1913, Hun was at the peak of his career: • Professor of Neurology for nearly 30 years • Well respected clinician (with no other neurologist practicing in the city) • Past President of the Association of American Physicians, an honor society established by Osler in 1885 • President-elect of the American Neurological Assn, an honor he shared with S.

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