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. Weir Mitchell, Bernard Sachs, Ramsay Hunt and Harvey Cushing. 1st edition copyright 1912, published 1913. Even for the author of A Guide to American Medical Students, the minute and meticulous detail that went into composing and editing the book had to have taken him years to put together The Introduction Tells It All
Book is aimed at medical students. Even in 1913, only a minority of MDs pursued further training. Postgraduate internships not required until 1920’s in most states. Specialty training available in major ciites. Onus on the medical faculty to produce competent physicians, capable of independent practice after passing state licensing exam. “The diagnosis of diseases of the nervous system is generally regarded by medical students as one of the most difficult subjects in their course of study…In the hope of making this task less difficult this book has been written.” Similar to a chemist performing qualitative analysis, Hun proposes to teach the student how to arrive at a diagnosis by a sequential process of elimination. An Illustrative Algorithm in the Introduction
Motor Paralysis Intermittent Continuous Reflexes - Reflexes + Atrophy + Atrophy – Precedes Paralysis Follows Paralysis Legs > arms Arms > Legs Duchenne Muscular Dystrophy A Book of Charts
After the 3 page introduction, the rest of the book consist of 22 charts. Divided into 3 sections:
• Part I: The Examination of Patients and a Physiological and Pathological Analysis of the Results Obtained from Such Examination: An Analysis of the Subjective and Objective Symptoms of Disease. Charts I-IX
• Part II: Differential Diagnosis: A Clinical Diagnostic Analysis of the Symptoms Obtained from the Examination of Patients. Charts X-XIX
• Part III: Localization of Lesions with the Nervous System by a Consideration of the Paralytic and Irritative Symptoms Resulting from Them. Charts XX-XXII Part I: Step-by-Step Instruction in How to Examine a Patient Taking A Neurologic History in 18 Easy Steps Chart III: Disturbances of Mental Activity An Analysis of the Objective Symptoms of the Case (Semeiology): Definition, Significance and Relationship of the Symptoms of Disease. Chart V: An Analysis of Reflex Activity Part II: Differential Diagnosis by (Complicated) Algorithm
Charts X-XIX are each devoted to the differential diagnosis of a specific ‘semeiology’ or clinical scenario Introduction showed a fairly simple example where we start with a person with ‘paralysis’ and end up 5 questions later with a specific dx of muscular dystrophy Many of the algorithms though are far more complex. A number of charts are in 11” X 24” quarto pages. A Common Semeiology: Stroke A Less Common Problem: Is the Patient Ataxic? Consult Chart IV Why is the Patient Ataxic? Consult Chart XIIa, #642 Part III: Localization of Lesions Within the Nervous System
Charts XX-XXId outline the motor, reflex and sensory changes that can be seen with destructive lesions on the central nervous system beginning with the conus and ascending level by level through the cord, brain stem, basal ganglia to the lobes of the cerebral hemispheres. Localization by Analysis of Symptoms: Chart XXII History of the Atlas
Went through 3 editions. The first edition of 2000 copies sold out in 18 months. Second edition, published in 1914, saw some changes. Twenty five pages of explanatory text are added between the introduction and the first chart. The charts themselves are ‘tweaked’ but not changed. Book sold ‘by subscription’ By 1920, 5000 copies sold, so a 3rd and final edition, not significantly changed from the second, is published in 1922. Dramatic Changes in Hun’s Career
In 1914, the year the second edition of his Atlas is published, as well as the year when he was President of the ANA, Hun abruptly resigns from the faculty after a 31 year tenure. Complicated ‘politics’ but basically he refused to take part in a major restructuring of the College demanded by the Trustees after the Flexner Report. Spent the last 10 years of his career as a private consultant at St. Peter’s Hospital Died of pneumonia in 1924, just shy of 70. His book died with him and rapidly fell into obscurity. Some Final Questions Educational Value of the Book?
Basic challenge is unchanged from 1913: How to teach the ‘art’ of a medical specialty, in this case neurology, as well as the science. In its own way, the highly impersonal and mechanical approach to diagnosis that the tables represent brings to mind many people’s worst fears about algorithmic medicine. To my mind the most effective parts of the book are the last few tables that are devoted to localization. I always felt the most satisfaction when a student or resident could evaluate a patient and then tell me where “the lesion” is localized. Once that barrier is passed, the rest flows naturally. Where Did He Get The Idea?
Hun tells us in the Introduction that his analytic tables are ‘unique’ and that “there was no model which could be followed in preparing it” No dearth of neurology textbooks in the US at the beginning of the 20th century. Looking at how the 11 texts Hun either required or recommended to his students over 30 years, plus an additional seven found through on-line searching, his claim is accurate. This is truly a unique book. Or is it? A contemporary has some thoughts on the matter. Smith Ely Jelliffe MD (1866-1945)
Lived and died in NYC, middle class parents. MD in 1889, then went an got an undergraduate degee followed by a PhD in botany in 1899. Joined faculty of Columbia in materia medica and pharmacognosy. Switched in midcareer to Freudian psychoanalytic psychiatry Editor of Journal of Nervous and Mental Diseases in 1914 & reviews Hun’s book Jelliffe’s Critique
Hun is applying the methodology of 17th and 18th century botany to the classification of disease. The diagnostic tables “use the familiar analytic methods of botanical and zoological manuals for the demonstration. Thus the principle of dichotomy is utilized throughout.” His basic criticism of the book though is philosophical. “The student of comparative nosology, as well as of systematic botany recognizes that the apparently clear formulae of one century have very little application for those of another, and that even within the course of a generation vast and important rearrangements of facts take place which entirely destroy the value of previous generalizations” Why Did the Book Fade into Obscurity?
Not really a practical tool for the busy clinician As Jelliffe noted, times change and the nosological approach to disease, popular in the 19th century, rapidly became obsolete in the 20th. Emphasis increasingly on mechanisms and treatment and far less on classification systems. Ironically, a text published in 1915, Diseases of the Nervous System, a Text- Book of Neurology and Psychiatry, emphasizing etiologies and mechanisms in addition to diagnostic criteria went through 6 editions and was in use up through 1940. The authors were William Alanson White and Smith Ely Jelliffe.