29 June 2009

Book Review: Robert Laureno, Raymond Adams: A Life of Mind and Muscle (2009)

Raymond Adams (1911-2008) was one of the most important American neurologists of the twentieth century. He possessed an almost complete knowledge of the neuropathology and neurophysiology of his day and used it to make original clinical contributions to many fields, including neurology, psychiatry, and psychology. His research touched on a variety of clinical research topics, most significantly diseases of muscle, nerves, and liver. The textbook Adams completed in 1977 with Maurice Victor, Principles of Neurology, remains a classic. Terminology he introduced such as asterixis, stratonigral degeneration, and pituitary apoplexy remain common medical parlance. He was one of the first neurologists to consider developmental disability from a neurological and biochemical perspective. He also sought to reclaim stroke as a neurological condition, insisted that clinicians view mental illness from that perspective as well, and drafted the first, legal definition of “brain death.” To his students, colleagues, and even his rivals, Adams elaborated through his work and teaching a complex monist worldview that claimed that neurology encompassed, “all diseases of the nervous system from the simplest disorder of muscle function to the most elaborate psychological derangement such as impaired memory, alertness and attention” (p. 151).

In this thorough and comprehensive oral history, Robert Laureno reveals much about this important and complicated figure. Born in 1911 in Portland Oregon, and the son of a farmer and oil distributor, Raymond Adams grew-up in modest middleclass circumstances. Following completion of his undergraduate degree in psychology from the University of Oregon in 1937, Adams matriculated at Duke University Medical School, where he was subsequently an Intern and Assistant Resident in Medicine. After receiving a Fellowship from the Rockefeller Foundation in 1938, Adams became a Resident in Neurology at the Massachusetts General Hospital, where he met Stanley Cobb who introduced Adams to psychoanalysis, a subject with which he quickly lost patience. In 1940, Adams continued his Rockefeller Fellowship in Psychiatry at Yale University, where he worked under Eugen Kahn and met such notable physiologists as John Fulton and Warren McCulloch. From 1941 until 1951, Adams was Neurologist at Boston City Hospital, Neuropathologist at the Mallory Institute of Pathology, and Assistant Professor of Neurology at Harvard Medical School. He eventually became Chief of the Neurological Service at Massachusetts General, and in 1954 the Bullard Professor of Neuropathology at Harvard Medical School, a position from which he retired in 1978 (picture on Left).

Given Adam’s illustrious career, I confess to a feeling of disappointment upon a cursory perusal of Robert Laureno’s book. Fortunately, I was greatly mistaken in my summary judgment. At first glance, this book appears little more than an unfinished work of oral history. Laureno has organized it mainly around transcripts of interviews he conducted with Adams in 2002 and 2003. He enhances those interviews with some short essays and interview summaries, and illustrates them further with numerous photographs, bibliographies, and primary sources from Adam’s career and private life. Reading through the transcripts of these almost fifty interviews with Adams, the richness and vitality of Adams’ perspective about his life and work become manifest. It would have been a tragedy not to publish these interviews in this form, for as a primary source to twentieth century neurology, neuroscience, and medicine they are invaluable. Robert Laureno has done a great service to neurology and historians of the neurosciences by persevering through the work entailed in producing this volume. I suspect that it will also be of use to medical historians interested in topics beyond the clinical and cognitive neurosciences.

Yet this volume is lacking in its discussion of historical context and is perhaps overly celebratory in its descriptions of Adams. This is a pity but nonetheless fair criticism. Still, the volume remains important, and historians of medicine and science should not dismiss it on those grounds. To understand why the historical context is so germane to Adams’ story, it is necessary to recognize that he did not single-handily transform neurology. Rather than a “phenomenon”, Adams should be understood to have been a distinguished representative of a new movement within the neurosciences and neurology in the twentieth-century. This becomes clear in Laureno’s interviews, but Laureno never pauses to explain to the reader fully why this matters. Instead, he mistakenly assumes that these are evident details to his readers. It seems, then, that a brief discussion of this point may help to further frame the value of Laureno’s volume.

The study of nervous diseases in the nineteenth century was a mainly clinical and descriptive pursuit. While nineteenth-century clinical medicine generally benefited from Rudolf Virchow’s cellular theory of pathology and Louis Pasteur and Robert Koch’s theories of disease transmission, the value of those discoveries for the study of the diseases of the nervous system was not immediately evident, except in a very few cases. To be sure, certain anatomical and physiological investigations throughout the century – e.g. those of Charles Bell, Robert Bentley Todd, Marshall Hall, Paul Broca, and David Ferrier – provided deeper insight into the multiple functions of the nervous system, but these rarely enhanced diagnosis or therapeutics.

Some of the most important scientific achievements came late in the nineteenth century. Santiago Ramóne y Cahal’s development of histological techniques that revealed that the nervous system was comprised of single cells were complemented further by Charles Sherrington’s contemporaneous formulation of synapse theory. Those studies, along with Paul Erlich’s later work on cellular membrane biochemistry, permitted novel approaches to the understanding of nervous diseases in the mid-twentieth century. One of the defining intellectual features of interwar and post-war neurology became the tendency for investigators – e.g. Walter Spielmeyer, Fritz Nissl, and Oskar and Cecil Vogt – to examine the histological architecture of the nervous system. This resulted in many atlases of the brain, and a more complete description of the anatomical organization of brain tissue.

Raymond Adams, more than most of his American contemporaries, combined pathological and physiological investigations with these developments in synapse theory, immunology, and histology-driven anatomy. He insisted, moreover, that his residents attend weekly conferences on neuropathology and microscopy (pp. 71-81). This new approach to neurological diseases reformulated many clinical problems in terms such as problems of synaptic transmission, disease at the level of the cellular membrane, and demyelination. All implied novel potential chemical interventions in the treatment of neurological diseases. In many respects, modern neurology originated through this conception of disease that emerged in the 1950s.

It would not be a stretch to argue that the study of nervous conditions prior this period was almost wholly different. There are, of course, exceptions to this claim, but the defining feature of clinical neurology prior to the 1950s was that it offered insight into the larger physiological functions of the nervous system. In other words, clinical neurology was valuable mainly because of its ability to reveal physiological function. The work of Adams and his contemporaries reversed this circumstance. By turning away from the holistic and clinical features of neurological lesions, and reformulating them in microscopic and biochemical terms, Adams and his contemporaries created the possibility for therapeutic intervention in nervous diseases in ways that had never existed. To use an old phrase from the history of science, their integration of multiple fields of knowledge at this most reductive level led to a paradigm shift in clinical practice – a shift that had profound implications in the organization and treatment of neurological and psychiatric patients.

Adams was not the only individual involved in this transformation, which really had been ongoing since the 1920s. But he was certainly important, and because of this, his own perspective on these events make worthwhile reading. I have no doubt that Raymond Adams will appear in many future works on American medicine and science, as well as neurology, psychiatry, and neurosurgery. Robert Laureno’s collection of interviews in this volume, as well as his short essays, will prove invaluable for many of those projects. I think it not an exaggeration to claim it as one of the most useful published sources on post-Second World War neurology.

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