What is a Neurologist?
Neurology is the specific branch of medicine “concerned especially with the structure, function, and diseases of the nervous system.” (Merriam-Webster.com). The nervous system is made up of the central nervous system – which includes the brain and spinal cord; and the peripheral nervous system – comprised of cranial, spinal and peripheral nerves, as well as motor and sensory endings (O’Rahilly, Müller, Carpenter, Swenson (2008)).
It is important to note the difference between a neurology and neuroscience. Though closely related, neurology is a medical discipline concerned with the treatment of neurological diseases and disorders, while neuroscience is a scientific pursuit concerned with the study of all things related to the nervous system. They evolved from the same line of inquiry, however neurologists are doctors who treat patients and neuroscientists are scientists who study systems.
History of Neurology and Neurologists
Thomas Willis (1621 – 1675)
Neurology can trace its history back to the late 17th century, to Thomas Willis and his Cerebri Anatome, published in 1664. Willis studied during a time of great upheaval in Europe, but found the loyalty he held during the Protectorate was rewarded during the Restoration. He aligned himself with both King Charles II and with the Church and secured a position at the University of Oxford. This relationship along with “relaxed statutory constraints” after the Civil War afforded him the opportunity to publish without restriction and lecture freely at University. (O’Connor (2003)).
Willis’s work was groundbreaking in that he and his colleagues (Richard Lower, Thomas Millington, and Christopher Wren) performed brain dissections by removing the brain from the skull and examining specimens with magnifying glasses, microscopes, dye injections, and experimentation. Drawings were created based on observation and theorization of what structures could be used for (O’Connor). This work led to the discovery of the “circle of Willis”, or “the circulatory anastomosis (connection between two blood vessels) that supplies blood to the brain and surrounding structures” (Circle of Willis).
Willis’s contributions, though important, weren’t without their flaws. Willis studied anatomy in general, and the brain and nervous system specifically, in pursuit of understanding the soul. His contributions formed the basis of neurology, but modern neurology wouldn’t develop until over one hundred years later.
Moritz Heinrich Romberg (1795 – 1873)
Moritz Heinrich Romberg finished his general studies in Germany in 1817 with an interest in pursuing a study of nervous system diseases. His first task in pursuing this life goal was to translate into German The Morbid Anatomy of the Brain, in Mania and Hydrophobia by London anatomist Andrew Marshal (who passed away two years prior to the publication of his own book). This task “introduced Romberg to contemporary English neuroanatomy and neuropathology” and to new teacher and guide, Sir Charles Bell (Viets: History of Neurology in the Last One Hundred Years).
In 1832 Romberg translated Bell’s The Nervous System of the Human Body to German, acknowledging it as Bells’ “great work” and stating “[Bell’s work] will ever serve as models of scientific inquiry.” (Viets) By 1834 Romberg was lecturing on neurology in Germany and in 1840 he became director of the wards at the University of Berlin Hospital, where he began observing patients.
During his time at the University, Romberg wrote Lehrbuch der Nervenkrankheiten des Menschen, his penultimate, three-volume text on neurological diseases. The text, organized into two sections, separated neurological functions into categories: senses and mobility. His book, in which he coined the term “neurosis” to differentiate from ailments caused by inflammation, also separated diseased according to afferent function (pathways to a given brain area that bring signals in) and efferent function (pathways to a given brain area that carry signals out). (Houseman, et al.: Moritz Heinrich Romberg)
While these discoveries were without a doubt important, it is Romberg’s’ work on tabes dorsalis for which he is most famous. Tabes dorsalis is a “slowly progressing degeneration of the spinal cord that occurs during the tertiary (third) trimester phase of syphilis a decade or more after originally contracting the infection” (Medical Definition of Tabes Dorsalis). 1853 saw the publication of the second edition of Lehrbuch der Nervenkrankheiten des Menschen, which included a discussion of “Romberg’s Sign”, which stated that a person is unable to stand without their vision. (Houseman, et al.). Romberg’s sign is still used today to aid in the diagnosis of many diseases and is used as part of the drunk driving field test.
Guillaume-Benjamin-Armand Duchenne de Boulogne (1806 – 1875)
Over in France at about the same time, Guillaume-Benjamin-Armand Duchenne de Boulogne was making some very interesting discoveries of his own. Duchenne’s work focused on electrostimulation and its effects on nerves and muscles and eventually led to the development of electroshock therapy (Duchenne de Boulogne).
Duchenne completed his medical studies in Paris and Douai and opened a medical practice in Boulogne to treat fishermen and their families. However, tragedy struck in his 20s when Duchenne’s wife died during the birth of their son. Consumed by depression and guilt, Duchenne surrendered custody of his son to his mother-in-law, and all but abandoned his medical practice (Biography of Guillaume Benjamin Armand Duchenne).
The only interest to keep Duchenne going was curiosity in electricity and its ability to make muscles contract. At the age of 36 he moved to Paris and reopened a medical practice. He would travel to local hospitals seeking patients with nerve and muscle disorders and would use “faradism”, or “the application or electricity to the skin for diagnostic or therapeutic purposes”, allowing him to “map and note the functions of the muscles in the body”. (Biography of Guillaume Benjamin Armand Duchenne). This was the earliest forms of electrotherapy.
Using “localized faradization” and an induction coil Duchenne was able to determine causes of paralysis. If a muscle did not contract when exposed to the “localized faradization” (electric stimulation) then the paralysis was due to damage to the muscle. If a muscle did contract when exposed to the faradization then the paralysis was caused by damage to the brain or the nerve.
1862 saw the publication of Duchenne’s The Mechanisms of Human Facial Expression in which not only was the process of localized faradization explained and documented, but for the first time, photographic examples were included to show the effects of the treatment. Using his technique Duchenne mapped over 100 facial expressions, and delineated the difference between fake, or “half-hearted” smiles and real smiles: real smiles include muscles around the eyes. (Biography of Guillaume Benjamin Armand Duchenne).
Though his is most famous for his work with “faradism”, and is often referred to as the father of electrotherapy, Duchenne’s contributions to neurology don’t end there. Duchenne studied extensively on the effects of electrostimulation on tabes dorsalis and poliomyelitis, and identified the diseases Progressive Bulbar Paralysis (known today as Progressive Bulbar Palsy) and Pseudohypertrophic Muscle Dystrophy (known today as Duchenne Muscular Dystrophy). (Biography of Guillaume Benjamin Armand Duchenne).
Jean-Martin Charcot (1825 – 1893)
No history of neurology, even a brief one, would be complete without mentioning Jean-Martin Charcot. Where Duchenne was the father of electrotherapy, Charcot is credited as being the father of modern neurology.
Charcot finished medical school in 1847 and interned at the Hospital de la Salpêtrière. He was promoted to Chief of Clinic in 1853 and again to “physician to the hospitals of Paris” in 1856. He received another promotion in 1872, after the Franco-Prussian War and the revolt of Paris, this time to “Professor of the Pathological Anatomy at the University of Paris”. (Kumar, Aslinia, Yale, Mazza (2011))
In the 1850’s and early 1860’s, using money from charitable donations, Charcot transformed the Hospital de la Salpêtrière to the Salpêtrière Hospital, a state of the art institution for the study of neurology. By 1862 there were upwards of 5,000 patients at the Salpêtrière Hospital, with over 3,000 suffering from neurological disorders. Each patient was examined by either Charcot or his colleague, and they were classified by neurological disorder. (Kumar, et al.) Charcot’s work at Salpêtrière brought him and the institution international recognition in 1881, and he was appointed to Chair in diseases of the nervous system by the French Parliament.
Through is studies at Salpêtrière, Charcot not only provided a complete clinical description of many neurological disease, but also the pathological changes that are associated with each disease. (Kumar, et al.). Of particular note are Charcot’s discoveries concerning Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS), Charcot’s Joint, and Charcot-Marie-Tooth Disease (CMT). His study in these diseases enabled him to identify them as separate from other diseases with similar symptoms, and in fact he was the first to diagnose Multiple Sclerosis in a living patient.
The works of these, among others, laid the foundations for what neurology is today. The 20th and 21st centuries have brought advances in the field to include technology, pharmacology, new techniques and new discoveries. Though the field has advanced dramatically since its foundation, there is still much left to learn.
A Selection of Notable Neurologists and Neurological Breakthroughs of the 20th Century
The 20th century brought a boon of advancement in the field of neurology. In 1906 Camillo Golgi and Santiago Ramòn y Cajal both won the Nobel Prize in Physiology or Medicine “In recognition of their work on the structure of the nervous system.” (Nobel Media AB 2014 The Nobel Prize in Physiology or Medicine 1906) Golgi believed that the nervous system was made up of one continuous network (Nobel Media AB 2014. Camillo Golgi- Facts), while Cajal maintained that the nervous system was comprised of individual structures (nerves) connected by nerve synapses that transferred impulses from one entity to another (Nobel Media AB 2014. Santiago Ramòn y Cajal- Facts). In the end, Cajal theory proved to be correct.
In 1910 Johannes Gregorius Dusser de Barenne studied and published his experiments with strychnine in the cerebral cortex, theorizing that any area “away from the area stimulated, which reacted, must have fibrous connections within it.” (Hillman, The Cellular Structure of the Mammalian Nervous System).
Harvey Cushing is known as the first neurosurgeon, starting his career in neurosurgery in 1899. He also developed the Cushing Brain Tumor Registry, which documented and archived over 2,000 different brain tumors that he operated on and studied throughout his 37-year career. (Cushing/Whitney Medical Library (2017))
Studying under Cushing at Harvard in the 1920’s was John Fulton, who in his career, while attempting to determine if the frontal lobe was involved in intelligence, discovered that the frontal lobe was, in fact, involved in emotional response (experiments that were performed on chimpanzees) (Moore, The American Lobotomy). These experiments led Egaz Moniz to perform the first lobotomy on a human patient in 1935. (Tartakovsky (2011)).
In 1932 Charles Sherrington was awarded the Nobel Prize in Physiology and Medicine for his work in the 1890s on reflexes. His discovery showed “how muscular contractions are followed by relaxation and how different reflexes are part of a complicated interplay in which the spinal cord and brain process nerve impulses and turn them into new impulses to muscles and organs.” (Nobel Media AB 2014. Sir Charles Sherrington- Facts)
Walter Dandy also studied under Harvey Cushing. Dandy’s career in vascular neurosurgery brought, among other contributions, the description of the circulation of cerebrospinal fluid in the brain, surgical treatment for the build-up of cerebrospinal fluid in the brain (hydrocephalus), and (in 1937) the first clipping of an intracranial aneurysm. (Awad)
The mid-1900’s saw contributions from Margaret Kennard, Walter Pitts and Warren McCulloch, James Papez, Paul MacLean, and Francis Schmitt.
Margaret Kennard worked under John Fulton in his primate laboratory at Yale from 1931 to 1943. Her work on motor cortex lesions led to the “Kennard Principle”, which basically postulates that the earlier in life at which a brain lesion occurs, the likelier it is the brain will have some form of recovery and compensation for the injury. (Dennis (2010))
Walter Pitts and Warren McCulloch, while at the University of Chicago, published “A Logical Calculus of the Ideas Immanent in Nervous Activity” in The Bulletin of Mathematical Biophysics (5:115-133). This paper discusses the brain as a network, and gave descriptions and rudimentary illustrations of a brain neuron and how it worked. This paper was key in the development of artificial neural networks. (Marsalli)
In 1937 James Papez identified the neural circuit that he believed “mediated emotion” through his study of the brain disease rabies, which was known to damage the hippocampus. Paul MacLean discovered the limbic system as a mechanism of emotion in 1957. (Koch)
Francis Schmitt is credited with creating the field of neuroscience when, in the late 1950’s and early 1960’s he worked with a multitude of scientists from different backgrounds, using a wide variety of techniques, to study and solve the problems of biology. This led to the creation of the Neurosciences Research Programs and established neuroscience and molecular neurology as legitimate fields of medicine. (Finger, Boller, Elsevier (2009))
The Society for Neuroscience was founded in 1969, with an original 20 founding members. Today it boasts over 38,000 members in 90 countries around world. (Society for Neuroscience)
1971 saw the discovery of “place-cells”, or cells in the hippocampus that fire based on spatial location. This discovery was made by John O’Keefe and Johnathan Dostrovsky (Hargraves (2007)). O’Keefe would win the Nobel Prize in Physiology or Medicine in 2014 for this discovery.
On July 17, 1990 President George H. W. Bush issued a proclamation declaring the decade from 1990 – 1999 the “Decade of the Brain” to “enhance public awareness of the benefits to be derived from brain research…” (Bush (1990)) The Project on the Decade of the Brain was a collaboration between the Library of Congress and the National Institute for Mental Health.
The Need for Neurology in the 21st Century
Today neurology is a burgeoning field of medicine. Despite the plethora of advancements and discoveries of the last two centuries there is still so much to be learned and so much work to be done. A 2007 report from the World Health Organization estimates that neurological disorders plague upwards of 1 billion people around the world (Neurological Disorders Affect Millions Globally). As the numbers grow, however, the American Academy of Neurology estimates the “supply of neurologist will fall 20 percent below demand by 2020.” (Compelling Statistics) The need for specialized and non-specialized neurologists is only going to become more urgent.
Fundraising and Awareness
The advent of the internet, and in particular social media, has become an effective medium for the spread of awareness of neurological disorders and fundraising campaigns for research, especially in the last several years. The 2014 ALS Ice Bucket Challenge raised over $50 million in a matter of weeks and directly led to the discovery of a new ALS gene (Landers). This challenge, the exact origin if which is still debated, was a grassroots challenge that began among friends and went viral on Facebook.
2015 brought the #50MillionFaces campaign started by Former First Lady of Massachusetts Ann Romney, partnering with celebrities Jack Osborn and Montel Williams, and gives a forum through Facebook and Twitter to the 50 million plus people in the world struggling with MS, ALS, Parkinson’s Disease and other neurological conditions while also encouraging people to donate to research efforts for treatments and cures. (#50MillionFaces)
The National MS Society organizes hundreds of fundraising events throughout the year all over the world through its chapters. Known for its walks and bike rides, this well-established organization has been fundraising and advocating for treatment options and cures, as well as providing a community for those directly and indirectly affected by MS since 1946. (National MS Society)
How to Become a Neurologist
To become a neurologist one must complete an undergraduate degree program from an accredited institution, then earn a medical degree from an accredited medical school and pass board examinations.
Upon graduating medical school, a one-year internship must be completed. The internship provides exposure to all areas of neurological career through rotations.
The internship is followed by a 3-year residency program. The residency is where the individual will gain more clinical experience and become exposed to a wide variety of neurological subspecialties. This is also where the individual will begin to focus their education either in general neurology or further into a subspecialty (see below).
A fellowship may be pursued after the residency is completed. One might consider a fellowship if they are pursuing a career in a subspecialty, though it is not necessarily required. Fellowships can last anywhere from 1 to 2 years.
Once residency and fellowship is completed, board certification is required in the field of study. (Become a Neurologist)
Branches of Specialization Within Neurology
There are many different areas in which a doctor may specialize in the field of neurology. For example:
Neurology also often finds itself combined with other specialties:
The need for research, diagnostics, treatment options, and cures for neurological diseases leaves no doubt about how essential neurology is in today’s medical arena. These are just a few of the dozens of neurological fields into which one may enter. Neurology offers boundless opportunities for great challenge and limitless reward.
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