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http://www.nejm.org/doi/full/10.1056/NEJMra1104781?query=TOC

Fifty years ago, when the curator of the Boston Medical Library, Henry Viets, collated a score of the most important articles that had been published in the first century and a half of the New England Journal of Medicine, 10 of the 20 related to neurologic conditions. Viets HR. A score of significant papers published in the Journal during the last hundred and fifty years. N Engl J Med 1962;266:23-28

On the occasion of its 200th anniversary, one might ask why so many articles on neurologic and psychiatric diseases have been published in the Journal and what impact these pieces have had on their respective fields. Although the Journal is replete with reports of neurologic conditions that have entered the canon of medicine, it has been the large number and the breadth of clinical trials that have redefined neurology and psychiatry as active, therapeutic specialties. This article reviews the evolution of our understanding of neurologic and psychiatric conditions during the past two centuries.

Modern scientific neurology, based on neuropathology and neurophysiology, began after World War II. By 1952, patients with tabes dorsalis and general paresis had practically disappeared from hospital wards. Antimicrobial agents had changed the course of bacterial and tuberculous meningitis, but poliomyelitis was still a nemesis. Denny-Brown‘s Shattuck Lecture on the state of neurology that year in the Journal pronounced that, freed from its preoccupation with syphilology and now separating itself from internal medicine and psychiatry, neurology had “entered on an extremely productive and virile phase.” Denny-Brown DE. The changing pattern of neurologic medicine. N Engl J Med1952;246:839-846

Denny-Brown emphasized recent contributions on the neurologic aspects of liver failure, the recognition that transient ischemic attacks were due to occlusion of the carotid artery, and the emerging understanding of increased intracranial pressure. There was little question at the time that neurologic and psychiatric diseases both acted on the same brain, but Denny-Brown’s position in his Shattuck Lecture marked the emergence of American neurology, pointedly disengaging it from the popular practice of neuropsychiatry and aligning it with internal medicine. He provided a modern manifesto for neurology, which nonetheless remained largely an elegant diagnostic specialty.

TWO INFLUENTIAL ARTICLES

A seemingly mundane clinical neurology article in the pages of the Journal had a highly felicitous effect on the relief of human suffering by addressing the problem of sciatica. That 1934 report by Mixter and Barr

Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 1934;211:210-215 established intervertebral disk rupture with nerve-root compression as the mechanism and also provided a remarkably sophisticated analysis of cervical-disk herniation and cord compression. It presented detailed instructions for the cure — in both instances, laminectomy. Twelve terse pages provided meticulous clinical descriptions and drawings of the corrective operation (Figure 1FIGURE 1Mixter and Barr’s Descriptions and Operation for Disk Rupture.). The enduring impact of that article, as well as the continuity of attention to this topic in the Journal, was affirmed by a 2007 report on a clinical trial that showed the superiority of surgery over conservative management. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:2245-2256

The excess of ill-advised laminectomies for back pain that followed Mixter and Barr’s article was not their doing; in a less frequently cited but more detailed contribution published in the Journal 6 years after their first report, they state, “We wish to emphasize at this point that a large proportion of the cases of sciatica resolve spontaneously or under conservative orthopedic treatment.” Mixter WJ, Barr JS. Protrusion of the lower lumbar intervertebral disks. N Engl J Med1940;223:523-529

Second article, An influential article in psychiatry from the New England Journal of Medicine with vast secular influence was “Neurasthenia, or Nervous Exhaustion” by George Beard, published in 1869. Beard G. Neurasthenia, or nervous exhaustion. Boston Med Surg J 1869;80:217-221

He spoke of “a condition of the system that is, perhaps, more frequently than any other in our time at least, the cause and effect of disease. . . . Both anemia and neurasthenia are most frequently met with in civilized intellectual communities. They are part of the compensation for our progress and refinement.” Beard G. Neurasthenia, or nervous exhaustion. Boston Med Surg J 1869;80:217-221

The use of the label “neurasthenia,” and probably its reported incidence, expanded greatly after Beard’s article appeared. It was called the “American disease” by the illustrious French neurologist, J.-M. Charcot, who took it up for study as a strictly neurologic condition. By medicalizing the misfortunes of life, for which care is still so frequently sought, physicians became comfortable invoking a patient’s constitutional makeup, as if it were a physical entity, as the substrate for exhaustion, melancholia, depression, discouragement, weakness, and headache.