Atlantic conjunctures in Anglo-American neurology: Lewis H. Weed and Johns Hopkins neurology, 1917-1942.

The emergence of neurology at Johns Hopkins presents a case study for reconsidering the international and institutional contexts of neurology generally. Using a variety of sources, Hopkins's interwar plans for neurology are presented and contextualized in the international environment of neurology, medical research, and philanthropy. During this period, neurology across the world, especially in Britain, was undergoing vast institutional changes. In order for Hopkins to remain at the forefront of excellence in both medicine and medical education, a program in neurology was deemed essential, and this would seem now to have been an unproblematic advance. Spearheading the project for the establishment of neurology at Hopkins was the dean of the medical school, Lewis H. Weed. Weed attempted from 1919 until 1942 to establish a department of neurology but had only limited success. The fact that finding support proved challenging for Weed and Johns Hopkins casts a provocative light on the broader historiography of neurology and illustrates the important role of the international context in defining neurology professionally.

Though historians have traditionally identified the emergence of neurology only with the production of neurological knowledge in the nineteenth century and the discoveries of individual physicians and scientists, some scholars are now arguing that clinical neurology emerged as a distinct specialist field of practice in the interwar period. The reasons for this revisionist view are varied. Despite the fact that a few fin-de-siécle physicians in Europe and North America thought of themselves as nerve specialists, it has not always been clear whether many of the earlier figures in the history of neurology practiced as exclusive specialists or thought of their work as distinctly neurological. As is well known, the boundaries between psychiatric and neurological diseases and their treatments were more amorphous throughout the late nineteenth and early twentieth centuries than current historical literature recognizes, and many of the physicians concerned sought to construct practice and research on the nervous system in an integrative fashion, embracing developments in such diverse fields as physiology, pathology, or psychiatry. Social scientists have claimed that such integrative ideals functioned as encroachments into the dynamic professional terrains of psychology, psychiatry, and even the ecclesiastic professions, a point that William Bynum amplified in his earlier work on neurology in nineteenth- and early twentieth-century Britain.

The predominant view outside of the history of neurology nevertheless remains much as Ellen Dwyer lamented at the close of the twentieth century: "little has been produced on the years since 1918. Although neurology, neuropsychiatry, and neuroscience usually are mentioned in the fast growing historical literature on psychiatry in the twentieth century, they most often appear in relation to psychiatry. Few histories start with neurology and then move out to explore its connections with other medical specialties . . ." Part of the challenge to telling this fuller story has been the general lack of historical literature focusing on neurology's institutional contexts, especially in the period following the First World War. Similarly, the paucity of studies analyzing neurology's international contexts comparatively has made it difficult to appreciate how the field's professional identity emerged cross-culturally. Thus although intellectual historians have recorded the diffusion of "neuroscientific concepts" through the multilingual medical research literature, few institutional, social, or cultural historians have followed suit by exploring variations in national practices and conditions, or cross-cultural connections. This is surprising, especially for Anglophonic nations like Australia, Canada, Great Britain, New Zealand, and the United States, where there are no language barriers preventing such an analysis, and where it is well understood that many of the field's most significant practitioners crossed national boundaries with startling frequency. For example, a recent study of Derek Denny-Brown (1901–81, born in New Zealand, trained in London, and appointed director of the neurological unit at Boston City Hospital in 1941) ignores the specific ways in which international experiences and training, not to mention institutional contexts, mediated his clinical outlook, practice, and research.

In this paper, I address these criticisms specifically, choosing for my case the efforts to create a department of neurology at Johns Hopkins Medical School, mainly between 1917 and 1942. It was during this period that Lewis H. Weed (1886–1952), head of the anatomy department and later director of the medical school, established a committee charged with building an internationally renowned department. These efforts foundered, raising several salient points about the professional status of neurology in North America and elsewhere, as well as highlighting the role that international discourses played in defining specifically local understanding of neurology's scope. The institutional papers and personal correspondence used in this study support the view that the connectivity and conjunctures between diverse international contexts were the integral justification for the Hopkins committee's efforts. Yet, it is clear that local practices and perspectives at Hopkins were predicated upon a supranational ideal of neurology, which was still in the process of forming in the interwar period. What knit together this otherwise locally negotiated ideal were common social and cultural practices and assumptions. Although varying in their local manifestations, these practices and assumptions eventually defined neurology's pedagogy, practicality, and purpose in the years following the Second World War.

Medical Specialization at Johns Hopkins

Almost since its foundation, Johns Hopkins Hospital and its Medical School—established in 1889 and 1893, respectively—have occupied a privileged place in the story of modern American medicine. That the ascendance of Johns Hopkins transformed American medical schools and medicine in the twentieth century is a now commonplace view. In brief, its domination can be attributed to its role in attracting exciting, scientifically oriented medical teachers, who pioneered a curriculum modeled upon mainly German lines, combining practical clinical experience with extensive training in laboratory practices. Such famous educators as William Osler (1849–1919), William Stewart Halsted (1852–1922), and William Henry Welch (1850–1934) were celebrated later for teaching their students the arduous art of medicine and the empirical finesse of the scientific method. They emphasized, moreover, how these skills could fit together into an interlocking paradigm of medical practice. The outcomes were a revolution in diagnosis and hospital administration, as well as the discovery of multiple treatments and palliative approaches.

Because of the success of the Johns Hopkins approach, the laboratory assumed a prominent place in medical practice in America, especially in aiding diagnosis and surgical intervention. Scientific disciplines like physiology and bacteriology, which had hitherto assumed a less significant role in medical school curricula, garnered increasing attention from medical students and physicians alike. The emergence of these sciences, their subsequent professionalization, and their advocacy for experimental approaches, catalyzed the formation of many medical specialties, especially at Johns Hopkins. A similar situation occurred in general surgery. Harvey Cushing (1869–1939), for example, following earlier work by William Macewen (1848–1924), Rickman Godlee (1849–1925), and Victor Horsley (1857–1916) in Britain, fashioned the discipline of neurosurgery by improving many of his techniques and knowledge through experiments that he initially conducted on animals or cadavers in Johns Hopkins laboratories and mortuaries.

Like many of his older contemporaries in medicine and surgery, the younger Cushing nevertheless perceived dangers in overspecialization. His colleague, Adolf Meyer (1866–1950), the psychiatrist and director of the Henry Phipps Psychiatric Clinic at Johns Hopkins, typified the anxieties specialization created when he wrote in 1913 to William Osler, who was by then regius professor of medicine at Oxford, "there must be a liberal willingness to let fields overlap and to have them in common, with frequent consultations and collaboration. Neurasthenia and hysteria and aphasia and apraxia are essential chapters in internal medicine, in neurology and in psychopathology alike." Osler, no less generalist in his appreciations, was likely sympathetic to Meyer's comment. He had cautioned his students to practice pluralism in their studies and to avoid coveting the "speedy success which often comes from the cultivation of a specialty."

Increasing specialization brought other problems as well. Maintaining any program of medical research in America was an expensive proposition, and economic support was scarce. Even an institution like Hopkins, idolized in Abraham Flexner's famous 1910 report on medical education, sometimes struggled. Complaining, for example, of the lack of funds for his research, Adolf Meyer, appointed professor in 1908 and director of the Phipps Psychiatric Clinic in 1913, wrote to Simon Flexner, "I have not had a cent of support for the Psychological Laboratory and only for the last two years about $600 for the Neurological Laboratory. And we are supposed to compete with . . . Imperial German Psychiatry . . . ?"

Fostering emerging medical specialties became one of the many administrative challenges confronting Johns Hopkins. In some cases one worker represented de facto an entire department. Henry M. Thomas (1861– 1925), for example, was the sole practicing specialist in nervous diseases on the Hopkins faculty from 1889 until 1925. Thomas, as well as Adolf Meyer, conducted neurological research, while Harvey Cushing and his later successor and former clinical assistant Walter Dandy (1886–1946), a pioneer of ventriculography, engaged in experimental neurological operations. With such a pedigree, it might seem now that the establishment of a department of neurology would have been an unproblematic development. That it was not is intriguing and informative about the professional status of neurology, nationally and internationally.

Working Toward a Department of Neurology at Johns Hopkins

Though Hopkins had hired Henry Thomas as a neurological specialist in 1889, the medical school and university struggled for decades to establish a formal department. The result of multiple endeavors was that from the late 1920s until 1969, when a department of neurology was finally established, only a small subdepartment existed in the hospital and university. Neurological patients were cared for in the general medical service and the chronic wards of the hospital. The teaching of neurology was broken up across many departments, and after Thomas died in 1925, it was reported that there was no one specializing in the subject. Why was a specialist institutional identity for neurology problematic when other specialties, for example, psychiatry (1909), pediatrics (1912), and ophthalmology (1925), were readily accommodated?

During this period numerous European postgraduates with interests in neurology and psychiatry toured through Hopkins, working for short durations in Meyer's psychiatric clinic and then returning home. Figures from Britain, such as neurologists Gordon Holmes (1876–1966) and Charles Symonds (1890–1979), pathologist Dorothy Russell (1895–1983), and psychiatrists like David Kennedy Henderson (1884 –1965) and Richard Gillespie (1897–1945), trained for as little as a few weeks to as long as one year in the Phipps Laboratories. All returned to Britain, improving Britain's impressive international neurological and psychiatric reputation. Even as Hopkins was attracting prominent figures in neurology and psychiatry, it was not retaining them.

The man spearheading the effort to institutionalize neurology at Johns Hopkins was Lewis H. Weed, a former student of Harvey Cushing. Appointed head of the Department of Anatomy at Hopkins Medical School in 1919, he had become dean of the medical school in 1923 and then director in 1929—a post from which he retired in 1946. His early research interests were in neuroanatomy and neurophysiology, especially in the biochemical composition of cerebrospinal fluid and its production and circulation through the cerebral ventricles. Like many of his contemporaries, he felt that laboratory analysis of cerebrospinal fluid would improve the diagnosis of neurological diseases such as multiple sclerosis, an insidious neurodegenerative disease. Although Weed is something of a neglected figure today, he had been a trustee of the Institute for Advanced Study and the Carnegie Institution in Washington, D.C., worked tirelessly as chairman of the National Research Council's Medical Sciences Division from 1939 until 1943, and, during that tenure, established an interagency collaboration with the British Medical Research Council. It was this international collaboration that supported research work on penicillin during the Second World War.

Weed's efforts to build a department of neurology at Hopkins were no less driven. He was a friend of Alan Gregg (1890–1957), the Rockefeller Foundation's medical officer, and by 1931 the holder of the Rockefeller purse for medical research. This friendship with Gregg, however, resulted in little more than cool support for Weed's ambitious plans; it was only in the late 1930s that the Rockefeller Foundation supported Hopkins neurology, and even then its generosity was subdued in comparison with contemporary allotments for neurology in Britain and Canada.

The reasons for this limited assistance are difficult to comprehend. Partly, the dramatic impact of the economic crisis of 1929 stifled promises by other interested philanthropies, such as the Commonwealth Fund, but there were other reasons as well. The plans for neurology at Hopkins were ambitious and unprecedented in the United States. At the time, the Neurological Institute of New York, which had been founded in 1909, had just affiliated in 1925 with Columbia University and the Columbia-Presbyterian Medical Center. Likewise, Stanley Cobb (1887–1968) had been given $350,000 from the General Education Board to create a university linked department of neurology at Harvard. Weed, however, judged Cobb's program to be too limited: "Abraham Flexner told me that he was delighted to have a man like Cobb, who was content with ten beds; I do not believe Cobb could develop a real School of Neurology under these conditions. There is no worry of any possible competition about a real department of neurology such as we hope for here. Cobb is a good man, but he is not going to have a great school of neurology."

Weed must have begun deliberating on the subject of neurology sometime in 1918, when Harvey Cushing wrote to him detailing his vision for a national institute for the investigation of disorders of the nervous system, which Cushing had proposed to Abraham Flexner as early as 1917. Cushing hoped to recruit Weed and others, including physiologist Charles Sherrington (1857–1952), to this new institute, where a national school of neurology would be built to rival "the National Hospital for Nervous Diseases in London, or the Salpêtriére in Paris." But Cushing's project was never realized. At the time, Flexner did not believe that there were "sufficient profitable problems" in neurology for research, and John Fulton later blamed the project's lapse on a mixture of Cushing's stormy personality and the fact that neurology was simply "not a branch of medicine which the philanthropic foundations were at the time disposed to support."

If Cushing's vision for the new institute was the fillip launching Weed's future endeavors at Hopkins, yet another stimulus was at hand by 1920, when he received a draft paper on the organization of an ideal neurological institute from Ernest Spiegel (1895–1985), an Austrian physician who eventually became professor of experimental neurology at Temple University in 1931. In his outline, Spiegel summarized the challenges to promoting neurology, captured the peculiar theoretical nature of neurological investigations and constructs, and offered important justifications for supporting such research. Fundamentally, he argued, there was no more important step in "scientific medicine" than the invention of an exact diagnosis, and this was especially true in clinical neurology. Studies of normal and pathological anatomy, and histology, were important, but more important still were experimental studies localizing functions to specific areas of the nervous system, for these offered the possibility of direct surgical interventions. Spiegel claimed that experimental neurology, if supported adequately, would eventually lay the foundations for many an "experimental therapy of nervous diseases." He concluded with an inventory of requisite facilities and equipment required for such experimental studies and remarked: "The problems which are to be studied in a neurological institute have to take their origin in clinical observation and so its work must be two-fold: at bedside and in laboratory." In other words, for clinical neurology to develop adequately, an environment like that offered at Hopkins was the minimum requirement.

Modified aspects of Spiegel's proposal found their way into a 1921 committee report on the teaching of neurology at Hopkins. Although some neurology was being taught as part of the medical school curriculum, the committee found that there was "no correlation between the various departments in regard to this required work," and sometimes "the neurological aspects of the general subject" were entirely ignored. In contrast with the ideal situation Spiegel had outlined, the relationships among pathology, anatomy, histology, and clinical medicine of Hopkins were not suited to coordinating experimental studies in neurology or even for teaching medical students; medical students with interests in neurology were not training in an environment combining bedside medicine with equivalent laboratory experiences, and such coordination would require the appointment of both a neurological intern and an assistant neurologist. This assistant neurologist was to hold a position in the medical school as an associate professor of neurology. In addition, this new position would create stronger integration between neurology and psychiatry in the hospital and medical school by centralizing a patient population in wards that could be used by both divisions. Moreover, it would strengthen the research capacity of the Henry Phipps Psychiatric Clinic's neurology laboratory.

Attracting the right person for this position was by no means a simple task. Many European physicians had passed through the Phipps Psychiatric Clinic, and some were natural candidates for recruitment. Adolf Meyer began to sound out former pupils. He hinted at the possibility in a letter to Charles Symonds (1890–1979), who was then physician of nervous diseases at Guy's Hospital and a former Radcliffe traveling scholar at the Phipps. But Lewis Weed orchestrated an alternative scheme. In late June 1924, Francis Rouse Martin Walshe (1885–1973), the newly appointed University College Hospital professor of neurology, received the enticing invitation to be visiting professor in neurology in 1925:58 "For some time we have been anxious to invite a neurologist to spend a month or two in Baltimore to give a series of clinics and lectures and advise us concerning the problems in the future development of the neurological clinic of the Johns Hopkins Medical School and Hospital." Walshe accepted the position gladly, expressing only joking trepidation at the thought of Baltimore's cold weather. Later he warned Weed modestly, "I am looking forward eagerly to my stay with you, but shall suffer from 'stage fright' if I think that you expect too much knowledge to distil from my tired brain."

No record indicating exactly why the committee selected Walshe has been found. He was clearly a young, prominent representative of the British clinical tradition in neurology, which by the close of the First World War was world renowned. London was the chief center of neurological activity in Britain, although Edinburgh and Manchester had prominent workers as well. Especially important was a small specialist hospital located in Bloomsbury, London, which in 1926 was called The National Hospital for the Relief and Cure of Diseases of the Nervous System including Paralysis and Epilepsy.

Despite the National Hospital's international reputation in neurology, Lewis Weed and others on the neurology committee may not have fully appreciated the professional status of neurology in British medicine and the mentality this status engendered. One noteworthy cultural difference, for example, was how British physicians—including many at the National Hospital—viewed medical specialization. Whereas interwar physicians in the United States rarely denigrated medical specialization, British clinical tradition still advocated a general medical outlook in the 1920s. Archibald Garrod, consulting physician to St. Bartholomew's Hospital, for one, captured this mindset when he acknowledged in 1919:

No more beautiful examples of scientific methods and reasoning can be quoted than those employed by the neurologist in localization of lesions of the brain and spinal cord, and in gaining insight into their nature. It is true that his conclusions are based upon anatomical and physiological observation, which enable him to carry in his mind a stereoscopic picture of the brain as transparent as the stereoscopic images of the radiographer, but the men who made those observations were, until recently, engaged in the practice of medicine or surgery, and some of them might even have been classed as "popular physicians."

Though this ethos of "generalism" was diminishing in the interwar period, the mentality remained forcefully alive, especially in hospital administrative consciousness. As late as 1932, Garrod's colleague and professor of medicine Francis Fraser (1885–1964) described a hopeless situation to Alan Gregg at the Rockefeller Foundation: "The plans for a neurological department failed to mature last year and will fail again this year . . . the formation of new special departments does not meet with approval. It is feared that such special departments must in the end mean more specialised instruction for undergraduates with further cramping of the curriculum." Thus, many British physicians with special interest and training in neurology, some of whom were viewed abroad as leading figures in this new area, held general appointments in hospitals and even self-identified as general physicians. If they consulted as specialists, they did so only in outpatient clinics and private practice.

Francis Walshe was at Hopkins for six weeks, and during his stay he lectured to students, facilitated practical study in the dispensary, and assisted physicians in the treatment of difficult nervous and mental patients. After Walshe returned to London, Lewis Weed invited him to return to Hopkins as professor of neurology and neurologist-in-chief at the hospital: "As you know, the present facilities for the teaching of Neurology and for the care of patients suffering from neurological disease are hopelessly inadequate. The Advisory Board feels that it is imperative that the general subject of Neurology be developed as rapidly as possible and that Neurology be given its proper place among the medical sciences." Walshe, however, was not tempted. Citing what seem to be genuine concerns for elderly parents, family considerations, and patriotism that he had conveyed in his formal letter declining the position, he nonetheless admitted privately to Weed that the refusal "has not been an easy one by any means, and I hate to make it. However, I know that being what I am, and having thought about it for the past month with much heart searching, it is the right one. I feel that I am doing the second best thing in staying here, but if I came to Baltimore it would have to be without any regrets or looking back over my shoulder if I am to do my duty by Johns Hopkins."

Walshe was divided over whether he had made the right decision. But it may have been an easier decision to make given the obvious challenges he would have confronted in building the department. Although Weed had promised the highest level of administrative cooperation, he could only cite "informal assurance that one of the large foundations will contribute generously." These informal assurances, even if they materialized, would leave an overwhelming gap to be filled financially, and the future of a neurological department was by no means secured. Comfortable in prestigious positions at both University College Hospital and the National Hospital, Queen Square, Walshe would have been sacrificing a lucrative private practice and university rank for a promising but nonetheless risky role as head of a department yet to be built. For Walshe, the challenge was not very tempting. Yet, as he reminded Weed, "there are as good fish in the sea as ever came out, and I hope you may find whom you want," and certainly the faculty at Hopkins had every reason to feel enthusiastic, even if they were disappointed by Walshe's refusal. Weed, who had confessed to Walshe that his "own interest in certain aspects of Neurology made me personally feel the overwhelming importance of a good Neurological Institute here," continued to plan his bold project.

In an open proposal written to potential philanthropists (although mainly for the Commonwealth Fund and the Rockefeller Foundation), Weed resorted to a familiar tactic. Describing neurology as the field of medicine that studies the brain, spine, and peripheral nerves, he claimed it was "no narrow specialty but a wide-spread medical science finding its sphere of activity in many of the common afflictions affecting mankind." Neurology offered fascinating research questions requiring patience, diligence, and resources; "in this way alone can advances be made." Then, noting the profound possibilities in neurology, Weed argued that Europeans had long recognized neurology's importance:

Great clinics devoted to the study of patients suffering from disease of the nervous system, with well-equipped laboratories for research in this subject, were established over a generation ago; in these clinics, schools of Neurology were developed and in them physicians and students trained. These clinics or institutes were all coordinated with the activities of universities, for without contact with physicists, chemists, biologists and others working in the fundamental sciences, advances in learning in this field could hardly be achieved.

Especially impressive, according to Weed, were the English and French schools, which could claim to have trained most Americans then practicing neurology. The situation was much worse in America, where

the subject of Neurology has never had its proper place. . . . A very few special hospitals devoted to disease of the nervous system (and usually also to Psychiatry) have been founded in different parts of the country but none of these special hospitals is properly coordinated with the activities of a good medical school. . . . As a result the teaching of Neurology in American medical schools has usually been of an inferior type.

Though it is unlikely that he realized it, Weed's positive characterization of especially French and British neurology misrepresented the specialty's professional status—it was not so monolithic. The contention was, moreover, a bold move in a proposal suggesting that an enormous endowment of $2,750,000 was required to build such a program in Baltimore. At a time when philanthropic foundations were investing in research and universities throughout the world, overstating the prowess of European centers risked heightening the competition's profile.

But mentioning the successful development of neurology in Europe also had advantages. The faculty at Hopkins needed to convince skeptical supporters that they merited support, would be able to deliver key ingredients for their program, and furthermore, that neurological practice offered something not provided by general medicine. The existence of purportedly prominent programs in Europe legitimated local calls for a program in neurological research and practice. By 1928, the committee at Hopkins had succeeded in securing funds. The Commonwealth Fund indicated its support for the project, with the caveat that the committee first find a prominent neurologist to head the new department.

As before, this proved surprisingly difficult. Although Hopkins brought in other European figures as visiting professors in neurology between 1929 and 1930, not one proved interested in committing to the position. Early in 1930, the internationally renowned British neurologist Gordon Morgan Holmes (1876–1966) was invited to Baltimore for the autumn term. The news of Holmes's visit passed through the Rockefeller Foundation, where it was heard, for example, that "Holmes may be possible head for projected institute of neurology at JHU." Optimistically, the Committee on Neurology recommended "that a definite proposal for the establishment of the Neurological Clinic . . . be prepared for submission to one of the great foundations." Holmes was offered the position toward the end of his stay in Baltimore but unexpectedly turned it down. Why exactly is unknown, but it seems likely that his material circumstances in London played a role. Holmes had a private practice and prominent hospital positions that rivaled those of his former pupil, Francis Walshe.

Holmes's refusal was a distressing blow and caused a period of reflection at Johns Hopkins on the outlook for the entire endeavor. A younger physician, Georges Schaltenbrand (1897–1979), was invited to come from Germany to Baltimore to discuss the project in June of 1931. With Schaltenbrand's guidance, the Committee on Neurology subsequently drafted a new, definitive statement highlighting eight problems requiring immediate research in neurology. These included the etiology of multiple sclerosis; the relationship between multiple sclerosis and myelopathic disorders; the identification and study of possible viruses causing neuritis, epidemic encephalitis, and poliomyelitis; and the question of whether there were "racial differences in the susceptibility to certain diseases of the nervous system." This new statement reversed the former contention about the status of neurology in Europe, suggesting instead that neurology throughout the world needed to emulate the ophthalmological and dermatological clinics already in existence. Taking a new line on neurology's international status (one echoed a few months later at the 1931 First International Neurological Congress in Berne), the committee argued that "so far most of the progress in neurology has been due to the efforts of practitioners, internists, and psychiatrists who got interested in the field. The development of some well organized neurological institutes in all the civilized nations of the world, would promise a great advance beyond the present condition." In contrast with their previous proposals, this newest formula proposed an evolutionary approach, advocating the "gradual development of the neurological clinic." It maintained "the order of development ought to be, e.g., Out-patient department, Clinical Service, Serological and diagnostic units, Pathology and histopathology, Animal divisions, Special clinics, X-ray and Neurosurgery."

Schaltenbrand had demonstrated great competence and confidence, and like they had of Walshe and Holmes before him, the faculty deemed that he "made a thoroughly happy impression, and his ability to work with other people seemed extraordinarily good—a characteristic which is eminently needed in a subject like clinical neurology." Weed thus offered him the position of head, and it seemed certain that Schalten-brand would accept. Writing to his friend Alan Gregg, Weed hinted "from our standpoint this action of course means, that if Schaltenbrand accepts, we are prepared to go ahead with the project whenever you are ready to present an official appeal . . . we shall be prepared to go ahead whenever you are ready. If you care to proceed immediately, I can prepare all the necessary official requests."

Weed would be disappointed, but not, as it turned out, by the Rockefeller Foundation. Instead, the Commonwealth Fund, which had promised funds in 1928, now jettisoned support. Writing in his diary, Alan Gregg noted Weed's disappointment. In a later conversation with an officer from the Commonwealth Fund, Gregg learned that the lack of inclination stemmed both from the ongoing depression, and the fact that preparations had taken so long at Hopkins since they had sent the original proposal. Since the 1928 promise, the Commonwealth Fund's overall funding focus had changed.

The administration at Johns Hopkins had been too slow. Such a situation was made further frustrating by the fact that Schaltenbrand had accepted the position. With a proposal in excess of $6,000,000 and the withdrawal of the main philanthropic player, the situation appeared hopeless: "They have no hopes for funds at this time." By April 1932, Lewis Weed had abandoned the project, "reason being insuperable difficulty of securing adequate funds for this development." Schaltenbrand, seeing that a position at Hopkins had evaporated, apparently left for London.

Ironically, Alan Gregg told Weed that he was relieved at the decision because "it seems a very difficult time to undertake so large a project." Hopkins's project for neurology—at the scale Weed had envisioned—was a lost cause. What Gregg had not admitted to Weed was that the Rockefeller Foundation was by then negotiating an endowment for the National Hospital in London. The British neurologists writing the proposal were none other than Gordon Holmes and Francis Walshe—two neurologists whose international prominence had been enhanced by Johns Hopkins's attempts to recruit them as department heads. Although the National Hospital's funding would finally materialize only in 1935, the Rockefeller support for their proposal was practically guaranteed from the initiation of the project in 1932, and Rockefeller's support for British neurology would be vast in comparison to what they committed to Hopkins in the remaining years of the 1930s and the 1940s.

From April 1932 until December 1934 there were few further improvements in the Hopkins strategy. Although news of the new British developments in neurology undoubtedly reached their ears, no evidence indicates how Hopkins received that information. Letters from Adolf Meyer in 1931 indicate that he was at least supportive of philanthropic contributions to British psychiatry. It is likely that such magnanimity would also have existed at Hopkins for neurologists like Holmes and Walshe. Philanthropy, while a zero-sum game for the institutions collectively, was nonetheless facilitating progress in neurology somewhere—just not at Hopkins.

In 1935, the Rockefeller Foundation once again refused Hopkins a small grant of $125,000 allotted over five years, although the reason this time was that their support at Hopkins for other projects was already too extensive. By 1936 they were more receptive, but only for a small grant to support the salaries of Frank Ford (1892–1970), a long-term member of the Hopkins staff but a newly appointed associate professor in neurology, and Orthello Langworthy, a fellow working in the Hopkins neuro-logical dispensary. By March of that year, Hopkins had received a grant of $8,000 annually for four years. Langworthy and Weed submitted a further proposal in 1937 for developing the by then established subdepartment of neurology into an autonomous department. Despite reading "one of the clearest and most useful" memorandums he had seen, Alan Gregg admitted unhappily that no further support could be forthcoming in the near future, although "you would be right in inferring that we are none the less interested in aiding neurology at Hopkins at a later time." Gregg did not continue to view the situation so favorably. In 1940 he advocated renewing the Foundation's commitment to Ford's and Langworthy's salaries because they "have been working under a real handicap in point of instruments," but suggested that a sliding reduction in the amount the Foundation contributed to those salaries each year was in order. He admitted to Weed that this derived from his conviction "that it is reasonable to expect after five years some increasing measure of local support as an evidence of the school's estimation of the value of the services of the group in neurology in teaching and consultation services." Neurology needed to demonstrate local support. This would be the last grant from the Rockefeller Foundation supporting neurology at Hopkins. For his part, Weed was grateful: "May I tell you of the great appreciation which we feel toward this renewal of the grant in support of our developing department of neurology. The taper in the appropriation will be very difficult to meet because of many other demands upon the resources of the school here but I can assure you that attempts will be made to carry on the work in neurology at a very high level of efficiency." Weed was reassuring Gregg that efforts for neurology at Hopkins would continue, but they both knew that the institution could no longer rely upon the Foundation's support. Weed's personal resources for continuing his efforts were probably drying up as well. He had been an advocate for neurology at Hopkins since 1919, and by 1940, faced with increasing responsibilities under wartime pressures at the National Research Council, he was probably unable to continue sustaining his time and energy. Weed's role in the development of neurology at Hopkins was also over.

Conclusion

Neurology remained a subdepartment at Johns Hopkins until 1969, when the department finally opened. Thomas Turner (1902–2002), dean of the medical faculty at Hopkins, wrote that neurology's status as a division of medicine came under scrutiny again in 1966, and at that time a department of neurology was recommended, with space allocated in the Traylor Building and beds earmarked in the hospital.

By then the landscape of the neurological sciences had shifted firmly toward an integrative biochemical, pathological, and histological approach, which, when augmented by electroencephalography, the electron microscope, and new clinical scanning technologies, was redefining normal and pathological events in the nervous system. Increasingly, the old divisions among anatomy, pathology, and physiology, as well as between clinical medicine and surgery, were breaking down. Throughout the world the trend seemed increasingly to be that clinicians might work in preclinical departments just as preclinical scientists might appear in clinical departments. The division of labor in American medicine was changing in favor of departmental synergy, a point that the professor of neurology at Columbia University, H. Houston Merritt (1902–79), was already making in 1951 when he told freshman medical students, "The old barriers have been destroyed . . . it is now the aim of the Medical School to give the students an integrated knowledge of the human body and its reaction to disease and injury."

It is clear that in the 1920s, a preconception of the supremacy of the European medical tradition continued to influence American medicine. In part, however, that preconception was rhetorical. In this case, it allowed administrators and physicians at Johns Hopkins to argue for modernization on the grounds that their status quo was inadequate or inefficient. Modernization seemingly called for a socio-institutional transformation only; progress was deemed to derive from the further incorporation of a division of labor into the structure of hospital medicine and medical training.

Contemporaneously, young European physicians and scientists in the early stages of their careers (as well as some of the more established medical elite) were falling under the sway of a new model of laboratory medicine that was being nurtured by American philanthropy. Thus, while figures at Johns Hopkins and elsewhere in North America were viewing the numerous European brain institutes and teaching hospitals devoted to nervous diseases as evidence of a need to incorporate specialist neurology into American medical practice and curriculum, physicians and scientists with "modernist" inclinations in Britain and Europe were reconsidering the role of the laboratory in medicine and neurology. Perhaps the physicians at the National Hospital, Queen Square were successful in acquiring Rockefeller Foundation support because they were seeking to adopt this newest form of medical practice. In contrast, their competitors in Baltimore were arguing that they needed financial capital to merely build specialist departments.

More broadly, it is noteworthy that in the post progressive-era United States, the Neurology Committee at Hopkins cited European and British centers of neurology as exemplars of how neurology could be developed in Baltimore and, moreover, that they sought leading figures mainly from Britain to head their new department. Although they might have used a North American tradition of neurology in their appeals for philanthropic aid, Lewis Weed and others turned instead to an internationalist mantra. In a period of Atlantic crossings and progressive-minded internationalist discourses, neurology's purpose and practicality became located within a supranational consensus forged between physicians and administrators with similar appreciations and dispositions.

Within this framework, then, was both a degree of unreality and competition on an international scale. Its unreality had to do with the deployment of a language that often failed to grapple with the nuances of local realities. Thus, although the clinical tradition of neurology was described as preeminent in Britain, many of the pivotal figures belonging to that tradition had little more institutional or research support than did their colleagues in North America. Hence, when Gordon Holmes died in 1965, the author of his London Times obituary could describe him in these heroic terms:

It is of interest to put on the record, in the highly organised medical world of today, that the principal scene of Holmes' labours was a small voluntary hospital, which though for many years a world-famous school of neurology, was neither recognised nor supported by a university. His very numerous additions to medical knowledge were the hard-won fruit of the unsubsidised labour of the spare time of a physician who was also engaged in and dependent upon private practice. This of course had been equally true of his predecessors in the National Hospital: Jackson, Ferrier, Bastian, Gowers, and Horsley—some of the greatest names in modern neurology—and Holmes was perhaps the last of this remarkable group of men; all inexhaustible, forceful, and immensely able, who created the prestige of British neurology out of their own intellectual resources.116

How had a world-famous school of neurology prevailed under such conditions? In the epistolary economy of the interwar period, reports of the local professional status of neurology trafficked in both directions across the Atlantic. Rife with comparisons, the authors of these messages—which existed as letters, reports, journal articles, or even personal conversation— routinely claimed that conditions elsewhere were better. These messages were negotiated and operated to fashion a supranational ideal for neurology's professional identity, which was informing higher level administrative decision making and defining the field's purpose and practicality. In part, for example, the National Hospital's fame was generated by its international acclaim in the Hopkins Neurology Committee's reports, which were circulated to the Rockefeller Foundation and others. At the least, from the vantage point of an international philanthropic organization, the depictions of the National Hospital, Queen Square as the exemplary model for neurology and an environment resplendent with sought-after figures made the hospital an attractive institution for support. Queen Square reaped substantial benefits, including a lavish endowment in 1935 for research. In contrast, Johns Hopkins received only small support until the late 1960s.