Neurology is referred to as the scientific study or knowledge of the anatomy, functions, and diseases of the nerves and the nervous system. At times, psychiatry is included in this science because it deals with diseases of the nervous system and related symptoms. A neuropathologist focuses on the laboratory aspect versus the patient aspect a neurologist would. Miriam Webster defines a neuropathologist as a physician skilled in the pathology of the nervous system. Neuropathology is the branch of medicine concerned with diseases of the nervous system. Pathology alone is defined as the study of the essential nature of diseases and especially of the structural and functional changes produced by them.
The nervous system is a complex, sophisticated system that regulates and coordinates body activities, and it is divided into the Central Nervous System (CNS) and the Peripheral Nervous System (PNS). The central nervous system consists of the brain and spinal cord, and the peripheral nervous system refers to all other neural elements of the nervous system including the eyes, ears, skin, and other sensory acceptors.
A neurologist treats disorders that affect the CNS and/or the PNS. It is important to note that a neurologist does not perform surgery. A patient would be referred to a neurosurgeon if surgery is required for their particular neurological disorder. A neuropathologist assists the neurologist by analyzing laboratory samples and test results for signs of disease. They may analyze blood or tissue samples to determine if a patient has a disease, how advanced the disease is, and whether there are other diseases at work (MED).
Some of the disorders a neuropathologist may analyze include the following: cerebrovascular disease (such as stroke), demyelinating diseases of the central nervous system (such as multiple sclerosis), headache disorders, infections of the brain or peripheral nervous system, movement disorders (Parkinson’s disease), neurodegenerative disorders (Alzheimer’s, Lou Gehrig’s disease), seizure disorders (epilepsy), spinal cord disorders, and speech or language disorders.
History of Neuropathology
The beginnings of neuropathology originated in the early 1800s when research from English scientists on the brain were published. The term neurologist dates back to 1832, the year that Moritz Heinrich Romberg introduced the work of Sir Charles Bell to his Berlin audience. He was the first physician to study structural diseases of the nervous system. Although there are many researchers, scientists, and doctors who have contributed to the neurology we know today, a few of the significant discoveries are discussed below.
History of Neurology
Mortiz Heinrich Romberg (1795-1873)
Romberg was born in Germany in 1795, and at age 22 he began to dedicate his life to the study of nervous system diseases. He translated the book The Morbid Anatomy of the Brain, in Mania and Hydrophobia by Andrew Marshal into German in order to read Marshal’s research on the appearance and anatomy of the brains of patients who died of mania. Marshal’s theory was that the brains of these patients had a gross appearance in all mania patient’s due to poor circulation. Although none of Marshal’s theories were correct, this book introduced Romberg to other English neurological research, eventually leading to the work of Sir Charles Bell.
Romberg translated Sir Charles Bell’s The Nervous System of the Human Body into German and published the translation in 1832. In this work, Bell identifies the trigeminal, facial, and vagus nerves and their motor and sensory characteristics which was a landmark in neurology). Romberg continued on his journey of neurology at the University of Berlin and the University Hospital in the 1840s where he began documenting his patient research building on Bell’s research.
The division of sensation and motion in the nervous system was first identified in Romberg’s research. He identified neuritis, causalgia, neuromas, facial neuralgia, ciliary neuralgia, sciatica, and many other conditions in the sensory section. In the motor section, he describes muscular spasm, particularly concerning breathing and talking, in addition to chorea, tetanus, epilepsy, facial paralysis, and tabes dorsalis. Tabes dorsalis is a term that refers to the loss of coordination of movement, due to a syphilitic disorder of the nervous system marked by wasting, pain, limb weakness, ataxia, and disorders of sensation and vision resulting from degeneration of the spinal cord.
Although the basis of Romberg’s fame originated from Sir Charles Bell, Romberg is famous for not only translating textbooks but for the definition of clinical aspects of tabes dorsalis and his observation that the posterior sensory roots are occasionally affected along with the posterior of the spinal cord, the anterior motor column and nerves retaining their normal structure.
Duchenne and Charcot
Duchenne de Bologne (1806-1875) published neurological research regarding electrical stimulation of the muscles for facial expression as related to muscle function. This progressed into clinical descriptions of various aspects of progressive muscular atrophy, poliomyelitis, tabes dorsalis, glossolabiolaryngeal paralysis and pseudo-hypertrophic paralysis. Duchenne’s description of the symptoms of these diseases that little has been added to this day. He described fully and accurately the symptoms and signs of progressive muscular atrophy.
Jean-Martin Charcot (1825-1893) is widely known as the greatest neurologist of all time. Although he began as a general practitioner, he established one of the first pathology laboratories and examined the tissues of the nervous system in order to identify morbid changes associated with the clinicals states that he saw in wards. He also identified progressive muscular atrophy in addition to studies in aneurysm and its association with cerebral hemorrhage. Modern day knowledge of the structural diseases of the nervous system can be directly associated with Charcot’s discoveries. Because of the significance of his research, he is considered the founder of modern neurology and his studies in cerebral localization led directly to the development of neurosurgery.
Erb and Jackson
About the same time Charcot made his discoveries, John Hughlings Jackson (1835-1911) began documenting and analyzing neurological principles. Jackson contributed three important concepts to neurological thought: the type of epilepsy that goes by his name, his theory of aphasia and his doctrine levels of function of the nervous system. Epilepsy studies performed by Jackson included speech defects and a variation of simple to complex levels of neurological disease.
The turn of the nineteenth century found William Heinrich Erb (1840-1921) interested in the electrical aspect of Duchenne’s work. He published works on diseases of the peripheral nerves and diseases of the spinal cord and medulla. Electricity was used for diagnostic and therapeutic aspects of nerve reaction and degeneration that now goes by his name. Heinrich’s greatest contribution was not necessarily his research, although valuable, but his development of orderly and systematic examination that is essential still today for proper analyzing and diagnosis.
Early 1900s - Modern Day
By 1909, neurology had become so acceptable culturally that three physicians—Joseph Collins, Joseph Fraenkel and Pierce Bailey—successfully sought public philanthropy for the establishment of the Neurological Institute of New York. This was the first hospital designated to care for and treat patients with nervous system conditions and disorders.
Tracy Putnam (1894 – 1975) was a Harvard-trained pathologist who went on to study neurology at Brigham Hospital. He became one of the first expert neurosurgeons and became of the Director of Neurosurgery and Neurology and Professor of Neurology at Columbia Medical School. For reasons probably related to his principled stand against institutional anti-Semitism, Putnam found himself ousted from his directorship by 1947. He then moved to Los Angeles and went on to specialize in multiple sclerosis.
His replacement as director was his one-time Harvard medical school collaborator, H. Houston Merritt (1902-1979). They had previously worked together performing research on anti-convulsants around 1935. Merritt and Putnam’s research aimed to alleviate the side effects medications were causing epilepsy patients such as hypnotic effects. Using an animal model of epilepsy and examining 19 chemicals structurally similar to phenobarbital, Putnam and Merritt demonstrated that the palliative properties of phenobarbital were separable from their hypnotic ones.
In their second paper, they reported that the most active substance—phenytoin—appeared highly anti-convulsant and less hypnotic than phenobarbital. Their discoveries led to the use of phenytoin as treatment for epilepsy. The duo went on to publish a total of seven neurological research papers together.
Raymond Adams (1911-2008) was one of the most important American neurologists of the twentieth century. He utilized his complete knowledge of neuropathology and neurophysiology to make significant contributions and advances in the fields of neurology, psychiatry and psychology, which focused on diseases of the muscle, nerves and liver. Developmental disabilities were first considered a neurological and biochemical disorder by Adams. His textbook Principles of Neurology is still cited in neurological research today.
The Specialization of Neuropathology
Neuropathology developed in the German-speaking world as the development and publication of neurological research became more readily available. Neuropathology combines psychiatry, neurosurgery, and anatomic pathology. Many neuropathology and other neuroscience fields originated from Alois Alzheimer, Franz Nissel, and Walther Spielmeyer at the German research Institute for Psychiatry.
Developments of neurosurgery occur in close association with the development of neuropathology. Sir Victor Horsley is generally considered to be the founder of modern neurosurgery. He was closely affiliated with Harvey Cushing, who, along with Percival Bailey, collaborated to form the basis of modern-day neuro-oncology. Bailey assisted Cushing with following the fate and clinical course of his neurosurgery patients and Bailey, as a neuropathologist, provided that opportunity.
During the 1950s, the German Society of Neuropathology was founded and the Association of German Neuropathologists was formed. The aim of this society still today is to establish the discipline of neuropathology by research, teaching, and patient care.
How to become a Neuropathologist
According to URMC, the following education is required in order to be a neuropathologist licensed to practice in the United States: Four years of pre-medical education in a college or university, four years of medical school resulting in an M.D. or D.O. degree (doctor of medicine or doctor of osteopathy degree), a one-year internship in either internal medicine or medicine/surgery, and at least 3 years of specialty training in an accredited neurology residency program.
Once the minimum requirements are met, many neuropathologists obtain additional specialized training and education in neurological areas such as stroke, epilepsy, neuromuscular, sleep medicine, pain management, or movement disorders. Below is some additional information from the Bureau of Labor Statistics:
Degree Level
Doctorate
Degree Field
Any bachelor's degree (science sometimes preferred); medical graduate degree required
Experience
3-5 years of residency
Licensure and Certification
Must be licensed by the state; certification is optional
Key Skills
Strong verbal and written communication skills, empathy, problem-solving skills, ability to work long hours
Salary (May 2014)
$189,760 per year (Mean annual salary for all physicians and surgeons)
Most neuropathologists work in hospital settings (in a laboratory) and many work more than 40 hours per week with irregular hours. As with any work in medical care, they do risk exposure to infectious diseases. While the potential for high income is present in this career, and the great reward of improving people’s health and saving people’s lives, it can be emotionally and physically challenging. In addition to the educational and training requirements, a successful neurologist will also need strong communication and leadership skills, attention to detail, organizational and problem-solving skills, patience and empathy.
As mentioned above, the first step to becoming a neuropathologist is to obtain a bachelor’s degree. Many future neuropathologists major in biological science, chemistry, physics or pre-medical, although there is no specific requirement for the bachelor’s degree. Before selecting a degree program, medical school requirements should be considered. Science programs typically have the classes and subjects that meet the standards to admittance into medical school.
The Medical College Admission Test (MCAT) will be taken during the third year of undergraduate study. Medical schools use this exam as a skills assessment to evaluate an applicant’s training and knowledge. In addition to the minimum requirements, volunteering at a hospital or medical center not only allows for hands-on training working with patients, but it may help an applicant stand out to the medical evaluation board. Participation in extra-curricular activities and learning a foreign language may also be beneficial in standing out and increasing the chances of acceptance into medical school.
Medical school typically consists of a four-year program. The first two years focus on classroom instruction of anatomy and physiology, nutrition, immunology and ethics. The last two years includes hands-on clinical training covering specialized medicinal areas such as cardiology, family medicine, or neurology. A Doctorate of Medicine (M.D. or Ph.D.) is rewarded after successful completion of the 4-year medical school program.
The United States Medical Licensing Examination (USMLE) and the Comprehensive Osteopathic Medial Licensing Exam (COMLEX) must be passed in order to practice medicine in the US. These exams are completed in multiple stages, which begins during medical school, and the final stage is typically completed immediately following medical school or in the beginning of the residency stage.
Aspiring neuropathologists begin their postgraduate training by entering a 1-year internship program in either internal medicine or surgery to gain advanced experience with patients and specific healthcare practices. Rotations allow for a variety of training experiences and education. After successful completion of the internship, a 3-year neurology residency program begins in which students attend lectures, participate in patient rounds, and complete case studies of clinical scenarios. Students gain experience in neurological disorders and issues, such as multiple sclerosis, epilepsy, and neuroradiology as part of a typical residency program. A fellowship program may also be considered in order to obtain advanced training specialized to neuropathology.
The American Board of Psychology and Neurology (ABPN) offers voluntary certifications for qualified neurologists by way of a certification examination. If the training requirements are met, a neurologist may participate in the ABPN 10-year certification maintenance program. Continuing education is important for a neurologist to stay up to date with trends, breakthroughs and advances in the field. Educational activities may include attending lectures, classes, meetings, or performing self-assessments.
In addition, a neuropathologist may choose to become board certified in pathology with the subspecialty of neuropathology.
Neuropathological research continues to search for a cure or better treatments for Alzheimer’s disease, Lou Gehrig’s disease, Parkinson’s disease, multiple sclerosis, and many other severe diseases of the central and peripheral nervous system. A neuropathologist should be detail-oriented, reliable, and a logical thinker.
Who should see a neurologist?
How do you know if you need to be examined by a neurologist? Most patients work with their primary care provider prior to visiting a neurologist; although some may choose to go directly to the neurologist depending on the severity of the symptoms. A neurologist can determine if the symptom is an effect of a central or peripheral nervous system disorder or dysfunction. Some symptoms that may lead to a neurology visit are listed below. Many of the symptoms are simply common insignificant medical issues experienced throughout a lifetime, but in some cases, they can be signs of a more serious issue.
Headaches – Although headaches are common and most of us have experienced at least one throughout our lifetime, there are times when a headache could be a sign of a more serious issue. Migraines, vomiting along with headache, a continuously severe headache, one that starts early in the morning, changes in vision, or seizures are signs of a more severe disorder and may require a visit to a neurologist.
Chronic Pain – Pain that lasts for a long duration of time, from months or even years is known as chronic pain. Although some chronic pain may be due to other illnesses or injuries, pain extending past the usual recovery time may be a symptom of a neurological disorder or dysfunction. Chronic pain along with weakness, numbness, or problems with bladder or bowel control may be symptoms of a neurological issue.
Dizziness - Neurologists treat dizziness that is a symptom of vertigo or disequilibrium. Vertigo makes you feel as if you or the things around you are spinning; disequilibrium is difficulty keeping your balance. As with most medical issues, a primary care provider is typically required to determine if the severity of dizziness requires the assistance of a neurologist.
Numbness or tingling – Many factors may lead to numbness or tingling in particular body parts ranging from sitting in a way that cuts off your blood circulation or not eating for an extended period of time. A neurologist may become involved if the numbness occurs with sudden onset or if it happens only on one side of the body. This can be the signs of a stroke, so the need for a neurologist is immediate.
Weakness or Muscle Fatigue – Obviously, the general feeling of muscle weakness or fatigue after a long hike or lifting weights is normal. Muscle weakness or fatigue is of concern when it takes extra effort to move your arms and legs or make your muscles work, and is a symptom that may require a neurologist. This can also be an early warning sign of a stroke or a serious condition of the nervous system.
Movement problems – Problems moving, like difficulty walking, being clumsy, unintentional jerks or movements or tremors can be symptoms of a nervous system disorder. A neurologist will become involved if the problems moving decrease the patient’s quality of daily life and activity, although some movement problems may be contributed to medication side effects for anxiety.
Seizures – Seizures range in variation of severity. Some may be unnoticeable and some may be very extreme and severe, possibly causing death. As may be expected, there are also a wide range of symptoms that precede a seizure. Symptoms may include staring, loss of consciousness, jerking movements of the arms and legs, breathing difficulties or confusion. Low blood sugar or withdrawal from addictive substances may also lead to seizures, however neurologist will typically only address seizures with sudden onset and no other obvious cause.
Vision problems – Sudden onset vision disorders (not caused by aging) or those that effect both eyes at the same time may require evaluation from a neurologist and could be signs of a peripheral nervous system disorder.
Memory problems or confusion – Problems speaking, extreme problems with memory, changes in personality or confusion are all symptoms that could indicate disorders or dysfunction in the central nervous system (brain, spinal cord, and nerves). These symptoms can be indicators of learning disabilities or a more severe disease such as Alzheimer’s.
Sleeping disorders – Although many sleeping problems are due to causes such as improper diet, sleep apnea, anxiety or nightmares, some may be a sign of a neurological disorder. For example, narcolepsy is a chronic genetic disorder with unknown causes that is a disorder of the central nervous system.
In all of these cases, a neuropathologist works with the neurologist to analyze blood or tissue samples, CAT scans, or MRIs in order to properly determine if a neurological disease is present.
As described above, there are a variety of signs and indicators of disorder or dysfunction of the nervous system. Neuropathologists specialize in diseases of the central nervous system and the peripheral nervous system, and as with any medical field, new discoveries and advances have contributed greatly to the field of neurology. While the training and education requirements are extensive, a career as a neuropathologist can be highly rewarding and has many other benefits. Neuropathologists will be the ones to cure Alzheimer’s disease, Lou Gehrig’s disease, multiple sclerosis, and other severe diseases of the nervous system.
References
Viets, Henry R. The History of Neurology in the Last Hundred Years. The Bulletin – New York Academy of Medicine, 1948 Dec; 24(12): 772–783.
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